Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 12 Carcinoma Stomach PPT-Powerpoint Presentations and lecture notes
Carcinoma Stomach
Liver tumours
Portal hypertension
Chronic liver disease
Carcinoma Stomach
Introduction
? Gastric cancer is endemic in Japan
? Late stage at diagnosis because of
? Low incidence
? Non specific symptoms
? Risk factors not definable
? Biological y more aggressive
? Increasing incidence of adenocarcinomas of proximal
stomach and distal esophagus
Etiology
? Low acid production
Body of stomach
? H pylori infection
? Low acid production
Esophagus & Cardia
? Reflux
? Obesity
? High BMI
? High glycaemic load diet
? GERD
? Smoking
? Alcohol
? Tobacco
Although no normal lymphoid tissue is found in the
gastric mucosa, the stomach is the most common site
for lymphomas of the gastrointestinal tract
Borrmann classification(depending on
macroscopic appearance)
? Type I: polypoid or fungating cancers
? Type II: ulcerating lesions surrounded by elevated
borders
? Type II : ulcerated lesions infiltrating the gastric wall
? Type IV: diffusely infiltrating tumors
? Type V: unclassifiable cancers
Patterns of Spread
? Local extension
? Lymphatic metastases
? left supraclavicular fossa (Virchow's node)
? left axil a (Irish's node)
? S/c periumbilical tumour deposits (Sister Mary Joseph's nodes)
? Peritoneal metastases
? Distant metastases
Clinical Presentation
? Weight Loss
? Anorexia
? Early satiety (Diffusely infiltrative type)
? Recurrent Vomiting (pyloric involvement )
? Dysphagia
? Bleeding
? Anemia
? Fatigue
? Epigastric pain
? Ascites, jaundice, or palpable mass indicates incurable
disease
? Transverse colon is a potential site of malignant
fistulization and obstruction from gastric primary tumor
? Diffuse peritoneal spread of disease frequently produces
other sites of intestinal obstruction
? Large ovarian mass ( krukenberg's tumor)
? Large peritoneal implant in the pelvis ( blumer's shelf)
? Macroscopic description of the tumor
? Extent of peritoneal metastases (P0-1)
? Extent of hepatic metastases (H0-1)
? Peritoneal cytology findings
Resection Classification
? R0: no gross or microscopic residual disease
? R1: microscopic residual disease (+ margins)
? R2: gross residual disease
Diagnostic work up
? Tumour Markers: CA 19.9,CA 72.4, CEA, CA 50
? Endoscopy & Biopsy:
? Chromo endoscopy: identification of mucosal abnormalities
through topical stains.
? Magnification Endoscopy: magnify standard endoscopic
fields by 1.5- to 150-fold.
? Narrow band imaging: increased visualization of the
microvasculature
? Confocal laser Endomicroscopy : 3D microscopy including
subsurface structures
? Overexpression or amplification of HER2 (EGFR2):
? occurs in approximately 20% of patients with
gastric cancer
? Recommended in metastatic, recurrent gastric
cancer
? Trastuzumab used in Her 2 neu + cancers
? Endoscopic ultrasound (EUS)
? Computed Tomography
? Magnetic Resonance Imaging:
? to characterize liver lesions on CT scan
? Positron Emission Tomography:
? 50% of primary tumors are FDG-negative
? diffuse (signet cel ) subtype most likely to be non-FDG
avid
? Staging Laparoscopy and Peritoneal Cytology:
? directly inspects the peritoneal and visceral surfaces
? done to spare nontherapeutic operations
Treatment
? Surgery (Gastrectomy with lymph node
dissection) `
? Radical Gastrectomy (Proximal gastric cancer)
? Subtotal Gastrectomy (mid & distal gastric cancer)
When the oncologic goal of an R0 resection can be achieved by a gastric-
preserving approach, partial gastrectomy is preferred over total
gastrectomy
A: Subtotal gastrectomy with a Bil roth II anastomosis
B: Total gastrectomy with a Roux-en-Y anastomosis
? Lymphadenectomy
? 15 nodes for adequate pathologic staging
? Partial Pancreatectomy and Splenectomy--Resect or
Preserve?
