Q: Make an exam oriented notes highlighting important points simple and crisp notes from the given source A: Here are crisp, exam-oriented notes on Carcinoma of the Stomach based on the provided source: --- CARCINOMA OF THE STOMACH A Concise Textbook of Surgery --- 1. INCIDENCE - One of the major causes of cancer mortality - UK/USA: 10-15 per 1,00,000/year Japan: 70 per 1,00,000/year - China small area: double that of Japan - Men Women; increases with age - Incidence falling at 1%/year body & distal stomach decreasing, proximal stomach increasing - Low socioeconomic group: body & distal stomach carcinoma more common - Higher socioeconomic group: proximal gastric cancer more common - H. pylori - associated with body & distal stomach cancer, NOT proximal --- 2. AETIOLOGY A. Diet - Positively correlated: starch, pickled vegetables, salted fish, fresh vegetables, Vit C, refrigeration - Increased salt intake → associated with stomach cancer - High nitrate intake → high risk populations - Cigarette smoking - well established association B. Environmental - High incidence: Japan, Iceland, Chile, Hawaii - Smoked fish & meat → carcinogenic hydrocarbons - Peculiar spirits China, Japan → gastritis → long-term cancer - Excessive salt + N-nitroso compounds C. Age & Sex - Rare 30 years - Peak age: 50-70 years both sexes, 59 - Males Females 3:1 in some reports D. Heredity - Blood group A → more frequent in gastric cancer patients - First-degree relatives: 2x risk - Reported in monozygotic twins E. H. pylori ⭐ - Associated with body & distal stomach cancer - Causes: gastritis → gastric atrophy → intestinal metaplasia → malignancy --- 3. PREDISPOSING CONDITIONS ⭐ Condition Key Fact ------ Chronic atrophic gastritis Hypo/achlorhydric; 10% develop cancer if followed 20 yrs Pernicious anaemia 10% develop malignancy; achlorhydria leads to cancer Chronic gastric ulcer Pyloric segment ulcers - always view with suspicion; 20% are malignant; large indolent ulcers on posterior wall → 10% malignant New growths polyps 2 cm polyps: 20% malignant; adenomatous polyps are premalignant Post-peptic ulcer surgery 4x more risk esp. with drainage procedures; reflux gastritis also increases risk Menetrier's disease Hypertrophic gastropathy; 10% cases develop cancer --- 4. DISTRIBUTION Fig. 44.18 - Antrum: 50% most common site - Body: 18% - Cardia: 10% - Fundus: 12% - Diffuse: 7% - Multiple: 3% - Commonest site = pyloric & antral regions, along lesser curvature --- 5. PATHOLOGY A. MACROSCOPIC TYPES ⭐ Type Features ------ 1. Ulcerative Most malignant & commonest; pyloric/lesser curvature; raised, rolled edges; floor necrotic 2. Proliferative / Cauliflower Bulky, cauliflower-like; projects into lumen; body/greater curvature/fundus; low grade; bleeds 3. Leather-bottle Linitis plastica Starts at pylorus; spreads to cardia; fibrotic, shortened, contracted; mucosa rugose; 2 varieties: localized pyloric & diffuse 4. Colloid/Mucoid Gelatinous degeneration 5. Ulcer cancer Pre-existing ulcer turning malignant B. MICROSCOPIC TYPES ⭐ 1. Adenocarcinoma - 95% of all gastric cancers; columnar/cuboidal/round cells; tubular, acinar, colloid, signet-ring cell types; undifferentiated type also seen 2. Squamous cell epithelioma - lower oesophagus grows into stomach 3. Adenoacanthoma - admixture of glandular + squamous elements rare --- 6. SPREAD ⭐ 1. Direct Spread - In stomach wall: upward along lesser curvature toward cardia submucous coat - 5 cm ahead of visible edge - To adjacent organs: colon, pancreas, liver, gallbladder, omentum, spleen, upper jejunum 2. Lymphatic Spread - Via embolism or permeation - Virchow's node = left supraclavicular fossa pathognomonic of stomach cancer - Spread along ligamentum teres → umbilical nodules 3. Blood Spread - Via portal vein → Liver most common organ affected - large, white, hard, umbilicated tumours - Also: lungs, pleura, bones - Subcutaneous nodules possible 4. Transperitoneal Spread - Cancer cells → peritoneal cavity → carcinomatosis peritonei - Krukenberg's tumour = bilateral ovarian metastases premenopausal women; transcoelemic implantation --- 7. CLINICAL FEATURES Symptoms in order of frequency: a Epigastric