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Benign and malign diseases of Stomach Prof. Dr. Öge TAŞCILAR.

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1 Benign and malign diseases of Stomach Prof. Dr. Öge TAŞCILAR

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5 Esophagus/Stomach Junction Esophagus: stratified squamous non- keratinized epithelium Stomach: Simple columnar epithelium

6 MİDE Mukoza Mukoza Submukoza Submukoza Muskularis Propria Muskularis Propria Seroza Seroza Mukoza Mukoza İntraepitelyal Mukoza İntraepitelyal Mukoza Epitel Epitel Bazal Membran Bazal Membran Lamina Propria Lamina Propria Muskularis Mukoza Muskularis Mukoza

7 MİDE Fonksiyon: Fonksiyon: Alınan gıdaların sindirimi ve emilimi Alınan gıdaların sindirimi ve emilimi Reseptif relaksasyon ve gastrik adaptasyon Reseptif relaksasyon ve gastrik adaptasyon İntragastrik basınç düşer. İntragastrik basınç düşer. 100cc cc 100cc cc

8 MİDE Mallory-Weiss Sendromu Mallory-Weiss Sendromu Kusma ÖG bileşke Kusma ÖG bileşke Mukoza submukoza yırtık ve kanama Mukoza submukoza yırtık ve kanama Endoskopi Endoskopi Alkol,diyabet,gebelik, üremi, Alkol,diyabet,gebelik, üremi, Tam kat olursa Booerhaave sendromu Tam kat olursa Booerhaave sendromu

9 MİDE Bezoarlar Bezoarlar Midede oluşan yabancı cisimler. Midede oluşan yabancı cisimler. Trikobezoar-fitobezoar Trikobezoar-fitobezoar Mide operasyonu sonrası Mide operasyonu sonrası Antrumun öğütücü işlevinin kaybolması Antrumun öğütücü işlevinin kaybolması HCL azalmasına bağlı Candida Albicans bezoar HCL azalmasına bağlı Candida Albicans bezoar Tanı: Radyoloji-endoskopi Tanı: Radyoloji-endoskopi Tedavi:Endoskopik-Cerrahi Tedavi:Endoskopik-Cerrahi

10 MİDE Menetrier Hastalığı Menetrier Hastalığı Hipertrofik mukozal gastropati Hipertrofik mukozal gastropati Fundus ve korpusta dev rugalar Fundus ve korpusta dev rugalar Foveolar hiperplazi Foveolar hiperplazi Hipoklorhidri ve Hipoalbüminemi Hipoklorhidri ve Hipoalbüminemi 50> erkekler 50> erkekler Epigastrik ağrı, kilo kaybı, (özellikle protein), kanama, diare, ödem Epigastrik ağrı, kilo kaybı, (özellikle protein), kanama, diare, ödem Medikal tedavi PPI Medikal tedavi PPI Destek tedavisi Destek tedavisi Çok ciddi olgularda rezeksiyon Çok ciddi olgularda rezeksiyon

11 Gastritis Acute gastritis often due to chemical injury (alcohol drugs) Acute gastritis often due to chemical injury (alcohol drugs)

12 Acute gastritis Drugs (non-steroidal anti-inflammatory drugs NSAID), alcohol cause acute erosion (loss of mucosa superficial to muscularis mucosae). Can result in severe haemorrhage Drugs (non-steroidal anti-inflammatory drugs NSAID), alcohol cause acute erosion (loss of mucosa superficial to muscularis mucosae). Can result in severe haemorrhage

13 Chronic gastritis ABC A – autoimmune(associated with vitamin B12 malabsorption (pernicious anaemia) A – autoimmune(associated with vitamin B12 malabsorption (pernicious anaemia) B – bacterial (helicobacter) B – bacterial (helicobacter) C – chemical(bile reflux, drugs) C – chemical(bile reflux, drugs)

