GASTRIC CARCINOMA

Presentan:
Shoofii Dzakiyyah Ulhaq
12100116175

Preceptor : dr. Hidayat Wahyu

Aji, Sp.,Rad
BAGIAN RADIOLOGI
RUMAH SAKIT UMUM DAERAH BANDUNG AL-IHSAN
BANDUNG
2017
ANATOMIC ASPECTS
The stomach wall is made up of 5 layers:
1. mucosa
2. submucosa
3. muscularis layer
4. subserosal layer
5. serosal layer
 GASTRIC NEOPLASM

Benign Malignant

Epithelial
1.Primary
Mesenchym Adenocarcinoma
al Gastrointestinal stromal
tumors GIST
Lymphoma

2. Secondary:
invasion from adjacent
tumors.
GASTRIC CARCINOMA
Suatu tumor epitel pada mukosa gaster yang bersifat
malignan dengan diferensiasi kelenjar. Bagian foveola
(cypt , pit) terutama lapisan sel generatif yang terletak
pada bagian basal yang sering mengalami keganasan.

EPIDEMIOLOGI
- Jenis karsinoma terbanyak keempat didunia tahun
2004-2005
- Diseluruh dunia terdapat 930.000 kasus baru dan
700.000 kematian setiap tahunnya. 6% kasus baru
muncul pada negara berkembang.
- Secara geografis insidensi tertinggi pada Chili, Unisoviet
dan Jepang.
- Rasio pria: wanita yaitu 2:1
- Usia rerata terdiagnosis 40-70 tahun, insidensi
meningkat dengan peningkatan usia
 GASTRIC CARCINOMA

Epidemiology
DEFINITION & Risklesion
Malignant Factors
of the stomach.

55 year old Japanese male who is living in Japan & working in

industry.
Incidence of Gastric
Carcinoma:
Japan 70 in100,000/year
Europe 40 in 100,000/year Twise more common
UK 15 in 100,000/year In male
Japan has the worldthan in female
dust ingestion
Can
USAoccur10 in at any age
100,000/year
ButStudies have highest
Peak incidece
Rate of
confirmed from a variety
It is that
decreasing worldwide.
gastric cancer. of industrial
Is 50-70 incidence
years old. decline in
Japanese
It is more immigrant to
aggressive processes
In younger America.
ages. may be a risk.
FAKTOR RISIKO & ETIOLOGI
Penyebab kanker gaster bersifat
multifaktoral:
inherited predisposition
environmental factors
Diet (tinggi nitrat pada makanan yg
dikeringkan, diasap dan diasinkan)
smoking
Helicobacter pylori infection
previous gastric surgery
pernicious anemia
adenomatous polyps
chronic atrophic gastritis
gastric ulcers
radiation exposure
obesity
TIPE GASTRIC TUMOR

1. Adenocarcinoma
Jenis kanker lambung paling sering (90-95%) dan
berkembang dari jaringan glandular
2. Lymphoma
Berkembang di jaringan limfatik dari dinding lambung
(5%)
3. Carcinoid Tumors
Berkembang di jaringan penghasil hormon dari lambung.
Kebanyakan tumor ini tidak menyebar ke organ lain (3%)
4. Gastrointestinal Stromal Tumors (GIST)
Berkembang di jaringan dinding lambung yang berisi
tipe sel spesifik yang disebut intestinal cells of Cajal.
GIST jarang membentuk sel kanker dan dapat muncul di
seluruh sistem pencernaan, paling banyak di gaster (2%)
5. Leiomyosarcoma
 KLASIFIKASI
Gambaran lesi makroskopis dari
hasil pemeriksaan endoskopi
( Japanese Gastroenterological
Endoscopic Society )
Type I : Lesi menonjol pada
permukaan mukosa ( polypoid,
nodular ataupun villous)
Type IIa : Lesi yang elevasi pada
permukaan mukosa
Type IIb : Lesi yang berbentuk rata /
flat dengan permukaan mukosa
Type IIc : Lesi yang depressed dari
permukaan mukosa
Type III : Lesi yang excavated dari
permukaan mukosa.
 PATHOLOGY
DIO CLASSIFICATION
LAUREN CLASSIFICATION:
1.Intestinal Gastric Ca:
Muncul diarea metaplasia usus untuk
membentuk polypoid tumor atau ulcer
2.Diffuse Gastric Ca
Terjadi infiltrasi dalam di gaster tanpa
membentuk lesi masa tertentu tapi menyebar
ke dinding gaster Linitis Plastica dan
menyebabkan prognosis yang lebih memburuk.
3. Mixed Morphology
PATOFISIOLOGI
MANIFESTASI KLINIS
Anamnesis
- Pada fase awal tidak menunjukkan gejala
(asimptomatik)
- Pada fase lanjut muncul keluhan, seperti:
indigestion
nausea
vomiting
dysphagia
postprandial fullness
loss of appetite
melena
hematemesis
weight loss
Epigastric pain
 MANFES
-Anemia.
-Penurunan BB (cachexia)
-Massa Epigastric,Hepatomegaly,
-Ascites , Jaundice.
-Blumers shelf (shelflike tumor of the anterior
rectal wall)
-Virchows node (pembesaran KGB di
supraclavicular)
-Sister mary joseph node (periumbilical metastasis
)
-Krukenberg tumor (tumor di ovarium gastric
ca)
-Irish node (pembesaran KGB di anterior axilla)
Paraneoplastic syndromes (poor prognostic)
berupa:
dermatomyositis
 DIFFERENTIAL DIAGNOSIS
1.Gastric ulcer
From history,
Cancer is not relieved by antacids
Not periodic
Not releived by eating or vomiting.

