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An Overview of Gastric Cancer
Transcript of An Overview of Gastric Cancer
Treatment The Plan Anatomy
Risk Factors Background Arteries and Lymph Nodes Anatomy Types of
Gastric Cancer Diagnosis Most patients with gastric cancer in the US are symptomatic on presentation, and have advanced incurable disease. Symptoms Physical Exam Basic Anatomy Venous
Drainage Epidemiology Incidence rate: 7.9 per 100,000 per year.
Twice as common in men as women.
Twice as common in blacks as whites.
Higher prevalence in Latin America, Northern Europe, and East Asia.
Median age of Diagnosis is 70 yo. Risk Factors Atrophic Gastritis H. Pylori Genetics Loss of parietal glands reduces the stomach's ability to produce acid, and leads to inflammation.
Causes include H. Pylori infection, Autoantibodies, and Surgical Resection of the Antrum.
9% of people with A.G. will get stomach cancer. H. Pylori-infected people are 8 times more likely to develop Gastric Cancer.
Induces a host-inflammatory response within the mucosa.
Can lead to Atrophic Gastritis, and is linked to Gastric MALT Lymphomas.
Most frequently affects the Antrum. Mutations in CDH1, a gene that encodes E-Cadherin, are present in 1/3 of familial cancer syndromes, and have a 70% chance of causing cancer.
Mutations in growth factors c-met and K-sam are over-expressed in linitis plastica.
Mutations to the tumor suppressor gene p53 are present in 64% of gastric cancers. Intestinal Linitis Plastica.
More common in women and people under 50.
Strongly associated with H. Pylori and CDH1 Gene mutations. Results from an inflammatory process. Gastritis Metaplasia Dysplasia Most common in elderly men. Diffuse V.S. By Cell Type Adenocarcinoma Sarcoma Lymphoma Cardia Antrum Body Arise from the gastric epithelium.
90% of all gastric cancers. > > 31% 26% 14% Can be ulcerative, polypoid, or linitis plastica.
Most common types are well-differentiated tubular and poorly differentiated signet-ring carcinoma. Symptoms
Genetic Screening Genetic Screening Endoscopy Imaging Weight Loss
Hematemesis Abdominal Mass
Gastric Distension Signs of Metastasis Virchow's Node
Sister Mary Joseph Node
Acanthosis Nigricans Contrast Studies CT Ultrasonography High Specificity (up to 85%), Low Sensitivity (down to 14%)
Preferred for suspected diffuse cancer, as linitis plastica is more obvious on a barium study than on endoscopy. Useful for identifying and staging metastasis.
Can visualize cancer size, shape and location.
Not tissue specific, so not useful for grading or typing. Abdominal U/S
Useful for evaluating possible Metastasis, primarily liver.
More accurate than CT for Tumor and Node staging (77-93% and 65-90% respetively). Most specific and sensitive means for diagnosis.
More than 90% of gastric cancers are found using endoscopy and biopsy.
Biopsies of benign-looking growths and ulcers can locate early cancers.
Linitis Plastica is difficult to diagnose endoscopically because it can infiltrate the submucosa and muscularis propria. Screening for CDH1 mutations is recommended for family members of young patients with diffuse-type cancer, whether or not they are symptomatic.
If a mutation is found, consider prophylactic gastrectomy.
Women with a CDH1 mutation have a ~45% risk of lobular breast cancer, and should be screened accordingly. Evaluation Staging
Resectability Staging Prognosis Resectability 1) Boorman evaluates Macroscopic Appearance.
2) Lauren differentiates between Diffuse and Intestinal.
3) TNM evaluates Depth of Infiltration. Tumor Classification Systems: TNM Staging T - Depth of tumor invasion through local tissues.
N - Metastatic Nodal Involvement.
M - Distant metastasis. TNM Staging is most important tool for developing a prognosis.
Most patients are diagnosed at Stages III and IV.
With no nodal involvement 5yr survival is ~62.3%.
With distant metastasis disease, 5yr survival is ~3.7%.
Worse prognoses are associated with disease in the cardia, rapid onset of symptoms prior to diagnosis, unresectability, and poor differentiation. Unresectable if there are distant metastases, or a major vascular compromise.
Locoregional lymph node metastases do not exclude the possibility of resection. Treatment Surgery
Palliation Surgery Chemotherapy Endoscopic Palliation References Type of resection is determined by location, size/extent, and histology. Total vs. Subtotal Gastrectomy Lymphadenectomy Roux-en-Y Esophagojejunostomy Roux-en-Y Gastrojejunostomy Billroth II Radiation Meta-analyses show a survival benefit for adjuvant chemo following total resection.
Common protocols in Japan and Europe include 1yr of post-op treatment with S-1 , or pre- and post- operative treatment with ECF, per the MAGIC trial. Adjuvant and Neoadjuvant Therapies For Locally Unresectable but Not Metastatic Disease Data from initial uncontrolled studies show up to 70% of initially unresectable patients becoming eligible for resection, and pathologically complete cure rates of up to 30%. No randomized control trials have been completed. Multiple uncontrolled studies report that some cancers can respond well enough to become resectable, but that pathalogically complete cure rates are as low as 5-15%. For Metastatic Disease Despite many trials, there is not a clearly preferred regimen. Survival time increases by ~5-12months. Multi-drug therapy does seem to have a slightly increased survival advantage over monotherapy, of 1.5 months. Chemoradiation for Initially Unresectable
Non-Metastatic Disease Adjuvant Chemoradiation is the standard of care in US, per American Intergroup Trial INT0116.
This study also shows improvement in overall survival rate, in node-positive disease, as compared to surgery alone (68% vs 44%). Dilation with a balloon or expanding stent to remove outlet obstruction.
Resection of polyps or tumor.
Electrocautery to stop bleeding.
Thermal photodestruction with infrared laser. Node Staging N1 - 1-6 (+) Nodes
N2 - 7-15 (+) Nodes
N3 - More than 15 (+) Nodes Bendell,Johanna, MD, Yoon, Harry, MD, MHS, Fidias, Panos, MD. Chemotherapy for locally advanced unresectable and metastatic esophageal and gastric cancer. In: UpToDate. Goldberg, Richard, MD, UpToDate, UpToDate, Waltham, MA, 2012.
Mansfield, Paul F. MD, FACS. Clinical features, diagnosis, and staging of gastric cancer. In: UpToDate, Tanabe, Kenneth, MD.
Johns Hopkins Medicine Gastroenterology and Hepatology. Gastric Cancer. Internet, (10/2012). <http://www.hopkins-gi.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Cat_ID=024CC2E1-2AEB-4D50-9E02-C79825C9F9BF&GDL_Disease_ID=DB2F8EAC-4421-41DD-B04E-684AFEF2AD94>.
Kaurah, Pardeep, MSc, CCGC, Huntsman, David, MD. Hereditary Diffuse Gastric Cancer. Internet (10/12). <http://www.ncbi.nlm.nih.gov/books/NBK1139/>.
American Cancer Society. Stomach Cancer. Internet, (10/2012) <http://www.cancer.org/acs/groups/cid/documents/webcontent/003141-pdf.pdf>.
Surveillnce Epidemiology and End results. SEER Stat Facts: Stomach. National Cancer Society. In: Internet, (10/2012). <http://seer.cancer.gov/statfacts/html/stomach.html>