Tiêu đề 14. Gastric Cancer.pdf ✅

Gastric Cancer ABU SAMN & MEERA General - Very bad prognosis. - MC site: distal third, near the antrum. - RFs: • Male. → But females have a worst type. • Age: 60-70s. • Japanese. • Blood group A. • Nitrosamine. • Diet: high salt, smoked fish, preserved food, low vegetables and fruits, low vitamin A and C. • Smoking, obesity, alcohol. • H.pylori. → Induces proliferation of lymphoid tissue→ gastric lymphoma. ➢ Diagnosed by endoscopy with biopsy. → Non-cardia gastric cancer. • Premalignant lesion: → Chronic atrophic gastritis: non-cardia gastric cancer. → Previous gastric surgery: ➢ Billroth 1: partial gastrectomy in which the stomach is anastomosed to the duodenum. ➢ Billroth 2: partial gastrectomy in which the stomach is anastomosed to the jejunum. → Pernicious anemia. → Gastric adenomatous polyps. • Familial gastric cancer (10%). - Blood supply to the stomach: • Right and left gastric arteries. • Right and left gastroepiploic arteries. • Short gastric arteries. Classification - According to histology: • Adenocarcinoma: MC 95%. → Everything in this lecture is about this type (even other classifications). → Remember: All the GIT is lined by columnar epithelium except upper esophagus and anal area. → Further classified into: 1. Tubular: MC. 2. Papillary. 3. Mucinous: bad prognosis. 4. Poorly cohesive: bad prognosis. • Non-adenocarcinoma. - According to histology, Lauren classification: • Intestinal: MC → Well differentiated→ good prognosis. → Seen in people with RFs: Japanese old male. → Environmental factors (e.g. diet) play a role. → H.pylori, chronic gastritis. → Blood-borne mets: liver then lung. • Diffuse: → Poor differentiated→ bad prognosis. → Sporadic, more common in young females. ➢ All types of gastric cancer are more common in males except the diffuse one. → More in low frequency population. → Genetic factors: inherited gastric cancer syndrome. → Lymphatic and intraperitoneal invasion.
Gastric Cancer ABU SAMN & MEERA According to course: • Early: Japanese macroscopic classification. → Limited to mucosa and submucosa. → Grossly: ➢ Type I: protruded ➢ Type II: superficial (IIa: elevated, IIb: flat, IIc: depressed). ➢ Type III: excavated. • Advanced: Bormann classification. → Extends to muscularis propria and serosa. → Endoscopic microscopic appearance: ➢ Type I: Polypoid. ➢ Type II: Fungating. ➢ Type III: Ulcerating. ➢ Type IV: Infiltrating. - According to anatomy: Siewert classification. • Type I: cardia. → In the lower esophagus, 5 cm above the gastroesophageal junction. • Type II: cardia. → In the cardia, 1 cm above and 2 cm below the gastroesophageal junction. • Type III: non-cardia. → Subcardial, 2-5 cm below the gastroesophageal junction. Clinical Presentation - Constitutional symptoms. - Epigastric pain: 70%. • Constant, not relieved by food, no radiation. - Dysphagia. - Gastric outlet obstruction. • Projectile vomiting, early satiety. - GI bleeding. - 3 As: blood group A, anemia, asthenia. - Advanced gastric cancer: • Metastasize symptoms according to site. → Liver (MC)→ jaundice, hepatomegaly. → Left supraclavicular LN→ Virchow’s LN/ Troisier's sign. → Pouch of Douglas→ Blumer shelf (palpable mass on DRE). → Periumbilical LN→ Sister Mary Joseph node. → Ovary→ Krukenberg tumor. Diagnosis - CBC: anemia. - Endoscopy: GOLD STANDARD. • When taking a biopsy, take 4-quadrants or brush cytology. Don’t take the biopsy from the necrotic center. - CT CAP: for mets. Staging - After diagnosis with gastric cancer, the next step is: staging. - “T” isn’t related to the size of tumor. Virchow’s LN Sister Mary Joseph node.
Gastric Cancer ABU SAMN & MEERA Treatment - Early stages: • Surgery: curative. → Along with radical lymphadenectomy and reconstructive procedures, followed by adjuvant chemotherapy. → Reconstructive procedures: Roux-en-Y, Billroth I/II. → If upper-third cancer: total gastrectomy with Roux- en-Y. → If middle and distal-third cancer: subtotal gastrectomy with Billroth I/II procedure. - Late stages: palliative. → 5-year survival rate is <5%. GIST tumor/ Leiomyoma - Intermediate malignant. - Mutation in c-kit gene. - High malignancy risk if: > 5cm, mitotic figure >5/HPF. - Spreads hematogenous. - Tx: imatinib, surgery. • Radioresistant. ْل َر ِِّب ا ْر َح ْم ُه َما َك َما َربَّيَانِي َصِغي ًرا ( ) َوقُ