14 Autoimmune chronic gastritis Autoantibodies to gastric parietal cells Autoantibodies to gastric parietal cells Hypochlorhydria/achlorhydria Hypochlorhydria/achlorhydria Loss of gastric intrinsic factor leads to malabsorption of vitamin B12 with macrocytic,megaloblastic anaemia Loss of gastric intrinsic factor leads to malabsorption of vitamin B12 with macrocytic,megaloblastic anaemia

15 Helicobacter pylori Adapted to live in association with surface epithelium beneath mucus barrier Adapted to live in association with surface epithelium beneath mucus barrier Causes cell damage and inflammatory cell infiltration Causes cell damage and inflammatory cell infiltration In most countries the majority of adults are infected In most countries the majority of adults are infected

16 Chemical gastritis Commonly seen with bile reflux (toxic to cells) Commonly seen with bile reflux (toxic to cells) Prominent hyperplastic response (inflammatory cells scanty) Prominent hyperplastic response (inflammatory cells scanty) With time – intestinal metaplasia With time – intestinal metaplasia

17 Peptic ulcer disease A surface breach of mucosal lining of GI tract occurring as a result of acid and pepsin attack A surface breach of mucosal lining of GI tract occurring as a result of acid and pepsin attack Sites: Sites: –Duodenum (DU) –Stomach (GU) –Oesophagus –Gastro-enterostomy stoma –Related to ectopic gastric mucosa (e.g. in Meckel’s diverticulum)

18 Chronic peptic ulcer Complex epidemiology Complex epidemiology –DU most common in Europe, GU in Japan –Incidence of DU declining, GU stable

19 Pathogenesis In normal acid/pepsin attack is balanced by mucosal defences In normal acid/pepsin attack is balanced by mucosal defences Increased attack by hyperacidity Increased attack by hyperacidity Weakened mucosal defence – the major factor (H. pylori related) Weakened mucosal defence – the major factor (H. pylori related)

20 MİDE DU son yıllarda azalmaktadır. DU son yıllarda azalmaktadır. Sigara azalması Sigara azalması HP etkin korunma HP etkin korunma H2 blokör, PPI H2 blokör, PPI Mukoza saldırgan faktörler etkili Mukoza saldırgan faktörler etkili HP, NSAİ, ZES HP, NSAİ, ZES

21 MİDE Duodenal Ülser: Duodenal Ülser: Duodenal HCO3 sekresyonu azalmış Duodenal HCO3 sekresyonu azalmış Gece asit sekres. Artmış Gece asit sekres. Artmış Duodenal asit yükü atmış Duodenal asit yükü atmış Bazal ve postbrandial gastrin artmış Bazal ve postbrandial gastrin artmış PH kitlesi artmış. PH kitlesi artmış. Tamamına yakın HP gastrit saptanmıştır. Tamamına yakın HP gastrit saptanmıştır.

22 Morphology of peptic ulcers Clean, non- elevated edge Clean, non- elevated edge Granulation tissue base (floor) Granulation tissue base (floor) Underlying fibrosis Underlying fibrosis

23 MİDE Klinik: Klinik: Yanıcı, kemirici, açlık ağrısı. Yanıcı, kemirici, açlık ağrısı. Epigastrium Epigastrium Antiasit ve gıda ile hafifler. Antiasit ve gıda ile hafifler. Mevsimsel bir ağrı. Mevsimsel bir ağrı. İlkbahar, sonbahar, stress dönemleri İlkbahar, sonbahar, stress dönemleri Penetre olursa ağrı özellikleri değişir. Penetre olursa ağrı özellikleri değişir.