Splenectomy:
? Intraoperative evidence of direct tumor extension into the
spleen
? Primary tumor is located in the proximal stomach along
the greater curvature
Partial Pancreatectomy:
? direct tumor extension into the pancreas
Stage specific Survival rates for gastric adenocarcinoma are
higher in Japan than in Western countries because:
? Better-prognosis intestinal-type tumors are more common
? Poorer-prognosis proximal gastric cancers are less frequent
? Widespread use of extensive D2 or D3 lymphadenectomy
Chemotherapy
? Adjuvant
? Neoadjuvant:
? Higher rate of R0 resections
? Early treatment of micro metastatic disease
? Periperative
Adjuvant Intraperitoneal Chemotherapy
? Hyperthermic intraoperative peritoneal chemotherapy
(HIPEC)
? Normothermic intraoperative chemotherapy (NI C)
? Early postoperative intraperitoneal chemotherapy (EPIC)
? Delayed postoperative intraperitoneal chemotherapy (DPIC)
Chemotherapy Drugs
? Cisplatin
? 5-Fluorouracil
? Taxanes
? Epirubicin
? Irinotecan
? Trastuzumab (targeted therapy in Her 2 neu + )
Radiotherapy
? Preoperative
? Intraoperative
? Postoperative
Liver Tumours
Benign tumours
? Liver Cell Adenoma
? Focal Nodular hyperplasia
? Hemangioma
? Mesenchymal hamartomas
Liver Cell Adenoma
? benign proliferation of hepatocytes
? young women (aged 20-40 years)
? associated with use of oral contraceptive pills (OCPs)
? usually singular
? Upper abdominal pain
? tumor markers are normal
? MRI scans of LCA have specific imaging characteristics
? two major risks are rupture & malignant transformation
? Hepatic artery embolization
? Resection of the mass
Focal nodular hyperplasia
? Second most common benign tumor
? young women
? small (<5 cm) nodular mass
? involves the right and left liver equally
? Related to developmental vascular malformation
? Nonspecific symptoms
? Contrast-enhanced CT and MRI scan
? Symptomatic pts: resection
Hemangioma
? Most common benign tumor of the liver
? Women more common than men (3:1 ratio)
? Mean age of about 45 years
? Occur equally in the right and left liver
? Usually single
? Lesions > 5 cm are arbitrarily called giant hemangiomas
? Tumor markers are usually normal
? CT and MRI scan
? Resection: enucleation with inflow control
Hepatocel ular carcinoma
Introduction
? Fifth most common malignancy worldwide
? Male-to-female ratio 2.4:1
? Poor prognosis
Etiology
? Infections with hepatitis B and C viruses
? Ethanol abuse
? Obesity
? Type 2 diabetes
? Non-alcoholic fatty liver disease
? Aflatoxin B1
Pathology
? Malignant epithelial neoplasms: 85% to 95%
? Benign: 6 %to 12%
? Malignant mesenchymal tumors: 1% to 3%
? Metastatic tumors
? Tumors metastatic to the liver are:
? Peripheral
? Multiple
? Cause umbilication of surface of the liver
? Primary liver tumors are:
? Central
? Solitary
? Exophytic
? HCC spreads most commonly to
? Lymph nodes around the liver
? Peritoneal cavity
? Lung
Characteristic feature of HCC is invasion of the
portal vein
Clinical Features
Symptoms
Signs
? Abdominal pain
? Hepatomegaly
? Weight loss
? Hepatic bruit
? Ascites
? Weakness
? Splenomegaly
? Ful ness
? Jaundice
? Anorexia
? Wasting
? Abdominal swel ing
? Fever
? Jaundice
? Virchow-Troisier nodes
? Vomiting
? Cutaneous metastases (red-blue nodules)
Paraneoplastic Syndromes
? Hypoglycemia
? Erythrocytosis
? Hypercalcemia
? Hypercholesterolemia
? Dysfibrinogenemia
? Carcinoid syndrome
? Increased thyroxin-binding globulin
? Sexual changes (gynecomastia, testicular atrophy, and
precocious puberty)
? Porphyria cutanea tarda
Diagnostic work up
? Liver function tests
? S. Alpha feto protein (70%)
? S.Des--carboxy prothrombin protein (80%)
? Four-phase CT scan: unenhanced, arterial, venous, and delayed
phases
? MR imaging
