INVESTIGATIONS, STAGING $ Rx of CARCINOMA STOMACH

INVESTIGATIONS
DIAGNOSTIC
OGD SCOPY RADIOLOGICAL ULTRASOUND, EUS/LUS CECT, PET

 METASTATIC WORKUP
Chest X-ray Bone scan CT brain PET scan Laparoscopy Tumor markers- CEA, Carbohydrate antigen

GENERAL WORKUP
CBC & ESR LFT SE

Radiologic diagnosis
Distal GC

Proximal GC

Linitis plastica

EUS

CT SCAN

STAGING
Early gastric cancer Advanced gastric cancer Lauren classification- intestinal and diffuse type Borrmann classification TNM staging

Early gastric cancer

Limited in the mucosa and submucosa layers, no matter with or without lymph node metastasis

Classified by the Japanese Society for Gastric Cancer

Morphology---early stage

Morphology---early stage

Morphology---early stage

Advanced gastric cancer

Invaded over submucosa According to Bormann classification

Morphology ---advanced stage

TNM CLASSIFICATION

T stage
T1-Mucosa and submucosa T2-Muscularis propria or subserosa T3-Serosa T4-Adjacent organs

N-Regional lymph nodes

N0- No regional lymph node mets N1- Metastasis in 1-6 regional nodes N2- Metastasis in 7-15 regional nodes N3- Metastasis in >15 regional nodes

M0- No distant metastasis M1- Distant metastasis(includes peritoneum and distant nodes)

TNM CLASSIFICATION (UICC)

N0 T1 T2 T3 T4 H1,P1,CY1, M1 IA IB II IIIA N1 IB II IIIA IIIB N2 II IIIA IIIB N3

IV

Ca stomach treatment

Ca stomach treatment
Adequate surgical resection is the only cure. Complete removal of gastric carcinoma with preferrably 5-6cm margin from the gross edge of the tumour.[5cm proximal and 2cm distal clearance]

 Extent of gastrectomy is site dependent Distal 1/3rd Distal subtotal gastrectomy Middle 1/3rd Total gastrectomy Proximal 1/3rd Oesophago gastrectomy

 Diffuse type Total gastrectomy Early gastric carcinoma involving mucosa only
Endoscopic submucosal resection laproscopic wedge resection.

Lymph node Resection

Important prognostic factor D1 all group 1[N1]nodes removed D2 all group 1[N1] and 2[N2]nodes removed D3 all group 1,2and 3[N1,N2,N3] nodes removed D4 all group 1,2,3 and para aortic nodes removed

JRSGC nodal stations

1. 2. 3. 4. 5. 6. 7. 8. 9. Right cardiac Left cardiac Lesser curvature Greater curvature Suprapyloric Infra pyloric Along left gastric art Common hept artry Celiac 10. Splenic hilar 11. Splenic artery 12. Hepatic pedicle 13. Retro pancreatic 14. Mesenteric root 15. Middle colic artery 16. paraaortic

N1 - 1 to 6 perigastric nodes N2 7 to 11 along named vessels N3 - 12 to 14 intraperitoneal nodes N4- 15 to 16

D2 Gastrectomy
Structures removed
1. 2. 3. 4. 5. 6. 7. Stomach with the growth Omental bursa Entire greater omentum Lesser omentum Anterior layer of mesocolon Anterior pancreatic capsule Lymphadenactomy upto D2 station

Preoperative preparations
1. 2. 3. 4. 5. 6. 7. 8. Correction of anaemia Correction of nutritional status Fluid and electrolyte Assessment of cardiac, respiratory and renal status Arrange adequate blood Preoperative stomach wash Nil per oral Prophylactic antibiotics

Total gastrectomy
Stomach is removed en bloc including the tissues of entire greater omentum and lesser omentum Incision:
Long upper midline incision bilateral subcostal incision

 careful examination for the extent of disease is performed assessing whether the disease is curable Transverse colon is completely seperated from greater omentum Subpyloric nodes are dessected and frst part of duodenum is divided Dessection of Hepatic nodes,supra pyloric nodes,left gastric artery,nodes at superiour aspect of pancreas and splenic hilum Seperation of stomach from spleen Division of oesophagus

Reconstruction
Oesophagojejunostomy Roux en Y Subtotal gastrectomy - Bilroth II, or Roux-en-Y gastrojejunostomy

Complications Early
1. 2. 3. 4. 5. Leakage of oesophagojejunostomy Duodenal stump leakage Biliary peritonitis Sepsis Haemorrhage

Late
Due to resection
1. Reduced Capacity 2. Dumping syndrome 3. Vit B12 Deficiency

Due to anastomosis
1. Loop obstruction 2. Alkaline Reflex Gastritis 3. Carcinoma of stump

Other Rx modalities
Radiotherapy Use is controversial. No. of radiosensitive tissue in the region of gastric bed limits the dose that can be given. Palliative treatment of painful bony mets.

Chemotherapy
Response well to combination cytotoxic chemotherapy. Neoadjuvant therapy improves outcomes. Combination of Epirubicin, Cisplatin and 5-FU or Capecitabine. Inoperable Cisplatin replaced by Oxyplatinin. 2nd line Rx Taxoterene combination

Outlook after surgery

5 year survival rate Japan 50-70% West 20-30% Difference in staging and higher standard of surgery. Stage migration : More thorough the staging, higher the stage is likely to be and therefore stage for stage outcome is better who are adequately staged pathologically.

Relapse
Most common site Gastric Bed Inadequate removal of primary tumour. Self Expansible Metal Stents

Signs of inoperability 1. Haematological mets

2. 3. 4. 5. Metastatic liver Pleural effusion Ascites Supraclavicular lymph node [Virchows node/ Troisiers sign] 6. Irish nodules [enlarged left axillary nodes]

7. Presence of Blumers shelf [Peritoneal mets in rectovesical / rectouterine pouch] 8. Presence of cutaneous nodules in umbilicus. [Sister Mary Joseph nodules] 9. Krukenberg tumour 10. N4 nodal status 11. Fixation to structures that cannot be removed.

Mx of inoperable cases
Chemotherapy Palliative surgery
Severe symptoms - Obstructions, bleeding, perforations

Palliative gastrectomy
Remove the tumour and reconstruct GIT. Need not be radical.

 Anterior Gastrojejunostomy with Roux loop Divines exclusion procedure instead of removal of tumour, it is excluded with Bilroth II anastomoses. Inoperable tumours in cardia
Palliative intubation Stenting Other recanalisation

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