0:05 gastric cancer introduction gastric cancer arises from malignant transformation of gastric cells 85% of gastric cancers are gastric edino carcinomas there are other subtypes of gastric cancer that occur more rarely example mucosa Associated lymphoid tissue lymphoma Leos saroma gastrointestinal stromal tumors histologically gastric cancers are defined as either intestinal or diffuse although gastric cancers can occur anywhere in the stomach there are epidemiologic differences between tumors that originate in the cardia and tumors with non-cardia Origins the rates of
0:52 gastric cancer have been declining since the identification and treatment of helicobactor pylori epidem ology the incidence of gastric cancer varies with different geographic regions overall sex is more in males than in females Peak incidence is 70 years the highest incidence rates are in eastern Asia and andian regions of South America and Eastern Europe while the lowest rates are in North America northern Europe and most countries in Africa and Southeastern Asia the there is also substantial difference in the incidence among different ethnic groups within the same region risk factors risk factors
1:38 for development of non-card gastric cancers include long-term ingestion of foods with high concentration nitrates such as dried smoked and salted Foods infection with hpylori atropic gastritis gastro esophagal reflux disease for cancers of gastro esophagal Junction higher incidents in individuals with blood type a lower socioeconomic status and migration from nations with high incidents of gastric cancer including nations in East Asia Eastern Europe and South America the risk of cardog gastric cancer is increased in patients with gastroesophagal reflux disease and those who are
2:24 obese age male sex tobacco use family history sedentary lifestyle and radiation are risk factors for all types of gastric cancer clinical features many patients with early superficial disease are asymptomatic as the disease progresses patients may present with weight loss and persistent abdominal pain are the most common symptoms at initial diagnosis weight loss is present in 62% of the patients abdominal pain in 52 2 nausea 34% dysphasia 26% Melena 20% early satiety
3:10 18% ulcer type pain 177% weight loss usually results from insufficient caloric intake rather than increased catabolism and may be attributable to anorexia nausea abdominal pain early satiety and or dysphasia when patient presents with abdominal pain it tends to be epigastric vague and milder in the early course of the disease but more severe and consistent as the disease progresses dysphasia is a common presenting feature in patients with Cancers arising in the proximal portion of the stomach or at the esophagogastric junction patients may also present with
3:56 nausea or early satiety from the tumor mass or for in cases of an aggressive form of diffused type gastric cancer called Linus plastica from poor distensibility of the stomach they may also present with gastric Outlet obstruction from an advanced distal tumor occult gastric bleeding with or without iron deficiency anemia is not uncommon while avert bleeding that is melena or hematemesis is seen in less than 20% of cases the presence of palpable abdominal mass is the most common physical finding and generally indicates long-standing Advanced disease a pseudo Acasia syndrome may occur as a
4:42 result of involvement in arback plexes due to local extension or malignant obstruction near the gastroesophagal junction for this reason gastric cancer needs to be considered in the differential diagnosis for older patients presenting with easia approximately 25% of patients have a history of gastric ulcer all gastric ulcers should be followed to complete healing and those that did not heal should undergo resection in later stages of gastric cancer clinical manifestations may include hepatomegaly atis verow node left supraclavicular adenopathy located where the thoracic
5:30 duct joins the subclavian vein at the Venus angle Sister Mary Joseph's node umbilical node indicating metastasis from a gastrointestinal or abdominal pelvic malignancy malignant acanthosis nigricans in particular associated with gastric adenocarcinoma pathology most common type is edoc carcinoma and 90% of cases typically localized exophytic lesion with or without alteration arise from glandular cells in the stomach usually located on the Lesser curvature of the stomach signant
6:15 ring cell carcinoma the carcinoma shows pattern of diffused growth multiple signant ring cells is equal to round cells filled with muin with a flat nucleus in the cell peripheral less common is osus carcinoma andus cell carcinoma Lauren classification of gastric edino carcinoma the diffuse and intestinal types of gastric cancer as classified by Lauren describe the two biological entities that are different with regard to epidemiology iology pathogenesis and behavior intestinal type approximately 50% of cases
7:01 intestinal gastric cancer is more common in males and older age groups it is more prevalent in high risk areas and is likely linked to environmental factors features polypoid glandular formation expanding non-infiltrative growth pattern with a queer border diffuse type in 40% of cases approximately the diffuse or infiltrative type is equally frequent in both sexes is more common in younger age groups and has a worse prognosis than the intestinal type features infiltrative growth and diffuse spread in the gastric wall no clear border note
7:48 that the main carcinogenic event in diffused carcinomas is loss of expression of e catarin a key cell surface protein for establishing intercellular connection c s and maintaining the organization of epithelial tissues mix type approximately seen in 10% of cases as the extent of the disease in mixed type carcinomas is often difficult to establish the same treatment principle is used as with diffused type carcinoma diagnostic procedures the two main modalities for gastric cancer screening are upper endoscopy and contrast radiography upper endoscopy is the best