Characteristic feature of HCC: rapid enhancement during the
arterial phase of contrast administration and "washout" during
the later portal venous and delayed phases
Portal venous phase of triphasic computed tomography scan
? PET CT Scan: not recommended
? Core biopsy: hal mark feature of HCC is stromal invasion
CHILD PUGH score for assessment of hepatic reserve
Quantitative assessment of hepatic
reserve
Indocyanine green clearance test
? Retention rate <10%: all resections are possible
? 10% to 20%: bisegmentectomy is well tolerated
? 20% to 29%: single segment can be excised
? 30% or more: risk of liver failure is high
Management
Stage I and II HCC
? Surgical resection
? Local ablation (radiofrequency ablation)
? Local injection therapies (ethanol injection):
? maximum size of tumor reliably treated is 3 cm
? Transplantation
Child-Pugh A: Resection
Child-Pugh B and C patients with stage I HCC tumors : transplant, if
appropriate
Adjuvant Therapy
? Trans arterial chemotherapy (TACE)
? Systemic chemotherapy
? Lipiodol
? Doxorubicin
? Mitomycin
? Cisplatin
Stage II and IV Tumors
? TACE
? Regional Chemotherapy
? Systemic Therapy
? External Radiotherapy (< 8 cm)
? Hepatic Arterial Radioisotopes
? yttrium-90 (90Y)
? 131 I antiferritin
Portal Hypertension
Anatomy
? The normal portal pressure is 5-7 mmHg (8-12
cm of water).
? Portal hypertension is present when the portal
vein pressure exceeds 12 mmHg
Causes
? Presinusoidal
? Sinusoidal
? Postsinusoidal
Sequelae & Clinical picture
? Porto-systemic collaterals
? Splenomegaly
? Congestion of the whole GIT
? Bleeding varices
? Ascites
Intra-abdominal venous flow pathways leading to engorged veins
(varices) from portal hypertension
Screening Tests for Portal Hypertension
? Ultrasound with doppler blood flow assessment.
? MRI venogram
? Contrast-enhanced helical CT scan
Detection of oesophageal varices
Management
? Management of patients with actively bleeding
oesophageal varices
? Resuscitation
? Correct coagulopathy
? Prevent encephalopathy
? Sclerotherapy
? Endoscopic Banding
? Drugs: Vasopressin,Somatostatin
? Balloon tamponade
? Trans-juguJar Intra-hepatic Porto-Systemic Shunt
(TIPSS )
? Shunt operations
? Portocaval shunt
? Proximal spleno-renal shunt
? Mesocaval (Drapanas) shunt
? Selective shunt (Warren shunt)
? Liver Transplant
Chronic Liver
Disease
Catabolism of hormones
Glucose homeostasis;
and other serum proteins
glycogenolysis & gluconeogenesis
Chronic Liver
Disease
Synthesis:
- Albumin
- Coagulation factors
Storage:
Bile excretion
- Glycogen
- Iron
- Cu, Iron, vitamins
Signs of CLD
Chronic Liver
Disease
Investigations
Bedside
? Observations, BM, fluid balance, weight
Blood tests
? LFTs (pre/post) (including albumin), INR
? FBC, U&Es, CRP
? Liver screen: autoantibodies, alpha-1 antitrypsin, caeruloplasmin,
serum copper, ferritin, viral hepatitis serology
Imaging
? US abdomen + portal vein doppler
? CXR, CT, MRI, MRCP
Special tests
? Ascitic tap, OGD (oesophageal varices), liver biopsy
What is your management plan?
Conservative
? Alcohol abstinence, optimise nutrition, low salt diet, fluid restriction
Medical
? Vitamin B supplementation (IV/PO), chlordiazepoxide
? Diuretics
? Paracentesis (give albumin)
? NG feeding
? Antibiotics (? SBP)
? Steroids + albumin (N.B. avoid NaCl)
? Lactulose (in hepatic encephalopathy)
Surgical
? TIPSS
? Liver transplantation
Complications of CLD
? Portal hypertension: oesophageal varices, ascites
? SBP
? Hepatic encephalopathy (constipation, GI bleed, infection, renal
failure)
? Hepatocel ular carcinoma
? Coagulopathy
? Hepato-renal syndrome
? Liver failure
? 5 year survival rate in cirrhotic CLD 50%
? Child Pugh Score: bilirubin, INR, albumin, ascites, hepatic
encephalopathy
This post was last modified on 08 April 2022