pain & indigestion b Anorexia c Loss of weight d Vomiting/haematemesis e Melaena f Abdominal mass g Dysphagia h Diarrhoea Groups of Presentation ⭐ Group Type Features --------- I New Dyspepsia Vague indigestion 40 yrs; no prior stomach history; achlorhydria/hypochlorhydria II Insidious onset Greater curvature/body; bleeding haematemesis/melaena; microcytic anaemia III Pain Most common 95%; continuous abdominal/epigastric pain; vomiting coffee-ground IV Obstructive Near pylorus; fullness, belching, vomiting; cardia → dysphagia V Lump 1/4th cases; incidental lump in epigastrium; vague dyspepsia, anorexia, weight loss VI Metastasis Primary silent; presents with ascites, jaundice, Krukenberg's, Virchow's node, Trousseau's sign Signs of Metastasis: - Virchow's node Troisier's sign - left supraclavicular node - Trousseau's sign - phlebothrombosis of superficial veins - Sister Mary Joseph nodule - umbilical metastasis - Krukenberg's tumour - bilateral ovarian metastases --- 8. INVESTIGATIONS ⭐ Test Key Point ------ Routine blood Low Hb, low RBC, high ESR 80% patients Routine stool Occult blood in 80% cases Gastric function tests Hypochlorhydria/achlorhydria; blood in basal secretion → favours cancer Barium meal X-ray Irregular filling defect = constant finding; regular filling = benign; short history + irregular = cancer Flexible endoscopy ⭐ Revolutionized diagnosis; justified if 40 yrs with dyspepsia; solidstate camera; biopsy essential; spray dye to detect mucosal abnormalities Ultrasonography Gastric wall thickening; endoluminal USG = best for staging; laparoscopic USG = best for liver metastasis CT Scan Detects gastric wall thickening; lymph node enlargement; extent of disease; guides treatment MRI No specific advantage over CT for gastric cancer Exfoliative cytology Washing of stomach/gastric lavage; 75% accuracy Tetracycline fluorescence Cancer cells absorb tetracycline → stain yellow under UV Serum Pepsinogen I Marker for intestinal metaplasia precursor of gastric carcinoma --- 9. TREATMENT General Rule: When gastric carcinoma is diagnosed → laparotomy should always be performed except absolute contraindications Contraindications to Laparotomy: - Unfit to stand operation - Disease beyond scope signs: growth fixed in pelvis, palpable metastasis even in-situ, multiple liver metastasis, palpable metastasis in left supraclavicular nodes Troisier's sign, jaundice, lung/bone metastasis Exploration - Contraindications to Radical Surgery: - Fixation to pancreas/posterior abdominal wall - Fixation of involved lymph nodes - Secondaries all over peritoneal cavity - Multiple liver secondaries except solitary resectable nodule Radical Operations: Radical gastrectomy = resection of growth with at least 1 inch of surrounding healthy wall + all draining lymph nodes 1. Total Radical Gastrectomy - for growths involving mid-stomach or whole stomach Linitis plastica; upper left paramedian incision 2. Upper Radical Partial Gastrectomy - upper 1/3 growths 3. Lower Radical Partial Gastrectomy - antrum/pylorus growths Prognosis: - Only 50% of cases will be qualified for exploration - Of those, 50% not suitable for radical operation - Only 5% of radical operation cases survive 5 years --- HIGH-YIELD EXAM POINTS ⭐⭐ 1. Most common site = Pylorus & antrum 50% 2. Most common macroscopic type = Ulcerative most malignant 3. Most common microscopic type = Adenocarcinoma 95% 4. Most common organ for blood spread = Liver via portal vein 5. Krukenberg's tumour = bilateral ovarian metastases transcoelemic 6. Virchow's node = left supraclavicular Troisier's sign 7. H. pylori = body & distal stomach cancer ONLY not proximal 8. Leather-bottle stomach = Linitis plastica fibrous, scirrhous 9. Best investigation = Flexible endoscopy with biopsy 10. Irregular filling defect on barium = favours carcinoma 11. Serum pepsinogen I = marker for intestinal metaplasia 12. Laparoscopic USG = best to detect liver metastasis 13. Blood group A = higher risk 14. Occult blood in stool = 80% of cases 15. Pyloric ulcer = always suspect malignancy 20% are primarily malignant --- Source: A Concise Textbook of Surgery, Chapter 44 - Stomach & Duodenum
