1. health and fitness
2. disease
3. cancer

.
Benign tumours: Rare
(1)Adenoma:
In the antrum
Sessile or pedunculated
Malignant change is rare.
Treatment: Excision
Small : endoscopic
Big: by surgery
(2)Fibroma, lipoma and leiomyoma:
Grow to outside
Mucosa may be stretched over the tumour and
may ulcerate.
Incidence: Most countries (20/100.000)
> In Japan (100/100,000)
Age: Above 50
Commonest between 70-80ys.
In Japan, Iran, South Africa it occurs at
younger age.
Sex: Male/Female = 2 : 1
Etiology: No definite etiological factor
1- Adenomatous polyps.
2- Pernicious anemia: Incidence of carcinoma is
3 times > normal individuals.
3- Chronic gastritis: atrophic gastritis, gastritis
following gastric operations
4- Chronic gastric ulcer.
5- Achlorhydria, especially when associated with
protein malnutrition, viral infection and
hypogammaglobulinemia.
6- Alcoholism.
7- Blood group A is more in cancer stomach
patients.
60% occur in the pyloric antrum
25% in the body
10% in fundus
5% diffuse in stomach
Recently there is an increase in the incidence of
carcinoma affecting the upper third of the stomach and
Macroscopic
cardia.
types
Gastric cancer is classified into two types:
A. Early gastric cancer: Mucosa or submucosa is
infiltrated.
Diagnosed in screening programs by endoscopy .
Early gastric cancer may be protruding, superficial, or
excavating (penetrating).
HISTOLOGY
AND
LOCAL INVASION
OF
GASTRIC CANCER
SITES OF
GASTRIC
CANCER
B. Advanced gastric cancer: Common and
diagnosed clinically. It may take the form of:
1) A fungating cauliflower-like mass.
2) An ulcer with raised indurated edges
and usually surrounded by smaller ulcers.
3) Colloid carcinoma. All layers of the
stomach are infiltrated by areolar tissue
containing transparent gelatinous
substance.
FUNGATING
CAULIFLOWER
GASTRIC
CANCER
GASTROSCOPY
MALIGNANT
ULCER TYPE
OF CANCER
STOMACH
PATHOLOGY
SPECIMEN
4) The diffusely infiltrating variety
Linitis plastica in which the wall of
the stomach is markedly thickened
and indurated and the lumen is
markedly reduced this may occur only in
the antrum or may affect the stomach
diffusely. The mucous membrane
is intact and the lesion may be missed
by endoscopy.
LINITIS PLASTICA
DIFFUSE
ADENOCARCINOMA
CANCER STOMACH
PATHOLOGICAL
SPECIMEN
Unfortunately,
All cases fall into the
category of late cancer due to absence
of Screening programs and the cases
are diagnosed when become clinically
evident at late stage.
Microscopically





