Gastric Neoplasms PDF

Gastric Neoplasms Dr. Burak Kankaya Istanbul Aydin University Department of General Surgery  Malignant tumors of the stomach The three most common malignant neoplasms of the stomach Adenocarcinoma (95%) Lymphoma (4%) Malignant GIST (1%) Rare malignant neoplasms of the stomach...

Gastric Neoplasms Dr. Burak Kankaya Istanbul Aydin University Department of General Surgery  Malignant tumors of the stomach The three most common malignant neoplasms of the stomach Adenocarcinoma (95%) Lymphoma (4%) Malignant GIST (1%) Rare malignant neoplasms of the stomach Carcinoid tumor Angiosarcoma Carcinosarcoma Squamous cell carcinoma Tumors that metastasize to the stomach Melanoma Breast Ca. Adenocarsinoma Age 6 ve 7. decade Men / Women 2/1 Socioeconomic level It increases as it falls Localization is changing Before antral location 50% antral-pyloric Cardia tm Increased risk Diet (nitrates, salt, fat) Smoking Family history Pernicious anemia Radiation A blood group Achlorhydria Environmental factors Familial polyposis EBV Helicobacter infection Aflatoxin Atrophic gastritis, intestinal metaplasia, dysplasia Gastric ulcer Premalignant lesions Polyps Atrophic gastritis Insignificant The most common premalignant Inflammatory (0.43%) lesion Hamartomatous Intestinal type Heterotopic 20% Premalign 3 types defined Hyperplastic (%2) Autoimmune Adenoma Proximal acid secretion is affected About diameter (2cm ↑20%) Hypersecretory Familial adenamatous polyposis FAP Antrum is affected (50% polyp in the stomach) Environmental Oxintic areas are affected  Intestinal metaplasia Benign gastric ulcer Complete type Gastric remnant cancers small intestine type Billroth 2 has the most goblet cells intestinal absorptive cell Roux at Y at least associated with H. pylori Menetrier's disease Hereditary nonpolyposis colorectal cancer Pathology Gastric dysplasia -- gastric adenocarcinoma In patients with severe dysplasia, gastric resection if the abnormality is diffuse or multifocal or EMR if severe dysplasia is localized Patients with mild dysplasia should be monitored under endoscopic biopsy surveillance and H. Pylori eradication Early gastric cancer Adenocarcinoma confined to the mucosa and submucosa of the stomach, regardless of lymph node involvement 10% lymph node metastasis 70% are well differentiated Small intramucosal lesions can be treated with EMR. Morphology Polypoid good prognosis Fungative good prognosis Ulcerative Scirrhous cancers (linitis plastica) prognosis is poor Location 40% distal, 30% middle, 30% proximal Histology (Lauren) Intestinal type From areas of intestinal metaplasia Replacement of gastric epithelium with Goblet-paneth cells H.pylori superficial gastritis→ atropic gastritis→ intestinal metaplasia→ dysplasia→ carcinoma in situ→ invasive carcinoma 85% of gastric tumors develop from a hypochlorhydric stomach Gastric cancer risk is directly proportional to the amount of metaplasia Epidemic cancer Related to H.pylori The decrease in gastric cancer occurred with the decrease in intestinal type  Diffuse type Less concerned with environmental factors Incidence increases with decrease in intestinal type More common in young people Independent of intestinal metaplasia and whole stomach Single cell mutation Poor prognosis Clinic Dysphagia Most common findings Cardia dominant finding Loss of appetite (most common symptom) Abdominal tenderness weight loss Palpable mass (50%) early satiety Paraneoplastic syndrome Pain Trousseau Syndrome thrombophlebitis Others (Nausea, vomiting, bloating) Acanthosis nigricans Anemia Pigment in axilla and groin ↑ Peripheral neuropathy Stool occult blood positivity Massive hematemesis 5% Gastric cancer Diagnosis and Staging Suspicion Endoscopy (Best –first) Biopsy - diagnosis Barium upper GiS series (single or double contrast) Complement Especially linitis plastica CT M phase Endoscopic US T and N phase Laparoscopy Staging N0: no lymph node metastasis N1:1–2 regional lymph node metastasis N2:3–6 regional lymph node metastasis N3: 7 or more regional lymph node metastases (N3a: 7–15 metastases, N3b: more than 16 metastases) Left supraclavicular lymph node: Virchow nodule Palpable umbilical nodule: Sister Joseph nodule Hard mass palpable on rectal examination: Blumer's rectal Shelf Treatment Radiotherapy-- chemotherapy Limited benefit Surgery Palliative Bleeding - Obstruction Curative Resection margins EMR early stomach cancer Localization Radical subtotal-total gastrectomy Lymph node dissection Prognosis 5-year survival 22% Survival depends on pathological stage and tumor differentiation Other important prognostic factors are; age, gender, tumor location, tumor size and depth Gastric Lymphoma More than half of primary GI lymphomas occur in the stomach 25% multiple 95% Non-Hodgkin B cell Lesser curvature and antrum on the HP floor Macroscopy Often Non-Hodgkin's lymphoma Primer tumoral mass Secondary (most common) Submucosal lymphocytic disease Finding Early satiety (first symptom) Loss of appetite and weight loss Bleeding is rare  Diagnosis Barium examination Diffuse infiltration findings similar to linitis plastica… Endoscopy and biopsy - Gold standard Treatment First option chemotheraphy H.Pylori eradication (malt cell lymphoma) Surgical Complication CT unresponsiveness Subtotal gastrectomy Adjuvant CT-RT Survival 85% with combined treatments limited to the stomach Node (+) 40-50% Gastrointestinal Stromal Tumor Most commonly in the stomach Pathology Originates from kajal cells c-kit mutation (tyrosine kinase activity) ***c-kit antibodies (+) Diagnosis Endoscopy, Endoscopic USG, CT Treatment Drugs that inhibit tyrosine kinase activity Wedge resection Local recurrence Gastric Carcinoid Tumors 1% of all carcinoids Some have malignant potential Etiology Permissive anemia Atrophic gastritis Submucosal slow-growing tumors May be confused with leiomyoma/ectopic pancreas Diagnosis EUS Treatment Resection (endoscopic-open surgery) Benign Gastric Neoplasms Leiomyoma Stomach leiomyomas are usually hard and solitary. If it is ulcerated, it may look like a belly button and bleed. Histologically, it appears to originate from smooth muscle. Lesions smaller than 2 cm are generally benign and often asymptomatic. They can be tracked. Enucleation can be used in treatment Large and symptomatic lesions can be removed by wedge resection.  Lipomas -They are mostly benign and asymptomatic. -They have typical appearances on EUS. -No intervention unless symptomatic.  Ectopic Pancreas Rare Antrum A belly-shaped depression within the submucosal stomach cluster Treatment Excision Rule out malignancy Persistent symptoms resistant to antiulcer therapy Hypertrophic Gastropathy (Menetrier's disease) Rare, inflammatory disease of the proximal stomach Epithelial hyperplasia Giant gastric folds Autoimmune? Pathology Loss of plasma proteins by permeability of the epithelium Hypochlorhydria Clinic Epigastric pain-weight loss-diarrhea hypoproteinemia Treatment Good nutrition and symptoms-oriented practices Hypoproteinemia is rare If it develops, surgical intervention is required Observation for stomach cancer