GASTRIC CANCER GASTRIC CANCER 4 5 th position

GASTRIC CANCER

GASTRIC CANCER 4% 5 th position nd n 2 cause of n cause of cancer related death in the world n 2 n n 5 y survival rate B: F=2: 1 More frequent in Japan, Latin America, Far East, North Europe. Incidence is droping

Pathology n Adenocarcinoma 90% n Sarcoma n Limfoma

CAUSES 66 -75% can be prevented with diet using high quantity of fruits and vegetables and low in salty foods. n Integral cereals and green teea can reduce the incidence n Vitamin C şi carotenoids probably decrease the risk n Alcoholmay increase the risk of GC in cardia region n Smoking increases the risk n

ETHIOLOGY n Atriphic gastritis n 9% will develop GC Chronic inflammation – destruction of glands – lower capacity of acid secretion – intestinal metaplasia Causes n n n Helicobacter pylori Ac anti parietal cells – Biermer Antral resection

n ETHIOLOGY Helicobacter pylori n n Distal GC + association with atrophy Appears to be protective against procimal GC 1/ 97 infectet patients develop CG Inf: noninf=8: 1, ONLY CERTAIN FENOTYPES

n Polyps n Hiperplastic – 80% n n Very high risck Familial risk n n n High risk over 0, 5 cm Adenomatos n n ETHIOLOGY 2 -3 X higher Mutation in gene CHD 1 -Ecadherina role in diferencietion and cel arhitecture Molecular fenotype n n n c-met, K-sam involved in cell groth p 53 suppressor gene– 64% cyclin E

n n PATHOLOGY Intestinal n n Atrophy – metaplasia displasia – adenoma cancer Difuz – linitis plastica n Submucosal invasion

n Macroscopic – Borrmann n n Type I - polipoid well defined Type II – polipoid with marked infiltration Type III – ulceratio with infiltrated margins Tip IV – linitis plastica Microscopic – OMS n n n n n Adenocarcinoma – intestinal, difuse Adenocarcinoma papilary Adenocarcinoma tubular Adenoacrcinom mucinos (>50% mucinous cells) Signet cells carcinoma (>50% signet cells) Adenosquamos carcinoma Squamos cell carcinoma Small cells carcinoma Nondiferentiated altele

Primary tumor (T): Tis = carcinoma in situ: intraepithelial tumor without invasion of lamina propria T 1 = tumor invades lamina propria or submucosa T 2 = tumor invades muscularis propria or subserosa T 3* = tumor penetrates serosa (visceral peritoneum) without invasion of adjacent structures T 4**, *** = tumor invades adjacent structures *A tumor may penetrate the muscularis propria with extension into the gastrocolic or gastrohepatic ligaments or into the greater or lesser omentum without perforation of the visceral peritoneum. **Structures adjacent to the stomach include the spleen, transverse colon, liver, diaphragm, pancreas, abdominal wall, adrenal gland, kidney, small intestine, and retroperitoneum. ***Intramural extension to the duodenum or esophagus is classified by the depth of greatest invasion in any of these sites, including the stomach). Regional lymph nodes (N): Include the perigastric nodes along the lesser and greater curvatures, and the nodes along the left gastric, common hepatic, splenic, and celiac arteries. N 0 = no regional lymph node metastasis N 1 = metastasis to 1– 6 regional lymph nodes N 2 = metastasis in 7– 15 regional lymph nodes N 3 = metastasis in more than 15 regional lymph nodes Distant metastasis (M): M 0 = no distant metastasis M 1 = distant metastasis

n Grading G 1 - well diferentiated->95% glands n G 2 – moderat diferentiated – 50 -95% glands n G 3 – poor diferentiated - <49% glands n Adc tubular – G 1 n Adc signet cells – G 3 n Adc small celss and non diferetiated – G 4 n

CLINICA PRESENTATION n Subjectiv n n Objectiv n n n n n General neoplastic simptoms Dispepsia UGI bleeding Tumor palpable Hepatomegaly, ascites, jaundice, splenomagaly Sister Mary Joseph – sign (umbilkical nodule) Virchow sign – left supraclavicular LN Krukenberg –ovarian MTS Blumer – rectal palpable mass Trousseau – migrating flebitis Leser-Trelat – seborheic keratitis Lab n n n Anemia Ocult bleeding ACE, CA 19. 9

Rx barium

CT, MRI, echoendoscopy+biopsy brush citology, laparoscopy, lapro echography

COMPLICATIONS n Bleeding n Perforation n Obstruction n Penetration

TREATMENT n n SURGICAL Rezection n n Limfadenectomy n n n R 0 – complete, no microscopic tumor left R 1 – microscopic tumor left in situ R 2 – macrosocopic residual tumor D 1 – stations 1 -6 D 2 – stations 7 -11 D 3 – stations 12 -14 D 4 – stations 15 -16 Omentectomy

n Endoscopic treatment n Mucosal resection in early gastric cancer Paliative n n Sclerotherapy Laser destruction Stent

TREATMENT n Chemotherapy Neoadjuvant / adjuvant n 5 -FU, doxorubicin şi mitomycin C (FAM) n Immunochemoterapy – CHT bound to specific tumoral ATB. Ag n n Radioterapy n n neoadjuvant Chemoradiation Adjuvant n Major discussions n