Stomach cancer is adenocarcinoma in
95% with various grades of differentiation
The less the differentiation the worse the
prognosis.
Both colloid carcinoma and Linitis plastica carry a
bad prognosis.
In linitis plastica, it is difficult to find malignant
cells under the microscope.
Rarely, stomach cancer is squmaous cell carcinoma
as a spread of oesophageal cancer to the cardia
HISTOPATHOLOGY
OF
ADENOCARCINOMA
(UP)
DIFFUSE
ADENOCARCINOMA
LINITIS PLASTICA
(DOWN)
COLLOIDAL
SIGNET RING
ADENOCARCINOMA
N.B: Lauren's classification:
Lauren classified cancer stomach into 2 groups
1) Group I (80%): (Intestinal gastric cancer):
cancer in this group developed from gastric
epithelium which has undergone intestinal
metaplasia and the cells resemble the cells of
small intestine ( have brush borders). The
growth appearance of this group includes
Fungating or polypoidal mass (40%), more in
body & fundus
or Malignant ulcer type (40%), more in pylorus
2) Group II (20%):
diffuse gastric carcinoma
or
infiltrative type.
Usually in pylorus.
Spread
1. Direct spread is infiltration of the wall of the
stomach in depth, in circumference, and in
length. The last is important because the
spread occurs for some length beyond the
edge of the tumour, a point to remember when
planning a radical operation. After the gastric
wall has been transgressed carcinoma will
infiltrate any neighbouring structure as the
liver, spleen, pancreas or colon.
DIRECT SPREAD
INTO GASTRIC WALL
AND
ADJACENT ORGANS
WITH
T STAGING
2. Lymphatic spread occurs both by
permeation and by embolization. It first
occurs to perigastric lymph nodes then to
more centrally placed groups. Good
knowledge of the lymphatic drainage of
the stomach is important in planning
radical surgery.
3. Blood spread occurs mainly to the liver
and very rarely beyond it to bones.
4. Transcoelomic spread occurs to the
ovaries in young females
(ovaries are not yet atrophic).
These ovarian secondaries are known as
Krukenberg's tumours. Metastases to the
Douglas Pouch lead to what is known as
Blumer's shelf.
Usually diagnosed at a late stage because of the
vague and mild symptoms, patients present late,
Also, late diagnosis by the clinician.
A high index of suspicion is needed for its
detection at an earlier stage.
Most of cases are discovered late due to absence
of a massive screening program.
Patients with carcinoma of the stomach may fall
into one or more of 5 groups:
1. Dyspepsia group.
A person above 40 years who begins to
complain of dyspepsia should be fully
investigated for the possibility of stomach
cancer. The patient has anorexia and vague
sense of discomfort after meals. Epigastric
pain may occur and in late cases and may be
severe. Nausea and early satiety is common.
A particular dislike to meat is often described
but is only rarely seen.
2. Insidious group (Anorexia, Asthenia, Anemia).
Restlessness, easy fatigue and unexplained
weight loss. Patient is found to be anemic.
Anemia in the elderly should always raise the
possibility of malignancy̦ the stomach being one of
the commonest to cause it.
Unfortunately, these symptoms may pass
unnoticed, and the disease is discovered late.
3. Mass group. An epigastric mass.
About 30% of patients presenting with
mass will be found to have inoperable
carcinoma on exploration.
4. Obstructive group. Carcinoma at one end of
the stomach causes obstructive symptoms
and will and will present earlier than the more
common variety occurring in the antrum or body.
At the cardia it will lead to dysphagia while at
the pylorus it causes vomiting (see pyloric
stenosis).
5. Metastatic group. A hard irregular liver due
to secondaries, jaundice, malignant
ascites, or an enlarged left supraclavicular
lymph node "Troisier's sign", all of which
are signs of inoperability.
Hematemesis and melena are
uncommon while perforation is still rare.
A patient known to have a gastric peptic
ulcer who becomes refractory to treatment
should be viewed with suspicion.
1. Blood picture. may reveal micro or macrocytic
anaemia.
2. Barium meal. 75% accuracy. It is the most
accurate for pyloric growths. It is important to
obtain a mucosal relief pattern before filling
the stomach with barium. Small growth may
overlocked if this is omitted. A barium study
with views taken in the Trendlenburg's position
to detect growths in the fundus and cardia.

If the lesion is of the cauliflower like
variety, it will appear as a persistent
irregular filling defect.

If it is a malignant ulcer it will appear as
an ulcer niche outside the ulcer bearing
area.