24 MİDE Anamnez, Anamnez, Radyoloji Radyoloji Endoskopi, biyopsi Endoskopi, biyopsi Tedavi: Tedavi: Medikal tedavi Medikal tedavi Antiasit Antiasit Sükralfat Sükralfat H2 blokör H2 blokör PPI PPI Prostoglandin analogları Prostoglandin analogları

25 MİDE DÜ Cerrahi Tedavi: DÜ Cerrahi Tedavi: BTV-PP BTV-PP BTV-Distal gastrektomi+GJ BTV-Distal gastrektomi+GJ PGV PGV

26 MİDE Mide Ülseri Mide Ülseri MÜ 5 tip vardır. MÜ 5 tip vardır. Tip 1: En sık %60. Küçük kurvatur. Tip 1: En sık %60. Küçük kurvatur. Tip 2:%20-25 Duodenuma yakın(Kombine gastrik, duodenal) Tip 2:%20-25 Duodenuma yakın(Kombine gastrik, duodenal) Tip 3: %20. Prepilorik antrum Tip 3: %20. Prepilorik antrum Tip 4: GÖ bileşkeye yakın Tip 4: GÖ bileşkeye yakın Tip 5: Diffüz Alkol, NSAİ Tip 5: Diffüz Alkol, NSAİ

27 Benign gastric ulcer (B)

28 MİDE Mide Ülseri Mide Ülseri MÜ Cerrahi tedavi: MÜ Cerrahi tedavi: Tip 2-3 duodenal ülser gibi tedavi Tip 2-3 duodenal ülser gibi tedavi Tip1: Ülseri içine alan distal gastrektomi+GJ Tip1: Ülseri içine alan distal gastrektomi+GJ

29 Complications of peptic ulcer Perforation leading to peritonitis Perforation leading to peritonitis Haemorrhage by erosion of vessel in base Haemorrhage by erosion of vessel in base Penetration of surrounding organ (liver/pancreas) Penetration of surrounding organ (liver/pancreas) Obstruction (by scarring) – pyloric stenosis Obstruction (by scarring) – pyloric stenosis (Cancer – rare event in true peptic ulcer) (Cancer – rare event in true peptic ulcer)

30 Complications of peptic ulcer Kanama: Kanama: DÜ kanama DÜ kanama Kanayan yere transfiksiyon+BTV+PP Kanayan yere transfiksiyon+BTV+PP Genç veya kronik olgularda: Genç veya kronik olgularda: Kanayan yere transfiksiyon+ Ülseri içeren antrektomi+BTV Kanayan yere transfiksiyon+ Ülseri içeren antrektomi+BTV

31 Complications of peptic ulcer Kanama: Kanama: MÜ kanama: MÜ kanama: Tip1: Ülseri içine alan distal gastrektomi+GJ Tip1: Ülseri içine alan distal gastrektomi+GJ Tip 2-3: DÜ kanamasındaki aynı tedavi Tip 2-3: DÜ kanamasındaki aynı tedavi

32 Complications of peptic ulcer Delinme Delinme DÜ DÜ Graham usulü Duodenorafi+PPI Graham usulü Duodenorafi+PPI Graham usulü Duodenorafi+ PGV Graham usulü Duodenorafi+ PGV

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34 Complications of peptic ulcer Delinme Delinme MÜ MÜ Tip1: Ülseri içine alan distal gastrektomi+GJ veya omental patch. Tip1: Ülseri içine alan distal gastrektomi+GJ veya omental patch. Tip 2: BTV+Antrektomi Tip 2: BTV+Antrektomi Tip 3: BTV+Antrektomi Tip 3: BTV+Antrektomi

35 NEOPLASMS OF STOMACH BENIGN__ 10% BENIGN__ 10% MALIGNANT__90% MALIGNANT__90% BENIGN BENIGN Polyps Polyps Lipomas Lipomas Leiomyomas Leiomyomas

36 MALIGNANT Adenocarcinoma 95% Lymphoma 4% Others 1% (sq.cell ca, angiosarcoma, carcinosarcoma, Gist) NEOPLASMS OF STOMACH

37 Less common gastric neoplasms Gastrointestinal stromal tumour (GIST) Gastrointestinal stromal tumour (GIST) Lymphoma Lymphoma Neuroendocrine (carcinoid) tumours Neuroendocrine (carcinoid) tumours

