Case Presentation

By Dr Saleem
 Scenario
50 years male with mass epigastrium
moving with respiration, associated
with vomiting, wt loss for two
months

O/E : Left supraclavicular node

palpable
Provisional Diagnosis

Ca Stomach
 Differential Diagnosis
• Ca transverse colon
• Ca lt lobe of liver
• Ca gall bladder
 History
• Age 50 years

• Sex Male

• Duration 02 months

• Nausea vomiting
 History

• Epigastric Discomfort,Dyspepsia

• Dysphagia

• Wt loss
anorexia and early satiety
 Contd:
• Haemetemesis

• Malena

• Altered Bowel habbits

• Bleeding P/R
 Contd:
•Shortness of breath

• Juandice

• Smoking

• Past history

• Family history
 Physical Findings
GPE
•Pallor

•Lymph nodes
Lt Supraclavicular (virchow) Ant
Axillary (irish nodes)
Cervical lymph nodes
 Contd:
• Trousseau,s sign
Thrombophelbitis

• Acanthosis
Nigricanus
Hyperpigmentation
 Abdomen
• Mass epigastrium
moves with respiration
hard
non tender irregular
seperate from liver
succussion splash
 Contd:
• Periumblical metastasis
Sister Mary Joseph
nodule

• Hepatomegaly
• Pelvic Masses (Krukenberg tumor)

• Ascites
 Title
• DRE
Blumer shelf
Hard nodularity extraluminaly and
anteriorly
also called ,Drop metastasis:
 Investigations
Baseline
Goal to assist for optimal therapy
•CBC

•LFT,s

•Stool for occult blood

 Diagnostic workup
• Upper GI endoscopy 95 % accuracy Tissue
diagnosis
Ulcerated lesion (take 6 biopsies around the
lesion)
 Contd:
• Double contrast upper GI
series And Barium swallow

75% accuracy

for obstructive lesions only

 Staging Investigations
• Endoluminal U/S
Accuracy for tumor penetration
involvement of adjacent structures
Lymph nodes involvement

Operater dependent
 Contd:
• Chest X ray
lung mets plurel
effusion

• U/S abdomen
liver mets
 Contd:
• CT scan Abdomen and Pelvis loccaly
advanced disease Metastasis
Extra regional lymphadenopathy

• PET Scan
To determine sites of unexpected metastasis
 Contd:
• Staging Laproscopy
To determine possibilty of curitive lesion
look for peritoneal and hepatic mets
 Staging
 Primary tumor
Tx- cannot be assessed T0- no evidence
Tis- carcinoma in situ, no invasion of lamina
T1- invades lamina propria or submucosa
T2- invades muscularis or subserosa
T3- penetrates serosa, no adjacent structure
T4- invades adjacent structures
 Regional lymph nodes
NX- cannot be assessed N0- no nodes
N1- mets in 1-6 regional nodes N2- mets
in 7-15 regional nodes
N3- mets in more than 15 regional nodes
 Distant Metastasis
 MX- cannot be assessed
 M0- no distant metastases
 M1-distant metastases
 Stages
• * Stage 0 - Tis, N0, M0
• * Stage IA - T1, N0 or N1, M0
• * Stage IB - T1, N2, M0 or T2a/b, N0, M0
• * Stage II - T1, N2, M0 or T2a/b, N1, M0 or T2, N0,
M0
• * Stage IIIA - T2a/b, N2, M0 or T3, N1, M0 or T4, N0,
M0
• * Stage IIIB - T3, N2, M0
• * Stage IV - T1-3, N3, M0 or T4, N1-3, M0, or any T,
any N, M1
 Title

Stage 4
Title
 Treatment
• Surgery is the only curative treatment
for gastric cancer.

• It is the best palliation

• provides the most accurate staging.

