Tumor board Ca stomach

1. Tumor Board
05/03/2019

2. Patient details
• Age/Sex : 45 Years / Male
• Hospital OP/ IP No: A19005664
• Biopsy no: 263/19
• Date of Receiving Specimen : 01-02-2019
• Date of Report : 07-02-2019
• Clinical Diagnosis : Carcinoma stomach
• Previous Biopsy reported outside :
Endogastric biopsy with features of diffuse gastric
adenocarcinoma (signet ring cell carcinoma)
• Nature of Specimen : Subtotal gastrectomy specimen
.

3. Gross Examination (Biopsy no:263/19)
Biopsy no: 263/19
Container labelled stomach
• Received partially cut opened
subtotal gastrectomy specimen
measuring 15 x 10 x 3 cm with
attached omental pad of fat.
• The stomach measures 23 cm
along the greater curvature
and 11cm along the lesser
curvature.
• The serosal surface is grey-
brown in color & fibrosed with
attached omental pad of fat on
the greater curvature
measuring 36 x 16 cm.

4. Gross Examination (Biopsy no:263/19)
• Cut surface of stomach
shows grey white irregular
circumferential ulcerative
growth involving pyloric
region measuring
3.5 x 3 x 1.5 cm.
• Focal areas shows tumor
surrounded by mucin.

5. Gross Examination (Biopsy no:263/19)
• Tumor is
– 7cm away from the
proximal surgical
margin
– 0.4 cm away from the
distal surgical margin
– 0.2 cm away from the
serosa
• Grossly, the tumor
appears to infiltrate
partial thickness of the
mucosa.

6. Microscopy (Biopsy no:263/19)
Sections studied show tumor arranged in diffuse sheets, cords and in glandular
pattern, embedded in dense mucinous pools.
4x 40x40x

7. Microscopy (Biopsy no:263/19)
Sections studied show individual tumor cells are highly pleomorphic with dense
hyperchromatic nuclei, prominent nucleoli and atypical mitosis.
Occasional signet ring cells seen.
40x 40x40x

8. Microscopy (Biopsy no:263/19)
Section studied shows tumor
extending upto the submucosa and
inner muscular layer and limited
within the serosa.
Section studied shows foci of
intestinal metaplasia
4x 40x

9. Microscopy (Biopsy no:263/19)
Sections studied also shows
• The proximal and distal resected margins are free of tumor.
• Adjacent mucosa shows chronic atrophic gastritis.
• Identified 7 lymph nodes with features of reactive lymphoid
hyperplasia with sinus histocytosis and are all free of tumor.

10. Gross Examination
Biopsy no: 264/19 - Container labelled right hepatic lymph
node:
Received single grey white to grey black soft tissue bits
measuring 2 x 0.5 x 0.3 cm. All embedded in one block.
Biopsy no: 265/19 - Container labelled splenic lymph node:
Received single grey yellow soft tissue bits measuring
2.5 x 1.5 x 1cm. All embedded in one block.
Biopsy no: 266/19 - Container labelled station -8 lymph node:
Received single grey yellow to grey black soft tissue bits
measuring 1 x 1 x 0.6cm. All embedded in one block.
Biopsy no: 267/19 Container labelled aortocaval value:
Received single grey yellow soft tissue bit measuring
2 x 0.5 x 0.5cm. All embedded in one block.

11. Microscopy (Biopsy nos: 264-267/19)
Biopsy no: 264/19 –
Section studied from right hepatic node shows reactive lymphoid
hyperplasia and free of tumor.
Biopsy no: 265/19 –
Section studied from splenic node shows reactive lymphoid
hyperplasia and free of tumor.
Biopsy no: 266/19 –
Section studied from station -8 lymph node shows reactive lymphoid
hyperplasia and free of tumor.
Biopsy no: 267/19 –
Section studied from aortocaval valve lymph node are free of tumor.

12. Final Impression
• Subtotal gastrectomy specimen shows features suggestive
of mucin secreting adenocarcinoma - pyloric antrum with
extension to submucosa and inner muscular layer.
• The outer muscularis, serosa and 7/7 lymph nodes shows
reactive lymphoid hyperplasia and free of tumor.
• Right Hepatic node shows features of reactive lymphoid
hyperplasia and is free of tumor.
• Splenic node shows features of reactive lymphoid
hyperplasia and free of tumor.
• Station 8 lymph node shows features of reactive lymphoid
hyperplasia and free of tumor.
• Aortocaval valve lymph node is free of tumor.