38 Gastrointestinal stromal tumours (GIST) Mesenchymal neoplasms Mesenchymal neoplasms Derived from interstitial cells of Cajal (pacemaker cells controlling peristalsis) Derived from interstitial cells of Cajal (pacemaker cells controlling peristalsis) Overexpress c-kit oncogene Overexpress c-kit oncogene –Used as diagnostic aid on tissue –A target for therapy with tyrosine kinase inhibitor imatinib (also used in CML)

39 GIST-spindle cell neoplasm of GI tract

40 GIST Larger tumours with high mitotic rate tend to behave malignantly Larger tumours with high mitotic rate tend to behave malignantly Stomach is commonest site Stomach is commonest site

41 GIST Risk categories were assigned according to current recommended NIH criteria. Tumors <2 cm and<5 mitosis per 50 high- power fields (HPF) were classified as very low risk. Tumors ranging from 2 to 5 cm and having <5 mitoses/50 HPF were classified as low risk.

42 Tumors <5 cm but having 6 to 10 mitoses/50 HPF were intermediate risk, as were tumors from 5 to 10 cm with <5 mitoses/50 HPF. Tumors >5 cm with >5 mitoses/50 HPF was defined as high risk, as was any tumor >10 cm or any tumor with >10 mitoses/50 HPF.

43 GASTRIC STROMAL TUMOURS PRESENTATION; Mass abdomen Mass abdomen Upper GI bleeding Upper GI bleeding Obstruction ObstructionPATHOLOGY; Difficult to ascertain benign or malignant nature Difficult to ascertain benign or malignant nature Size & Histology is the criteria Size & Histology is the criteriaTREATMENT; Surgical resection Surgical resection Lymph node resection not necessary. Lymph node resection not necessary.

44 MİDE LENFOMA NHL klasik olarak lenf nodlarından gelişir. NHL klasik olarak lenf nodlarından gelişir. Ama NHL %30 olguda ekstranodal(Solid organ kaynaklı) olarak gelişebilir. Ama NHL %30 olguda ekstranodal(Solid organ kaynaklı) olarak gelişebilir. GI sistem tüm NHL %20 GI sistem tüm NHL %20

45 MİDE LENFOMA GI lenfoma; oral kaviteden rektuma GI lenfoma; oral kaviteden rektuma En sık; Mide En sık; Mide Sonra ince barsak Sonra ince barsak Kolon Kolon Pankreas Pankreas

46 MİDE LENFOMA NHL, ekstranodal lenfoma ve GI lenfomanın en sık görülen tipi diffüz B hücre lenfoması. NHL, ekstranodal lenfoma ve GI lenfomanın en sık görülen tipi diffüz B hücre lenfoması. MALT lenfoma MALT lenfoma Burkitt lenfoma Burkitt lenfoma T- hücre lenfoma T- hücre lenfoma

47 Gastric lymphoma Malignant neoplasm of mucosa associated lymphoid tissue (MALT) Malignant neoplasm of mucosa associated lymphoid tissue (MALT) A (usually) low grade B-cell (marginal cell) lymphoma A (usually) low grade B-cell (marginal cell) lymphoma

48 MİDE LENFOMA GASTRİK LENFOMA GASTRİK LENFOMA DLBCL (%55)ve MALT tipi lenfoma(40), %3 Burkitt Lenfoma DLBCL (%55)ve MALT tipi lenfoma(40), %3 Burkitt Lenfoma Antrum ve distal mide Antrum ve distal mide Proksimal yerleşebilir. Proksimal yerleşebilir. Karın ağrısı, erken doyma Karın ağrısı, erken doyma Bulantı, kusma, halsizlik Bulantı, kusma, halsizlik Abdominal dolgunluk Abdominal dolgunluk Kronik kan kaybı, anemi melena Kronik kan kaybı, anemi melena

49 Gastric lymphoma (maltoma) Neoplastic cells infiltrate the epithelium (lymphoepithelial lesions) Neoplastic cells infiltrate the epithelium (lymphoepithelial lesions) Strongly associated with chronic H. pylori and can be cured by eliminating infection. Strongly associated with chronic H. pylori and can be cured by eliminating infection.

