Gastric_Carcinoma-1

Gastric_Carcinoma-1 - Gastric Carcinoma Vic Vernenkar, D.O....

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Unformatted text preview: Gastric Carcinoma Vic Vernenkar, D.O. St. Barnabas Hospital Department of Surgery Background ♦ Second most common cancer-related death. ♦ Korea, Japan, China, Taiwan high rates. ♦ 22,000 diagnosed annually in US. ♦ 14th most common cancer. ♦ Difficult to cure, as advanced disease. ♦ Most die of recurrent disease even after resection for cure. Anatomy ♦ Stomach begins at GE junction, ends at duodenum. ♦ 3 parts- uppermost is cardia, largest part in middle is body, the last part is pylorus. ♦ Cardia contains mucin producing cells. ♦ Fundus or body mucoid cells, chief cells, parietal cells. ♦ Pylorus has mucin producing cells. Anatomy ♦ Five layers: Mucosa, submucosa, muscular layer, subserosal layer, serosal layer. ♦ Peritoneum of greater sac covers anterior surface ♦ A portion of lesser sac drapes posteriorly over stomach. ♦ The GE junction has limited serosal covering. Anatomy ♦ The site of the lesion is classified on basis of relationship to long axis of stomach. ♦ 40% lower part ♦ 40% middle part ♦ 15% upper part ♦ 10% more than one part ♦ Recently the # of lesions proximally has increased. Pathophysiology ♦ Understand vascular supply, allows for understanding of routes of spread. ♦ Derived from celiac artery. ♦ Left gastric supplies upper right stomach. ♦ Right gastric off common hepatic- lower portion. ♦ Right gastroepiploic -lower portion of greater curve. Pathophysiology ♦ Understanding lymphatic drainage can clarify nodal involvement. ♦ Complex drainage ♦ Primarily along celiac axis. ♦ Minor drainage along splenic hilum, suprapancreatic nodal groups, porta hepatis, and gastroduodenal areas Frequency ♦ US: seventh leading cause of cancer deaths, with 22,000 diagnosed yearly, and 14,000 deaths. ♦ Internationally: second most common cancer. Tremendous geographic variation, with highest death rates in Chile, Japan, and former USSR. Mortality and Morbidity ♦ 5-year survival for curative resections ranges from 30-50% for stage II disease and 10-25% in stage III. ♦ High likelihood of systemic and local relapse. ♦ Adjuvant therapy is offered . ♦ Operative mortality is less than 3% for curative resections. Race ♦ Higher in Asian countries. ♦ Japanese detect patients at very early stage, patients appear to do quite well. ♦ In Asian studies, patients with resected stage II and III disease have better outcomes than similar stages in the west. ♦ Some believe this reflects a biologic difference between diseases in Asia and west. ♦ Black race, low socioeconomic class. Sex, Age ♦ Men>women ♦ Most are elderly at diagnosis. Median age 65 years. The ones that present in younger patients may represent a more aggressive variant. ♦ Cigarettes History ♦ Early disease has no symptoms, some patients with incidental complaints get an early diagnosis. ♦ If symptoms, it reflects advanced disease; These may include indigestion, nausea, dysphagia, early satiety, anorexia, weight loss. History ♦ Late complications include: pleural effusions, peritoneal effusions, GOO, GE obstruction, SBO, bleeding, jaundice, cachexia. Physical ♦ All physical signs are late events. ♦ Too late for curative procedures. ♦ Palpable stomach with succussion splash, hepatomegaly, Virchow nodes, sister MJ nodes, Blumer shelf, weight loss, pallor from bleeding and anemia. Etiology ♦ Diet ♦ H. Pylori ♦ Previous stomach surgery ♦ Pernicious anemia ♦ Polyps(rarely a precursor) ♦ Atrophic gastritis ♦ Radiation, genetics Diet ♦ Certain diets are implicated. ♦ Rich in pickled vegetables, salted fish, excessive dietary salt, smoked meats. ♦ A diet that includes fruits and vegetables rich in vitamin C may have a protective effect. Helicobacter ♦ Implicated as precursor of gastric cancer. ♦ H. Pylori associated with atrophic gastritis, and patients with a history of prolonged gastritis have a 6-fold increase in risk. ♦ Particularly true of tumors of antrum, body, and fundus of stomach, but not in cardia. Previous Surgery ♦ Implicated as risk factor, the rational being that previous gastric surgery alters normal pH of stomach. ♦ Retrospective studies show that a small percentage of patients who have a gastric polyp removed have evidence of invasive carcinoma in the polyp. ♦ Polyps may therefore be premalignant. Genetic Factors ♦ Poorly understood ♦ Some familial aggregation exists Laboratory ♦ Assists in determining optimal therapy. ♦ CBC identifies anemia, with may be caused by bleeding, liver dysfunction, or poor nutrition. ♦ 30% have anemia. ♦ Electrolyte panels and LFTs are also essential to better characterize patients clinical state. Imaging Studies ♦ EGD: safe, simple, providing a permanent color photographic record. ♦ Obtains tissue for diagnosis. ♦ UGI: detects large tumors, but only occasionally detects extension into esophagus or duodenum, especially if small or submucosal. Imaging Studies ♦ CXR: done to evaluate for metastases. ♦ CT scan or MRI of chest, abdomen, pelvis: evaluate local disease process, and areas of spread. Some tumors are deemed unresectable based on the testing. ♦ Accurately predicts stage 66-77%. ♦ Poor nodal status prediction. Endoscopic Ultrasound ♦ Endoscopic ultrasound: becoming extremely useful as a staging tool, when CT fails to show T3, T4, or metastatic disease. ♦ Used with neoadjuvant chemo to stratify pts ♦ Can achieve resolution of 0.1 mm. ♦ Cannot reliably distinguish between tumor and fibrosis. ♦ Overall staging