Gastric Carcinoma

 

Premalignant Conditions of Gastric Carcinoma:

  • 1. Chronic atrophic Gastritis
  •                   • Environmental Multifocal atrophic Gastritis
  •                   • Autoimmune metaplastic atrophic Gastritis
  • 2. Intestinal metaplasia and dysplasia
  • 3.Gastric polyp
  • 4.Intestinal Metaplasia & Dysplasia
  • 5.Gastric Polyp
  • 6.Previous Gastrectomy
  •                • 20 years after surgery, risk increase if surgery done before 50 years age
  •                • Occur at/near surgical anastomosis
  • 7.PUD
  • 8.Menetrier’s disease

       

           Gastric Dysplasia

  • – Prevalence in low-risk area : 0.5 %
  • – Prevalence in high-risk area : 20 %
  • – Low grade dysplasia regress in upto 60 % cases
  • – High grade dysplasia regress rarely
  • – 10-20% low grade dysplasia may progress to high grade dysplasia

Lauren Classification of Gastric Carcinoma

  • – Intestinal type
  • – Diffuse type
  •      Intestinal type:
  •               – Contains gland-like tubular structure
  •               – More closely related to dietary risk factors and environmental risk factor
  •               – Predominant in high risk area
  •               – Normal mucosa   Hyper proliferative epithelium   Early adenoma    Late adenoma ⇒   Carcinoma
  •      Diffuse type:
  •              – Lacks glandular structure
  •              – Consists of poorly cohesive cells that infiltrate the wall of the stomach
  •              – Occurs at young age (<40 years)
  •              – Worse prognosis than intestinal type

Boremann classification of Gastric Carcinoma

  • I. Polypoid/ Fungating
  • II. Ulcerated with elevated borders
  • III.Ulcerated with infiltrating gastric wall
  • IV. Diffusely infiltrating
  • V. Unclassifiable

 

Broder’s classification of Gastric Carcinoma

  • I. Well differentiated
  • II. Moderately differentiated
  • III. Poorly differentiated
  • IV. Anaplastic

Other Classification of Gastric Carcinoma

  • – Proximal (esophagogastric junction, cardia)
  • – Distal tumor
  •                 √ Fundus
  •                 √ Body
  •                 √ Antrum
  • – Early ( Mucosa + Submucosa)
  • – Advanced

Classification of Early Gastric Cancer based on endoscopic findings

  1. Superficial polypoid
  2. Superficial Flat/Depressed
  3. Superficial excavated

 

  Figure: Japanese Classification of Early Gastric Cancer

 

Symptoms of gastric carcinoma:

  • Early gastric carcinoma :
  •                   – Asymptomatic – 80%
  •                   – PUD like symptoms when symptomatic
  • Advanced gastric cancer :
  •             – Weight loss
  •             – Abdominal pain
  •             – Nausea, vomiting
  •             – Dysphagia
  •             – Melena
  •             – Early satiety
  •             – Pyloric obstruction

Paraneoplastic symptoms of Gastric Carcimoma

  • – Thrombophlebitis
  • – Neuropathy
  • – Nephrotic syndrome
  • – DIC
  • – Acanthosis nigricans
  • – Seborrheic dermatitis

Common sites of Gastric Cancer Metastasis

  • – Metastasis present in 33 % cases at the time of diagnosis
  • – Liver
  • – Peritoneum
  • – Umbilical LN (sister marry joseph’s nodule)
  • – Pouch of Douglas (blummer’s shelf)
  • – Ovaries (krukenberg’s tumor)
  • – Other sites:
  •               • Kidney
  •               • Brain

 

Criteria for EMR (Endoscopic Mucosal Resection) in Gastric Carcinoma

  • – Intramucosal cancer without lymph node involvement
  • – Tumor size <2 cm when the lesion is slightly elevated
  • – Tumor size <1 cm when the lesion is flat/slightly depressed
  • – No evidence of multiple gastric cancer/simultaneous abdominal cancer
  • – Cancer is intestinal type

Criteria for ESD (Endoscopic Submucosal Dissection) in Gastric Carcinoma

  • – Mucosal intestinal type cancer of any size without ulceration
  • – Mucosal intestinal type cancer <3 cm with ulceration with submucosal invasion < 500 µm
  • – Submucosal intestinal-type cancer <3 cm and with submucosal invasion < 500 µm

                               

                         

                                 Palliative Measures of Carcinoma Stomach

  • Endoscopic:
  • 1.For distal esophageal obstruction:
  •                – Esophageal stent
  •                – Endoscopic Laser therapy
  •                – Percutaneous endoscopic gastrostomy tube (PEG)
  •                – Esophageal dilatation
  • 2.For distal stomach obstruction
  •               – Duodenal stent

 

  • Surgical
  •               – Gastrojejunostomy
  •               – Partial gastrectomy

 


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