GASTRIC MASS

GROUP-6

GANTA, KUNDAN CHOWDARY

GAUTAMI THAMBIRAJ
HARIKRISHNAN, MANIKANDAN
HARIKRISHNAN, SINDHUJA
JINSFIN METILDA ASHOK
JOHN ALEXANDER, POULINE ROMILA
KAMAR DHEEN, MUHAMMUD IMRAAN
KAMBLE, PRATIBHA SHRIPATI
MALIKCK, NIZAMDEEN
MICHAEL, SANTHOSH
OUTLINE
• CASE
• GASTRIC MASS
• EPIDEMIOLOGY
• ETIOLOGY AND RISK FACTORS
• CLINICAL MANIFESTATIONS
• APPROACH
• DIAGNOSTICS AND WORK UPS
• STAGING
• MANAGEMENT
CASE
62/Female came in to the ER due to 3 months hx of abdominal discomfort associated
with
(+) Abd. pain : LUQ, sharp, continuous, PS 3-4/10
(+) Nausea
(+)Early satiety
(+)Bloatedness
(+)Weight loss: 5pounds/month
PAST MEDICAL : (-)Hypertension, (-)Diabetes, (-)Asthma, (-)PUD,
(-)Hospitalization/ Surgeries

FAMILY MEDICAL: (+) Hypertension-paternal

(+) Diabetes-maternal
(-)Cancer
PERSONAL-SOCIAL: Occupation-Housewife
(-) Smoking
(+) Alcoholic -1-2 beers/month
Diet- 3x/day regular filipino diet

OB/GYNE : G2P2(2002)
Menopause-43 y/o
 REVIEW OF SYSTEM

(-) vomiting
(-) heartburn
(-) change in bowel habits
(-) anorexia
(-) melena
PHYSICAL EXAM:

Awake, Alert, NIRD, GCS15 with vital signs

vitals BP : 130/90mmHg
HR : 71 bpm
RR : 20 cpm
T : 35.6
ABDOMEN:-
I: Flabby, non-distended, no scars/lesions
A:Normoactive
P:Tympanitic
P:Soft, tenderness at LUQ
Admiting Impression:

T/C Gastric Mass probably sec. to Malignancy

MALIGNANT NEOPLASMS OF THE STOMACH

Malignant GIST (1%)

Lymphoma (4%),

Adenocarcinoma (95%)
ETIOLOGY
Gastric cancer is more common in patients with
1) Pernicious anemia
2) Blood group A
3) Family history of gastric cancer.
The commonly accepted risk factors for
gastric cancer
ADENOCARCINOMA The infectious and
Normal inflammatory causes result
Diet Low in Vit C,E and in immune cell infiltration
H.pylori
High Salt diet(pickled foods) and cytokine production
which damage mucosal
Chronic Superficial Gastritis cells.

Atrophic Gastritis

Intestinal Metaplasia

Dysplasia

Cancer
 Normal
Diet Low in Vit C,E and
H.pylori
High Salt diet(pickled foods)
Chronic Superficial Gastritis

Atrophic Gastritis

Intestinal Metaplasia

Dysplasia

Early gastric cancer Cancer 10% of patients - lymph node

Limited to the mucosa metastases.
and submucosa of the
stomach, regardless of
lymph node status.

The overall cure rate with adequate

gastric resection and
lymphadenectomy is 95%.
PATHOLOGIC TYPES OF EARLY GASTRIC CANCER

Type 0-I (protruding) * Polypoid tumors – Non ulcerative

Intraluminal
Type 0-II (superficial) Tumors with or without minimal
elevation or depression relative to
the surrounding mucosa.
Type 0-IIa Slightly elevated tumors.
(superficial elevated)
Type 0-IIb Tumors without elevation or
depression. (superficial flat)
Type 0-IIc Slightly depressed tumors.
(superficial depressed)
Type 0-III (excavated) Tumors with deep depression

*Tumors with less than 3-mm elevation are usually classified

as –IIa, with more elevated tumors being classified as 0-I.
GROSS MORPHOLOGY AND HISTOLOGIC SUBTYPES :

Four gross forms of gastric cancer:

1. Polypoid,
2. Fungating,
3. Ulcerative, and
4. Scirrhous.
POLYPOID - Not ulcerated Intraluminally
FUNGATING - Elevated and Ulcerated
Ulcerative - Self descriptive.
Scirrhous tumors - infiltrate the entire
thickness of the stomach Wall of the
and cover a very large stomach
surface area.
- poor prognosis
CLINICAL MANIFESTATIONS

• The most common symptoms - weight loss and decreased food

intake due to anorexia and early satiety.

• Abdominal pain also is common.

• Other symptoms include nausea, vomiting, and bloating.