accuracy of 75% ♦ Poor for T2 lesions (38%) ♦ Better for T1(80%), T3 (90%) Histology ♦ Adenocarcinoma 95% ♦ Lymphomas 2% ♦ Carcinoids 1% ♦ Adenocathomas 1% ♦ Squamous cell 1% Histology ♦ Adenocarcinoma is classified according to the most unfavorable microscopic element present: tubular, papillary, mucinous, signet-ring cells. ♦ Also identified by gross appearance: ulcerative, polypoid, scirrous, superficial spreading, multicentric, or Barrett ectopic. ♦ Variety of other schemes: Borrmann, Lauren. Borrmann Classification ♦ 5 categories ♦ Type I: polypoid or fungating ♦ Type II: ulcerating lesions with elevated borders ♦ Type III: ulceration with invasion of wall ♦ Type IV: diffuse infiltration ♦ Type V: cannot be classified Lauren System ♦ Epidemic or endemic ♦ The intestinal, expansive epidemic type gastric cancer is associated with atrophic gastritis, retained glandular structure, little invasiveness, sharp margins. It would be a Borrmann I or II. Lauren System ♦ The epidemic or Borrmann I or II carries better prognosis, shows no family history. ♦ The diffuse, infiltrative, endemic, is poorly differentiated, with dangerously deceptive margins, invades large areas of stomach. Younger patients, genetic factors, blood groups, and family history. 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 Metastases ♦ MX- cannot be assessed ♦ M0- no distant metastases ♦ M1-distant metastases Prognostic Features ♦ Depth of invasion through gastric wall, presence or absence of regional lymph node involvement ♦ The greater number of positive nodes, the greater the likelihood of local or systemic failure postoperatively Spread Patterns ♦ Directly, via lymphatics, or hematogenously ♦ Direct extension into omentum, pancreas, diaphragm, transverse colon, and duodenum. ♦ If lesion extends beyond wall to a free peritoneal surface, peritoneal involvement is frequent. Spread Patterns ♦ The visible gross lesion frequently underestimates true extent. ♦ Abundant lymphatic channels in submucosal and subserosal layers allow for easy spread. ♦ The submucosal plexus is prominent in esophagus, the subserosal plexus prominent in duodenum, which allows for proximal and distal spread. ♦ Liver mets common, from hematogenous spread. Laparoscopy ♦ Inspect peritoneal surfaces, liver surface. ♦ Identification of advanced disease avoids non-therapeutic laparotomy in 25%. ♦ Patients with small volume metastases in peritoneum or liver have a life expectancy of 3-9 months, thus rarely benefit from palliative resection. Lymph Node Dissection ♦ AJCC: number rather than location of LN is prognostic. ♦ Extent of dissection controversial. ♦ Nodal involvement indicates poor prognosis, and more aggressive approaches to remove them are taking favor. ♦ Ongoing trials regarding this in Europe. ♦ Critics argue that the apparent benefit associated with extended LND reflects stage migration (each LN is reviewed more carefully). Residual Disease R Status ♦ Tumor status following resection. ♦ Assigned based on pathology of margins. ♦ R0- no residual gross or microscopic disease. ♦ R1- microscopic disease only. ♦ R2- gross residual disease. ♦ Long term survival only in R0 resection. “D” Nomenclature ♦ Describes extent of resection and lymphadenectomy. ♦ D1- removes all nodes within 3cm of tumor. ♦ D2- D1 plus hepatic, splenic, celiac, and left gastric nodes. ♦ D3- D2 plus omentectomy, splenectomy, distal pancreatectomy, clearance of porta hepatis nodes. ♦ Current standards include a D1 dissection only. Type of Surgery ♦ In general most surgeons perform total gastrectomy ( if required for negative margins), esophagogastrectomy for tumors of the cardia and GE junction, and a subtotal gastrectomy for tumors of the distal stomach. ♦ Similar 5 year rates for subtotal vs. total in tumors of distal stomach. ♦ Extensive lymphatics require 5cm margin. Outcome ♦ 5-year survival for a curative resection is 30-50% for stage II disease, 10-25% for stage III disease. ♦ Adjuvant therapy because of high incidence of local and systemic failure. ♦ A recent Intergroup 0116 randomized study offers evidence of a survival benefit associated with postoperative chemoradiotherapy Complications ♦ Mortality 1-2% ♦ Anastamotic leak, bleeding, ileus, transit failure, cholecystitis, pancreatitis, pulmonary infections, and thromboembolism. ♦ Late complications include dumping syndrome, vitamin B-12 deficiency, reflux esophagitis, osteoporosis. Adjuvant Therapy ♦ Rationale is to provide additional loco- regional control. ♦ Radiotherapy- studies show improved survival, lower rates of local recurrence when compared to surgery alone. ♦ In unresectable patients, higher 4 year survival with mutimodal tx, in comparison to chemo alone. Chemotherapy ♦ Numerous randomized clinical trials comparing combination chemotherapy in the adjuvant setting to surgery alone did not demonstrate a consistent survival benefit. ♦ The most widely used regimen is 5-FU, doxorubicin, and mitomycin-c. The addition of leukovorin did not increase response rates. Advanced Unresectable Disease ♦ Surgery is for palliation, pain, allowing oral intake ♦ Radiation provides relief from bleeding, obstruction and pain in 50-75%. Median duration of palliation is 4-18 months ...
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This note was uploaded on 12/27/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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Gastric_Carcinoma-1 - Gastric Carcinoma Vic Vernenkar, D.O....

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