8:34 initial test upper endoscopy allows for direct visualization of gastric mucosa and for biopsies to be obtained for diagnosing precancerous lesions such as gastric atrophy intestinal metaplasia or gastric dysplasia in addition to gastric cancer although it is more invasive and has a higher cost upper endoscop is also more sensitive for diagnosing a variety of gastric lesions as compared with alternative diagnostic strategies contrast radiography double contrast barium radiographs with photo fluorography or digital radiography can identify malignant gastric ulcers infiltrating
9:21 lesions and some early gastric cancers however a false negative barium study can occur in as many many as 50% of cases in early gastric cancer the sensitivity of a barium study may be as low as 14% the one scenario in which a barium study may be superior to Upper endoscopy is in patients with lit as plastica the decreased distensibility of the stiff leather flask appearing stomach is more obvious on the radiographic study and the endoscopic appearance may be relatively normal other tests serum pepsinogen a low serum pepsinogen 1 concentration and a low
10:06 serum pepsinogen 1 or two ratio are suggestive of the presence of atropic gastritis a risk factor for gastric cancer serum pepsinogen testing has therefore been proposed to identify higher risk individuals who could benefit from gastric cancer screening with upper endoscopy serum troil Factor 3 is a small stable protein expressed in the goblet cells of the small and large intestine and in gastric intestinal metaplasia micrornas at least three micr rnas microrna 421 micr RNA 18a and microrna 106a are highly
10:53 expressed in gastric cancers and are detectable in peripheral blood and gastric aspirates serological markers tumor necrosis Factor Alpha as possible future tumor marker some studies suggest that tumor necrosis Factor Alpha increases the risk of gastric cancer according to these studies tumor necrosis Factor Alpha may have an application in the future as a tumor marker tumor necrosis Factor Alpha levels are higher among patients colonized by AG pylori however the clinical significance of this finding has not been fully established clinical staging and the selection of treatment although staging is most accurately determined through surgical pathology clinical staging
11:40 directs the initial approach to therapy patients who appear to have local Regional disease stage 1 to 3 after pre-operative testing are potentially curable all patients with a primary tumor that is considered to invade through the sub mucosa T2 or higher with a high suspicion of nodal involvement on pre-treatment staging studies should be referred for multidisiplinary evaluation to identify the best treatment strategy patients with Advanced stage 4 disease usually referred for pallative therapy depending on their symptoms and functional status multiple studies indicate both longer survival and better quality of life with
12:26 systemic treatment suspected gastric cancer upper endoscopy with biopsy is done which is the first initial best test if it's negative consider other diagnosis if it's positive confirmed at inoc carcinoma next there is staging first abdominal and pelvic CT scan further tests include abdominal ultrasound thoracic CT scan pet scan or CT scan endosonography diagnostic laparoscopy very early stage there's only mucosa no metastasis limited stage there's resectable tumor no distant metastasis Advanced stage has an unresectable tumor
13:13 and or distant metastases for the very early stage endoscopic resection is the treatment of choice limited stage surgery tumor resection lymphadenectomy pallative therapy with chemotherapy surgery if obstruction is present is a treatment of choice for advanced stage indicators of unresectability the only widely accepted criteria of unresectability for gastric cancer are the presence of distant metastasis and invasion of a major vascular structure such as iorta or disease encasement or occlusion of the hepatic artery or Celiac axis or proximal splenic artery
14:01 distal splenic artery involvement is not an indicator of unresectability the vessel can be resected and block with a left upper quadrant exenteration stomach spleen and distal [Music] pancreas treatment exact therapy which may be either Curative or pallative depends on staging and the type of tumor and scopic resection it is only for tumors diagnosed at a very early stage when they are still limited to the in lining of the stomach in the US this is not usually the case therefore this treatment method is seldom used surgery peroperative chemotherapy sometimes
14:49 radiotherapy trastuzumab is indicated for hr2 plus gastric edoc carcinomas this type of tumors Express human epid dermal growth factor receptor 2 this protein is responsible for normal cell growth however it has also been linked to breast and gastric cancer progression Tris aab a monoclonal antibody interferes with this protein slowing or stopping tumor growth surgery radical gastrectomy or lymphadenectomy operative standard reection of the Lesser and greater amum and radical lymphadenectomy Ru Andy gastric bypass the surgeon separates the proximal jum from the
15:35 deinum and creates an endtoend anastomosis of the judum with the remaining part of the stomach this is known as gastrostomy or in case of total gastrectomy with the esophagus esophago jomy deodal stump is connected distantly with the judum using an endtoend an asmosis an asmosis between deinum and judum resembles a y alternative is subtotal gastrectomy prognosis since there are no early signs gastric cancer is often diagnosed very late at diagnosis 60% of cancers have
16:21 already reached an advanced stage that does not allow for Curative treatment early gastric canc cancer has the best prognosis distant metastasis or peronal carcinomatosis dramatically worsen the prognosis and are lethal most of the time