• Acute GI bleeding is somewhat unusual (5%)

• Dysphagia - if cardia is involved

 Although none of the above mentioned
symptoms alone is specific for gastric disease,
when elicited in the context of a careful history
and physical examination, they point to a
differential diagnosis, which can be refined with
certain tests.

Mostly at the time of diagnosis – stage 3 or 4

Diagnostics and work-ups
Esophago-gastro-duodeno-scopy (EGD)
EGD – gold standard for the diagnosis of gastric malignancy

Upper GI endoscopy - Early endoscopy should be considered

in patients presenting with recent onset of alarm symptoms
(weight loss, anemia, dysphagia, vomiting) particularly those
over 55 years of age.

Biopsy specimen can also be obtained through endoscopy

Submucosal masses are commonly discovered during
routine EGD.

If the suspicion of cancer is high and the biopsy is negative ,

the patient should be reendoscoped and more aggressively
biopsied

Magnifying endoscopy with narrow band imaging (NBI) has

been reported to be accurate and reliable in the diagnosis
of early gastric cancer
Barium upper GI study
Double contrast upper GI series may be better than
EGD in elucidating gastric diverticula, fistula , stricture ,
size or morphology of hiatal hernia and tortuosity
In some patients with gastric tumors, upper GI series
can be helpful in planning treatment

Although a good double contrast barium upper GI

examination is sensitive for gastric tumors up to 75%
CT and MRI
Acts as a routine staging workup for malignant
gastric tumor patients rather than as a primary
workup choice
Preoperative staging of gastric cancer is best
accomplished with abdominal/pelvic CT
scanning with IV and oral contrast
MRI is probably comparable
Endoscopic ultrasound (EUS)is
EUS is the best way to clinically stage
adenocarcinoma locoregionally, which gives fairly
accurate (80%) information about the depth of the
tumor penetration into the gastric wall and can
usually show enlarged (>5mm) perigastric and
celiac lymphnodes
 Useful in the evaluation and management of
gastric mass Lesions

EUS is more accurate in distinguishing early

gastric cancer (T1) from more advanced tumors.

Suspicious nodes can be sampled with EUS-

guided endoscopic needle biopsy.
 Malignant tumors that are confined to the mucosa on
EUS may be amenable to endoscopic mucosal resection
(EMR).

EUS also can be used to plan for preoperative

(neoadjuvant) chemo radiation therapy and to assess
tumor response to chemotherapy
There are endoscopic characteristics of benign
and malignant mesenchymal tumors, and thus,
EUS can provide reassurance, but no guarantee,
that small lesions under observation are
probably benign. Thus, EUS-guided needle
biopsy should be considered.
Limitations
Highly operator dependent and may
underestimate lymph node involvement
because normal sized nodes (<5mm) can also
harbor metastases.
Positron emission tomography (PET)
scan or CT/PET scan
It is most useful in the evaluation of distant
metastasis in gastric cancer, but it can also be useful
in locoregional staging of certain patients with
gastric malignancy.
PET scan is accurate when combined with
spiral CT (PET-CT)155 and should be considered
before major surgery in patients with particularly
high-risk or locally advanced tumors.
Staging Laparoscopy and Peritoneal
Cytology
Laparoscopy has emerged as a valuable
adjunct to gastric cancer staging, particularly in
patients with more substantial tumors.
This modality allows for rapid identification
of macrosopic peritoneal metastases.
 Peritoneal lavage identifies an additional subset
of patients with microscopic dissemination.

Gastrectomy should be deferred in patients with

positive peritoneal cytology without obvious
peritoneal metastases.
 Patients with gastric cancer who undergo R0
resection (i.e., no gross residual disease) and are
found to have positive peritoneal cytology (no
gross carcinomatosis) have a much poorer
prognosis than those with negative cytology
(median survival 14.8 months vs. 98.5 months).
 Stand-alone laparoscopy may influence
management in up to 36% of cases and is
increasingly advocated to allow appropriate initial
treatment selection.
The yield is likely highest in patients with T3
or T4 tumors, proximal tumors, or evidence of
regional nodal involvement; such patients may
benefit from neoadjuvant therapy and laparoscopy
should be offered prior to initiation of treatment.
Systemic therapy is the cornerstone of therapy
for patients with Stage IV disease and surgery
is generally reserved for palliation of
symptoms (e.g., an obstructing distal tumor) in
patients with metastases identified during
laparoscopy.
 Cancer

The overall cure rate with

adequate gastric resection and
lymphadenectomy is 95%.

Some gastric tumors, particularly More than 15

the diffuse variety. resected lymph
Extend well beyond the tumor nodes are
mass; thus, gross margins beyond required for
5 cm may be desirable. adequate staging.