1. Dr. Amina Abdul Rahman
Junior Resident
Dept. of Radiotherapy

2.  Epidemiology
 Anatomy
 Classification
 Pathology
 Clinical Features
 Staging
 Prognosis

3. Epidemiology

4.  Fourth most common cancer in the world
 Second most common cause of cancer related
death
 Marked geographic variation
 High risk areas : Japan, Korea, Latin America,
USSR
 Low risk areas: USA, Israel, Kuwait, Canada

7. But the incidence of proximal gastric cancers is
increasing in the west…

9.  Most common site was Antrum 48%
 40% was found to be in the body
 10% was found to be in the proximal stomach

10. GEJ Tumors
Cardia Tumors

11.  Acquired
High salt consumption
High nitrate consumption
Poor food preparation (smoked, salt cured)
Lack of refrigeration
Diet low in Vit A and C
Smoking, heavy alcohol consumption

12. Helicobacter pylori
 3 to 6 times increase in risk of gastric cancer
 intestinal type of cancer in the distal stomach
 Decreases acid production causing chronic
atrophic gastritis

13.  Radiation exposure
 Prior Gastric surgery for benign ulcer disease

14.  Genetic Factors
Type A blood group
Pernicious anemia
Family history
HNPCC
Li-Fraumeni syndrome
Peutz Jegher Syndrome
BRCA2 mutation

15.  Fresh fruits and vegetables
 NSAIDs

16.  CDH1mutation
 Codes for E-Cadherin
 Prophylactic gastrectomy

17. Proximal Gastric Cancer Distal Gastric Cancers
Includes GEJ, Tumors of the Cardia Includes Body and Antrum
Rapidly increasing incidence in the
west
World wide incidence is declining
steadily
Mainly diffuse type Mainly intestinal type
M:F = 1:1 M>F
Younger age Older age
More aggressive Less aggressive
More in the developed countries More in developing countries
Not associated with H. pylori Associated with H. pylori
Associated with GERD Associated with atrophic gastritis

18. ANATOMY

28. 12 – Hepatoduodenal ligament
13 – On the posterior surface of the head of
pancreas
14 – Root of mesentery
15 – Para aortic
16 - Paracolic

31. Classification of Gastric Tumors

32. Type I : Adeno Ca Distal
Esophagus, infilt GEJ from
above
Type II : Adeno Ca of the
real cardia, true GEJ
Type III : Subcardial Gastric
Adenoca, infilt GEJ from above

33. Early Gastric Cancer
•T1a and T1b, any N
Advanced Gastric Cancer
•T2 and above

36. PATHOLOGY

37. WHO Classification
•On histologic appearance alone
Lauren’s Classification
•Histology and morphology

38.  Epithelial tumors
Adenocarcinoma
Small cell carcinoma
Carcinoid tumor
 Malignant Lymphoma
Maltoma
Mantle cell lymphoma
DLBCL

39.  Non epithelial tumors
Leiomyoma
Schwannoma
Granular cell tumor
Leiomyosarcoma
GIST
Kaposi Sarcoma

40. ADENOCARCINOMA
 Tubular
 Papillary
 Mucinous
 Signet ring cell carcinoma
 Undifferentiated

41. Intestinal type
•54%
Diffuse type
•32%

42.  Form exophytic or ulcerated growth
 More in the distal stomach
 Due to H. pylori
 This type is declining worldwide
 Older patients with a male preponderance
 M:F = 2:1
 Better prognosis
 Form glandular elements in histology

43. Chronic atrophic gastritis
Intestinal metaplasia
Dysplasia
Carcinoma in situ

45.  Mainly affects cardia
 Form infiltrative lesions
 No precancerous lesions
 Loss of CDH1 gene
 Discohesive cells that do not form glands
 Signet ring cells
 Younger age, M = F
 Worse prognosis

47.  Her2-neu amplification in 12 to 27%
 More in intestinal type than diffuse type
 Prognostic significance has not been
identified
 4 tier scoring
 Trastuzumab in Her2-neu 3+ or FISH positive
locally advanced or metastatic stomach
cancer

48. CLINICAL FEATURES

49.  Lesions of proximal stomach – Dysphagia
 Diffuse infiltrative lesions produce early
satiety
 Gastric outlet obstruction
 Trousseau sign
 Blumer’s Shelf
 Virchow’s node (Troisier’s sign)
 Irish node
 Sister Mary Joseph Nodule

52.  Adjacent organ invasion
 Hematogenous spread
 Peritoneal Seeding:
Krukenberg tumor
Blumer Shelf
 Lymphatic spread:
Virchow’s node (Troisier’s sign)
Irish node

53. TNM Staging

55.  N0 : No regional lymph node metastases
 N1 : 1to 6 regional lymph node metastases
 N2 : 7 to 15 regional lymph node metastases
 N3 : More than 15 regional lymph node
metastases

56.  Involving Lymph node stations 12 onwards
 Omental deposits
 Positive peritoneal cytology

58. Prognostic Factors

59.  Age
 Sex
 Primary tumor Site
 Lauren Classification
 Number of Positive and Negative lymph nodes
 Depth of invasion

61. Disease specific survival

63. To Be
Continued….