50 MİDE LENFOMA Ann Arbor Musshoff Modifikasyonu: Ann Arbor Musshoff Modifikasyonu: IE: Diyafragmanın bir tarafında bir organda veya tek lenf nodu bölgesi IE: Diyafragmanın bir tarafında bir organda veya tek lenf nodu bölgesi IE1: Mukoza-submukoza IE1: Mukoza-submukoza IE2: Muskularis invaze IE2: Muskularis invaze

51 MİDE LENFOMA Ann Arbor Musshoff Modifikasyonu: Ann Arbor Musshoff Modifikasyonu: IIE: Ek olarak Diyafragmanın bir tarafında lenf nod tutulumu IIE: Ek olarak Diyafragmanın bir tarafında lenf nod tutulumu IIE1: Bölgesel lenf nodlarında IIE1: Bölgesel lenf nodlarında IIE2: Uzak lenf bölgelerinde IIE2: Uzak lenf bölgelerinde

52 MİDE LENFOMA Ann Arbor Musshoff Modifikasyonu: Ann Arbor Musshoff Modifikasyonu: IIIE: Diyafragmanın her iki tarafında organ ve/veya lenf nod tutulumu IIIE: Diyafragmanın her iki tarafında organ ve/veya lenf nod tutulumu IVE: Ekstra GI organ tutulumu IVE: Ekstra GI organ tutulumu

53 MİDE LENFOMA Tedavi Tedavi HP tedavi edilmeli. HP tedavi edilmeli. Bir zamanlar cerrahi Bir zamanlar cerrahi Şimdi Konservatif, bazı olgularda cerrahi Şimdi Konservatif, bazı olgularda cerrahi Low grade lenfoma(MALT) Low grade lenfoma(MALT) HP eradikasyonu, KRT, HP eradikasyonu, KRT, High Grade: High Grade: Antihelikobakter tedaviye cevap vermeyen erken evre PGL, ileri evre lenfoma, diffüz büyük hücreli lenfoma ise cerrahi tedavi Antihelikobakter tedaviye cevap vermeyen erken evre PGL, ileri evre lenfoma, diffüz büyük hücreli lenfoma ise cerrahi tedavi KT-RT KT-RT Residual hastalık: KT-cerrahi Residual hastalık: KT-cerrahi

54 Neuroendocrine tumours Carcinoids are tumours of resident neuroendocrine cells in gastric glands Carcinoids are tumours of resident neuroendocrine cells in gastric glands Usually seen in context of chronic atrophic gastritis (driven by gastrin) Usually seen in context of chronic atrophic gastritis (driven by gastrin) Clinical behaviour variable Clinical behaviour variable

55 GASTRIC CANCER 5 year survival 5% 5 year survival 5% Early diagnosis is key to success Early diagnosis is key to success Only treatment to cure the disease is,SURGERY Only treatment to cure the disease is,SURGERY INCIDENCE INCIDENCE 15/ per year in UK 15/ per year in UK In japan 70/ per year In japan 70/ per year Men

56 Carcinoma of the stomach The second most common fatal malignancy in the world (after lung cancer) The second most common fatal malignancy in the world (after lung cancer) Commonest in Far East (Japan) Commonest in Far East (Japan) Incidence declining Incidence declining High mortality unless disease detected early High mortality unless disease detected early

57 SITES OF GASTRIC CANCER 30 years before Present days

58 ETIOLOGY 1.HELICOBACTER PYLORI CA of body & distal stomach CA of body & distal stomach  Gastritis  Gastric atrophy  Intestinal metaplasia 2.PERNICIOUS ANEMIA 3.GASTRIC POLYPS 4.Pt. with surgery of peptic ulcer disease  Billroth II or polya gastrectomy  Gastroenterostomy  Pyloroplasty  4 times increased risk