If the lesion is linitis plastica there will
be marked narrowing of the lumen of the
stomach but the flow of barium is not
interrupted .
BARIUM MEAL
IN CANCER
STOMACH
(UP)
CAULIFLOWER
FUNGATIN
(DOWN)
DIFFUSE
LINITIS PLASTICA
3. Endoscopy
It directly view the tumor and multiple biopsies
should be taken.
Endoscopy can detect tumours at an earlier
stage than can radiology.
4. An abdominal US is essential for the detection of
liver metastases.
Its role in assessing lymph node involvement is
less important.
ENDOSONOGRAPY FOR EVALUATION OF LOCAL
SPREAD
GASTROSCOPY
FOR
CANCER STOMACH
(UP)
ULCER TYPE
(DOWN)
DIFFUSE
LINITIS PLASTICA
TYPE
ENDOSONOGRAPHY
FOR
CANCER STOMACH
5. CT scan is more accurate for the detection of
lymph node involvement than a US and may
be helpful in pre-operative staging of the
disease
6. Estimation of CEA antigen has a better value
for prognosis rather than diagnosis.
CT FOR
PREOPERATIVE
EVALUATION
&
STAGING OF
CANCER
STOMACH
Early cases. The aim of treatment is cure.
A radical operation has to be performed.
This entails removal of the tumour with an
adequate safety margin above it of at least
5 cm and 1.5 cm of the duodenum below
it, together with both omenta.
SURGERY
FOR GASTRIC
CANCER
All the draining lymph nodes must be
removed
ligation and division of the vessels
around which they are located,
the left gastric,
the right gastric,
the two epiploics.
and
REMOVAL
OF DRAINAING
LYMPH NODES
According to the site of the neoplasm, the extent of
resection will be determined:
(a)For tumours of the lower third of the stomach, a
lower radical partial gastrectomy is performed
with anastomosis of the remaining upper stomach
to the jejunum. This anastomosis is called
( Billroth II or Polia) gastrectomy.
(b) For tumours of the middle third of the stomach a
total radical gastrectomy is performed and the
oesophagus is anastomosed to a Roux-en-Y loop
of jejunum .
(c) Tumours of the upper third are treated by
oesophagogastrectomy through a thoraco abdominal incision to guarantee an upper safety
margin. The upper oesophagus is anastomosed
to a Roux-en-Y loop of jejunum.
1. Palliative gastrectomy. If it can be
performed, gastrectomy offers the best
chance of palliation.
2. For irremovable tumours in the pyloric
region an anterior gastrojejunostomy is
performed ( Devine gastric exclusion)
3. For irresectable lesions in the upper
stomach, an oesophagojejuostomy can
be performed.
4. Radiotherapy and chemotherapy. These
are used in the inoperable, non
resectable, incompletely resected or
recurrent cases.
Prognosis is very bad.
The 5 years survival rate is very low and the
only hope of cure depends upon early
diagnosis and treatment. Carcinoma arising
on the top of a pre-existing peptic ulcer
carries the best prognosis as the associated
chronic inflammation obstructs the lymphatic
retards the spread.
Sarcomas of the Stomach (3%):
Sarcoma of the stomach is a rare tumour and
it may be in the form of a Liomyosarcoma,
lymphosarcoma or Hodgkin's sarcoma.
Sometimes resection gives better results
than for carcinoma; more-over irradiation may
be of value.
Gastrostomy is indicated for feeding when there is
obstruction above the stomach as in carcinoma of the
cardia, oesophagus, pharynx, and of the oesophagus .In
cases of malignancy of oesophagus , it is usually a
permanent procedure, but in cases of stricture, it is
temporary.
(1) Temporary Gastrostomy:
In which the stoma heals spontaneously after removal
of the gastrostomy tube
GASTROSTOMY
TUBES
Technique of temporary gastrostomy
(Stamm's gastrostomy):
It is usually done under general anesthesia.
Through a left paramedian or transverse
incision. The stomach delivered into the
wound, 3 purse string stitches are taken in
the anterior wall as high as possible and
near the lesser curve away from the tumor.
The stomach is stabbed in the centre of the
inner one, and the stitches are tightened
one after the other to invert part of the
stomach wall around the tube .
PER ENDOSCOPIC GASTROSTOMY (PEG)
is possible sometimes.
PLACEMENT
OF
GASTROSTOMY
TUBE
Along the tube, fluid foods and drugs are
given to the patient. If stomach is found
infiltrated and cannot be delivered into the
wound, jejunostomy is done, as it serves
the same purpose of feeding.
(2) Permanent Gastrostomy :
In which the tract between the skin and
the stomach wall is lined by mucosa , using a
flap from the stomach wall . In this way the
tract will be kept open ( does not heals ) even
after removal of the gastrostomy tube.