 Exceptions
• patients who cannot tolerate an
abdominal operation, and

• patients with overwhelming metastatic

disease.
 Goal of Treatment
• resection of all tumor

• all margins (proximal, distal, and radial)

should be negative and an adequate
lymphadenectomy performed

• negative margin of at least 5 cm

 Subtotal gastrectomy
• standard operation for gastric cancer is radical
subtotal gastrectomy
 Lower radical partial gastrectomy
• carcinoma of the lower third of the
stomach.
• ligation of the left and right gastric and
gastroepiploic arteries at the origin
• en bloc removal of the distal 75% of the
stomach, including the pylorus and 2 cm of
duodenum
• the greater and lesser omentum, and all
associated lymphatic tissue
 Reconstruction
• Reconstruction is usually by Billroth II
gastrojejunostomy,

• if a small gastric remnant is left (<20%), a

Roux-en-Y reconstruction is considered.
 Esophagogasrectomy

growth involving the cardia

and gastroesophageal
junction
 Upper radical partial gastrectomy
• Growths of upper third
Reconstruction
• esophagogastrostomy
• Pyloroplasty
• An isoperistaltic jejunal interposition
(Henley loop) between the esophagus and
antrum could be considered.
 Total Gastrectomy
• Survival similar compared with subtotal
gastrectomy

• Complications higher

• Total gastrectomy with jejunal pouch/

esophageal anastomosis may be the best
operation for patients with proximal gastric
adenocarcinoma ,linitis plastica
Reconstruction
 Lymphadenectomy
The extent of resection is described as
•D1. Limited Lymphadenectomy. All N1 Nodes
removed en bloc with the stomach

•D2. Systematic Lymphadenectomy. N1 & N2

nodes en bloc with stomach

•D3. Extended Lymphadenectomy. A more

radical en bloc resection including N3 nodes
 Extent of lymphadenectomy
• Two randomized trials compared D1 with D2
lymphadenectomy in patients who were
treated for curative intent.

• postoperative morbidity (43% versus 25%)

and mortality (10% versus 4%) were higher
in the D2 group.

• Drawback
 Recommended
• A pancreas and spleen-preserving
D2 lymphadenectomy
Carcinoma upper third
Carcinoma middle third
Carcinoma lower third
 Post op complications
Early complications

• Paralytic ileus.
• Leakage from suture line.
• Leakage from duodenal stump.
• Acute Cholycystitis, Pancreatitis
• Stomal obstruction.
 Title
Late complications

• Early Dumping syndrome

• Late dumping syndrome.
• Bilious vomiting.
• Gastric stump cancer
• Vit B12 deficiency
• Osteoporosis
 Adjuvant Therapy
• Rationale behind radiotherapy is to provide
additional local-regional tumor control.

• Adjuvant chemotherapy is used either as a

radiosensitizer or as definitive treatment for
presumed systemic metastases.
 Adjuvant Radiotherapy
• lower rates of local recurrence in patients
who received postoperative radiotherapy
than in those who underwent surgery alone
(British stomach cancer study group)

• Improved survival
(mayo clinic randomized patients)
 Intra operative radiotherapy
• allows for a high dose to be given in a
single fraction while in the operating room
so that other critical structures can be
avoided.

• Stage 3 and 4

• Median survival (21 months vs 10 months )

with IORT
 Adjuvant Chemotherapy
• No consistent survival benefit.

• Epirubicin . 5 florouracil ,cis platinium

(ECF)

• Combination of chemoradio therapy has

better outcome
 Neo adjuvant chemotherapy
• downstaging of disease to increase
resectability,
• decrease micrometastatic disease burden
prior to surgery
• allow patient tolerability prior to surgery
• determine chemotherapy sensitivity
• reduce the rate of local and distant
recurrences, and ultimately improve survival.
 Palliative Care
• radiotherapy provides relief from bleeding,
obstruction, and pain in 50-75%

• wide local excision, partial gastrectomy, total

gastrectomy, simple laparotomy,
gastrointestinal anastomosis, and bypass for
food intake or pain relief
Summary