59 5.Cigarette smoking &dust ingestion 6.Diet  Consumption of potatoes,pickled vegetables,dried/salted fish & less milk  Alcohol ingestion  Excessive salt intake  Deficiencies of anti oxidants  Exposure to N- Nitrosocompounds 7.Familial predisposition  Relatives of CA stomach pt. are 4 times more at risk  Genetically H-ras, C-erb B2 & APC gene mutations have some role in pathogenesis of CA stomach  Blood group A 8.Gastric ulcer 3-5% of cases?? 3-5% of cases?? 9. İntestinal metaplazi Tip1,2 ve 3 Tip1,2 ve 3 En tehlikeli olanı Tip 3 En tehlikeli olanı Tip 3

60 Helicobacter factors in pathogenesis Some strains are more pathogenic than others. The Cag A (cytotoxic) antigen is one important virulence factor Some strains are more pathogenic than others. The Cag A (cytotoxic) antigen is one important virulence factor Human variability also plays a part (e.g. individuals who produce high levels of IL- 1b in inflammation get pan gastritis and GU, lower levels associated with antral gastritis and DU) Human variability also plays a part (e.g. individuals who produce high levels of IL- 1b in inflammation get pan gastritis and GU, lower levels associated with antral gastritis and DU)

61 Pathology Gastric epithelial cancers are Gastric epithelial cancers are adenocarcinomas adenocarcinomas sqamous cell carcinomas sqamous cell carcinomas LAUREN CLASSIFICATION OF GASTRIC CA 1. Diffuse type 1.well differentiated 2.poorly differentiated 3.undifferentiated 2. Intestinal type 3. Others EARLY & ADVANCED GASTRIC CANCER 1. EARLY GASTRIC CANCER 1. EARLY GASTRIC CANCER cancer limited to mucosa & submucosa with or without involvement of lymph nodes ( T1, any N) cancer limited to mucosa & submucosa with or without involvement of lymph nodes ( T1, any N) With surgery 5 year survival rate is 90% With surgery 5 year survival rate is 90% Further classified by Japanese classification in to Further classified by Japanese classification in to 1.Protruding 1.Protruding. Elevated. Elevated. Flat. Flat. Depressed. Depressed 2. Excavating 2. Excavating

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63 ADVANCED GASTRIC CARCINOMA Cancer involving muscularis BORMANN CLASSIFICATION (MACROSCOPIC TYPE)

64 PATHOLOGY MACROSCOPIC CLASSIFICATION 1. Schirrous (lintis plastica) 2. Ulcerative 3. Polypoid 4. Superficial spreading HISTOLOGICALLY (W.H.O) PapillaryTubular Mucin secreting Mucin secreting Signet ring cell Signet ring cell

65 Clinical Features GASTRIC CANCER GASTRIC CANCER Early feeling of fullness after meal Early feeling of fullness after meal Bloating, distention Bloating, distention Vomiting Vomiting Pallor – iron deficiency anemia due to tumour bleed Pallor – iron deficiency anemia due to tumour bleed Dysphygia –epigastric fullness or vomiting due to obstrution of gastric outlet Dysphygia –epigastric fullness or vomiting due to obstrution of gastric outlet Epigastric mass – ¼ of cases Epigastric mass – ¼ of cases Non metastatic effects ; thrombophlebitis Non metastatic effects ; thrombophlebitis Deep venous thrombosis Deep venous thrombosis ( by affecting thrombotic & haemostatic mechanism) ( by affecting thrombotic & haemostatic mechanism)

66 Ascites Ascites Jaundice Jaundice Trosier sign(virchows node) Trosier sign(virchows node) Sister mary joseph nodule Sister mary joseph nodule krukenberg tumour krukenberg tumour Blummer Shelf Blummer Shelf

