Anatomy of the stomach
Gastric carcinoma
- Gastric carcinoma is the second commonest cause of cancer deaths world wide
- Accounts for 7000 deaths per year in the UK
Risk factors
- Diet low in Vitamin C
- Blood group A
- Pernicious anaemia
- Hypogammaglobulinaemia
- Post gastrectomy
Precursor states
- Helicobacter pylori infection
- Atrophic gastritis
- Intestinal metaplasia
- Gastric dysplasia
- Gastric polyps
Clinical presentation
- Most present late and are not amenable to radical surgery
- Upper GI endoscopy should be considered in all with dyspeptic symptoms over 40 years
Staging of gastric carcinoma
- Requires a combination of preoperative investigations and intraoperative assessment
- OGD confirms diagnosis, site and extent of tumour
- Endoscopic ultrasound may allow assessment of intramural tumour penetration
- CT will assess nodal spread and extent of metastatic disease
- Laparoscopy will identify peritoneal seedlings
- Peritoneal lavage will identify free tumour cells
Birmingham Staging System
- Clinicopathological system
- Does not require detailed lymph node status
- Stage 1
Disease confined to muscularis propria
- Stage 2
Muscularis and serosal involvement
- Stage 3 Gastric and nodal
involvement
- Stage 4a Residual disease
- Stage 4b Metastatic disease
Survival
- Prognosis if generally very poor
- Overall 5 year survival is approximately 5%
- Survival is 70%, 32%, 10% and 3% for Stages 1,2,3 and 4 respectively
Management
- Surgery is the only prospective of cure
- Antral tumours may be suitable for a partial gastrectomy usually with Polya reconstruction
- Other tumours will need a total gastrectomy with oesophagojejunal anastomosis and Roux-en-Y biliary
diversion
- A tumour is considered resectable if confined to stomach or N1 or N2 nodes involved
- Nodes less than 3 cm from tumour = N1 nodes
- Nodes greater than 3 cm from tumour = N2 nodes
- If tumour and N1 nodes resected = D1 gastrectomy
- If tumour and N2 nodes resected = D2 gastrectomy
- Evidence to support the use of D2 gastrectomy is incomplete
- D2 gastrectomy associated with increased post-operative mortality
- May be associated with improved long-term survival
- Even in patients with incurable disease surgery may palliate symptoms
- Results from adjuvant chemotherapy post surgery are disappointing
- Chemoradiotherapy may reduce relapse and improve survival
Picture provided by Miss Avril Chang, Central Middlesex Hospital, London, United Kingdom
Picture provided by Shyllashree Chikkamuniyappa, UTHSCSA, San Antonio, USA
Other gastric tumours
Leiomyosarcoma
- Accounts for 2-3% of all gastric tumours
- Arises from the smooth muscle of the stomach wall
- Lymphatic spread is rare
- 75% present with an upper gastrointestinal bleed
- 60% have palpable abdominal mass
- Diagnosis can be confirmed by endoscopy and CT scanning
- Partial gastrectomy may allow adequate resection
- 5-year survival is approximately 50%
Gastric lymphoma
- Stomach is the commonest extranodal primary site for non-Hodgkin's lymphoma
- Accounts for approximately 1% of gastric malignancies
- Clinically presents similar to gastric carcinoma
- 70% of tumours are resectable
- 5-year survival is approximately 25%
- Both adjuvant radiotherapy and chemotherapy may be useful
Sister Mary Joseph Nodule
- Sister Mary Joseph was Head Nurse to William Mayo
- Was first to notice that a 'nodule' in the umbilicus was often associated with advanced malignancy
- Presents as firm, red, non-tender nodule
- Results from spread of tumour within the falciform ligament
- 90% of tumours are adenocarcinomas
- Commonest primaries are stomach and ovary
- Primary tumour is almost invariably inoperable
Picture provided by Sampurna Tuladhar, B & B Hospital, Katmandu, Nepal
Bibliography
Bryan R T, Cruickshank N R, Needham S J et al. Laparoscopic peritoneal lavage in
staging gastric and oesophageal cancer. Eur J Surg Oncol 2001; 27: 291-297.
Cuschieri A, Fayers P, Fielding
J et al. Postoperative morbidity and mortality after D1 and
D2 resections for gastric cancer: Preliminary results of the MRCS
randomised controlled surgical trial. Lancet 1996;
347: 995-999.
MacDonald J S, Smalley S R, Benedetti J et al. Chemoradiotherapy after surgery
compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Eng J Med
2001; 345: 725-730.
Ravichandran D, Lamah M, Carty
N J, Johnson C D. Extended lymph node dissection (D2 resection) should now be performed in the curative surgical
treatment of gastric carcinoma. Ann R Coll Surg Eng 1995;
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Sasako M. Surgery for gastric cancer.
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