13. DISCUSSION

14. Prognostic Factors
1 Patient's age
• Gastric carcinomas in the young have traditionally been
associated with a grim prognosis, this being the result of
– delay in diagnosis.
– higher percentage of diffuse cases in this age group.
2 Tumor stage
• The deeper the penetration, the greater the chance of
metastases.
• Polypoid, largely intraluminal neoplasms have a much lower
incidence of metastases than those growing primarily within
the wall.

15. Prognostic Factors
3 Location within the stomach
In 80% of the 5-year survivors, the lesion is in the distal half of the
stomach.
no long-term survivors among those with lesions of the cardia, fundus,
or esophagogastric junction.(Dupont et al)
4 Tumor margins
• The presence of a pushing or expanding border is a favorable
prognostic sign.
• Diffuse infiltration is associated with a decreased survival rate.
• prognosis for the expanding type of gastric carcinoma in Ming's
classification is better than for the infiltrative type.

16. Prognostic Factors
5 Tumor size
• Small tumor size is associated with a better prognosis, but
this is closely linked to the depth of penetration.
6 Microscopic type and grading
• The intestinal-type tumors in Lauren's classification behave
relatively better than the diffuse types.
• Intracellular mucin content and tubular differentiation
(Goseki's grading) is significantly related to survival.
• Low-grade desmoplastic diffuse type has a better prognosis
whereas high-grade anaplastic diffuse type has the worse
prognosis.

17. Prognostic Factors
7 Inflammatory reaction
The finding of a cellular infiltrate at the interface between
the tumor and normal tissue, often associated with
degenerative changes in the tumor, is a good prognostic
sign.
8 Perineurial invasion
In one series of stage T2 gastric carcinomas, tumors showing
perineurial invasion had a poorer prognosis than negative
cases.

18. Prognostic Factors
9 Surgical margins
When carcinoma is found at the limit of the excision, early
recurrence is to be expected.
10 Type of surgery
• In one large series, subtotal gastrectomy was the procedure
performed most frequently, but radical subtotal gastrectomy
resulted in the best survival.
• In another series, radical lymphadenectomy led to better
survival than standard lymphadenectomy.

19. Prognostic Factors
11 Regional lymph node involvement
• If lymph nodes are found to be negative on a thorough
pathologic examination, over 50% of the patients may
be expected to survive for 5 years.
• With nodal involvement, the figure drops to less than
10%.
• The number of nodes involved is more significant
prognostically than nodal stage
• There is some evidence that the presence of
immunohistochemically detected micrometastases may
also carry some prognostic significance

20. Prognostic Factors
12 DNA ploidy and cell proliferation
The results of several series suggest that determination of
DNA ploidy with flow cytometry and determination of rate
of cell proliferation with a variety of markers (p105, PC10)
may be a reliable indicator of prognosis in gastric carcinoma.
13 c-ERBB-2 protein
Overexpression of c-ERBB-2 protein in gastric carcinoma
(occurring in about 20% of cases) was found to be an
independent indicator of poor prognosis.

21. Prognostic Factors
14 P53 protein
In one series from England & another from Portugal, gastric
carcinomas overexpressing the product of the TP53 gene
were associated with a decreased survival.
15 Cathepsins
– Increasing levels of cathepsin D detection by
immunohistochemistry have been associated with a
poorer survival.
– High expression of cathepsins B & L has been found to
be related to a greater tumor capacity for invasion and
metastases.

22. Prognostic Factors
16 p27Kip1 expression
Immunohistochemical detection of this cyclin-dependent
kinase inhibitor is said to be an indicator of reduced survival.
17 Fhit
Preliminary studies seem to indicate that loss of Fhit protein is
an indicator of poor prognosis.

23. Prognostic Factors
18 T antigen
Expression of this precursor of the blood MN system is said
to correlate with depth of invasion and metastatic spread
in gastric carcinoma.
19 EBV expression
EBV-positive gastric carcinomas have a better prognosis,
possibly related to the presence of an activated cytotoxic
T-cell infiltrate.