67 INVESTIGATIONS 1. BLOOD COMPLETE EXAM Anemia 2. STOOL EXAM. --- for occult blood in ½ of pts. 3. CARCINOEMBRYONIC (CEA) LEVEL--- elevated in 65% of cases 4. GASTRIC JUICE ANALYSIS--- 20% are achlorhydric after maximal stimulation 5. DOUBLE CONTRAST BARIUM MEAL--- mucosal irregularities and to assess the size, shape, margins of lesions 6. GASTROSCOPY & BIOPSY---minimum of 6 biopsies for accuracy --- brush cytology --- brush cytology 7. C.T. SCAN 8. ENDOSCOPIC USG 9. LAPAROSCOPY

68 Advanced Gastric CA TYPE ( I )

69 Advanced Gastric CA TYPE ( II )

70 Advanced Gastric CA TYPE ( III )

71 Advanced Gastric CA TYPE ( IV )

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76 Macroscopic Pathology Gross types Gross types –Polypoid –Ulcerative –Infiltrative (extreme is linitis plastica – “leather bottle stomach)

77 Microscopy Intestinal type (forms glands – like cancers of colon and oesophagus) Intestinal type (forms glands – like cancers of colon and oesophagus) Diffuse type – dissociated tumour cells often containing a mucinous “blob” – signet ring cells Diffuse type – dissociated tumour cells often containing a mucinous “blob” – signet ring cells

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79 STAGING TNM Staging of Gastric CA Tis tumour limited to limited to mucosa without penetration through basement memb into lamina propria Tis tumour limited to limited to mucosa without penetration through basement memb into lamina propria T1 Tumour limited to mocosa or mucosa and submucosa T1 Tumour limited to mocosa or mucosa and submucosa T2 Tumour extendind into muscularis propia and may extend into but not through the serosa T2 Tumour extendind into muscularis propia and may extend into but not through the serosa T3 Tumour penetrates serosa without invadind contiguous strutures T3 Tumour penetrates serosa without invadind contiguous strutures T4 Tumour invading adjacent strutures T4 Tumour invading adjacent strutures N0 No metastasis to regional lymph nodes N0 No metastasis to regional lymph nodes N1 Involvement of perigastric lymph nodes within 3cm of primary tumour N1 Involvement of perigastric lymph nodes within 3cm of primary tumour N2 Involvement of regional lymph nodes more than 3cm from the primary tumour including nodes along left gastric,splenic, celiac and common hepatic arteries N2 Involvement of regional lymph nodes more than 3cm from the primary tumour including nodes along left gastric,splenic, celiac and common hepatic arteries N3 Involvement of other nodes such as para-aortic, hepatoduodenal, retropancreatic and mesenteric nodes. N3 Involvement of other nodes such as para-aortic, hepatoduodenal, retropancreatic and mesenteric nodes. M0 No distant metastases M0 No distant metastases M1 Distant metastasis present N1—1-6..REGIONAL NODES INVOLVED N NODES INVOLVED N3– MORE THAN 15 NODES INVOLVED

80 MİDE KANSERİNDE CERRAHİ TEDAVİ PRENSİPLERİ JRSGC’ nin Lenf nod klasifikasyonu(1981) JRSGC’ nin Lenf nod klasifikasyonu(1981) 1 Sağ parakardiyal 1 Sağ parakardiyal 2 Sol parakardiyal 2 Sol parakardiyal 3 Küçük kurvatur etrafı 4 Büyük kurvatur etrafı N1 3 Küçük kurvatur etrafı 4 Büyük kurvatur etrafı N1 5 Suprapilorik 5 Suprapilorik 6 Infrapilorik 6 Infrapilorik 7 Sol gastrik arter civarı 7 Sol gastrik arter civarı 8 A. Hepatika Kommunis civarı N2 8 A. Hepatika Kommunis civarı N2 9 Çöliak arter etrafı 9 Çöliak arter etrafı 10 Splenik hilus 11 Splenik arter boyunca 10 Splenik hilus 11 Splenik arter boyunca

81 MİDE KANSERİNDE CERRAHİ TEDAVİ PRENSİPLERİ 12 Hepatoduodenal ligament civarı 12 Hepatoduodenal ligament civarı 13 Pankreas baş ve arkası 13 Pankreas baş ve arkası 14 Mezenter Kökü N3 14 Mezenter Kökü N3 15 Transvers mezokolon 15 Transvers mezokolon 16 Paraaortik N4 16 Paraaortik N4 110 Alt torakal paraözefagiyal lenf nodları 110 Alt torakal paraözefagiyal lenf nodları 111 Diyafragmatik lenf nodları 111 Diyafragmatik lenf nodları

82 Lymphatic drainage of stomach and nodal stations by the Japanese classification

83 Regional lymph nodes of stomach

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85 CT STAGING OF GASTRIC CA STAGE I Intraluminal mass without wall thickening STAGE I Intraluminal mass without wall thickening STAGE II Wall thickening greater than 1 cm STAGE II Wall thickening greater than 1 cm STAGE III Direct invasion of adjacent structures STAGE III Direct invasion of adjacent structures STAGE IV Metastatic disease STAGE IV Metastatic disease STAGING STAGING IA T1 N0 MO IA T1 N0 MO IB T1 N1 M0 IB T1 N1 M0 II T1 N2 M0 II T1 N2 M0 III T2 N2 M0 III T2 N2 M0 IIIB T3 N2 M IIIB T3 N2 M IV AnyT Any N M1 IV AnyT Any N M1

86 SPREAD 1. DIRECT : 2. LYMPHATIC : By permeation Emboli Emboli Trosier,s sign Trosier,s sign 3. BLOOD BORN METASTASIS Liver Liver Lung,bones Lung,bones 4. TRANSPERITONEAL SPREAD Indicates incureability Indicates incureability Manifests as ascities Manifests as ascities Krukenberg tumour Krukenberg tumour Sister joseph nodule Sister joseph nodule Blumer,s shelf Blumer,s shelf

87 TREATMENT 1.SURGERY; --curative --palliative --palliative2.RADIOTHERAPY3.CHEMOTHERAPY SURGICAL TREATMENT SURGICAL TREATMENT Incurable disease is not subjected to radical surgery Incurable disease is not subjected to radical surgery Evidence of incureability are; Evidence of incureability are; --Haematogenous spread --Haematogenous spread --Distant peritoneal involvement --Distant peritoneal involvement --N4 nodal disease & disease beyond N4 nodes --N4 nodal disease & disease beyond N4 nodes --Fixation to structures that can not be removed --Fixation to structures that can not be removed Cure resection should be considered in remaining pts. Cure resection should be considered in remaining pts.

88 Total Gastrectomy

89 Subtotal Gastrectomy

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93 3.PALLIATIVE SURGERY; In symptoms of obstruction & bleeding In symptoms of obstruction & bleeding Only tumour is removed &GIT continuity is restored by ROUX LOOP Only tumour is removed &GIT continuity is restored by ROUX LOOP Gastric exclusion & oesophagojejunostomy Gastric exclusion & oesophagojejunostomy Palliative intubation & stenting (for inoperable cardia tumours) Palliative intubation & stenting (for inoperable cardia tumours)RADIOTHERAPY; Results are disappoiting in CA stomach Results are disappoiting in CA stomach But have benefits in painful bony metastasis But have benefits in painful bony metastasisCHEMOTHERAPY; Epirubacin + cispltinium+5-FU Epirubacin + cispltinium+5-FU Mitomycin C– impregnated charcoal in intraperitoneal route ( in Japan) Mitomycin C– impregnated charcoal in intraperitoneal route ( in Japan) RELAPSE & METASTASIS; Common site of relapse is Gastric bed Common site of relapse is Gastric bed Metastasis occur in –intra peritoneal & distal LNs Metastasis occur in –intra peritoneal & distal LNs -- liver -- liver -- lungs & bones -- lungs & bones


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