2.Other gastric neoplasms

3.Gastritis
4.Gastric Polyp
5.Crohns disease.
DIAGNOSIS
Double contrast radiographic
examination
Membantu mendeteksi lesi kecil
didaerah mukosa & submukosa,
terbagi:
Type I - Elevated lesions that protrude
more than 5 mm into the lumen
Type II - Superficial lesions that are
elevated (IIa), flat (IIb), or depressed
(IIc)
Type III - Shallow, irregular ulcers
surrounded by nodular, clubbed
mucosal folds
Spesifitas 90%
Kekurangan: lesi superfisial awal
mukosa lambung dapat terlewat
& tidak dapat membedakan antara
benign ulcer & ulcerating
adenocarcinoma.
DIAGNOSIS

Double contrast
barium swallow
has 90%
accuracy and is
cost effective.
No ability to distinguish
between malignant and
benign ulcers.
 Double-contrast upper gastrointestinal series

Barium Contrast Radiography:

large crater which erodes into a
mass( filling-defect) on the lesser
curve, below the gastric angle.
irregular narrowing and rigidity of the
stomach, giving rise to the typical linitis
plastica, or "leather bottle," appearance.
Although some are lobulated lesions in
the fundus or body, others consist of
thickened, irregular mucosal folds and
nodularity without significant narrowing.
 X-ray showing Extensive
carcinoma involving
X-ray showing Gastric ulcer the cardia & Fundus
With symmetrical radiating
Mucosal folds.
By histology, no evidence of
Malignancies was observed.

Pyloric stenosis
 Gastroscopy
Tidak wajib dilakukan jika:
Gambaran radiografi menunjukkan benign.
Penyembuhan total yang terlihat pada xray selama 6
minggu
Follow-up radiografi kontras pada beberapa bulan
selanjutnya menunjukkan gambaran normal.
Dapat melihat ulcer (25%), polypoid mass (25%), penyebaran
superfisial (10%) atau infiltrasi (Linnitis Plastica) sulit untuk
dideteksi.
Akurasi 50-95% bergantung pada gambaran kasar, ukuran,
lokasi dan biopsi.
 IF YOU SEE ULCER ASK UR SELF
BENIGN OR MALIGNANT?
MALIGNANT BENIGN
Irregular outline with Round to oval punched out
necrotic or hemorrhagic lesion with straight walls &
base flat smooth base
Irregular & raised margins Smooth margins with
normal surrounding
mucosa
Anywhere Mostly on lesser curvature
Any size Majority<2cm

Prominent & edematous Normal adjoining rugal

rugal folds that usually do folds that extend to the
not extend to the margins margins of the base
ENDOSCOPY
IMAGING STUDIES

Esophagogastroduodenoscopy has a
diagnostic accuracy of 95%
PREOPERATIVE WORKUP
Ketika diagnosis gastic cancer dilakukan, CT Scan
berguna untuk evaluasi kelanjutan penyakit. Once
diagnosis of gastric cancer has been made, CT scan is
useful for evaluation of any distant disease.
Lemah dalam mendeteksi metastasis tumor yang awal dan
primer (<5mm).
Accuracy of lymph node staging ranges from 25 to 86%.
Membantu menilai penebalan dinding dan metastasis
(peritoneum, lever dan lymph nodes)
Jika CT scan negatif, maka direkomendasikan dilakukan
laparoscopy untuk evaluasi lebih lanjut.
Chest radiograph
CT scan or MRI of the chest, abdomen, and pelvis

Endoscopic ultrasound
 HISTOLOGIC FINDINGS

adenocarcinoma of the stomach constitutes 90-95% of all gastric

malignancies
lymphomas
gastrointestinal stromal tumors (2% of gastric neoplasms)
leiomyomas
leiomyosarcomas
carcinoids (1%)
adenoacanthomas (1%)
squamous cell carcinomas (1%) Histology of gastric
cancer with signet ring cells
 STAGING SYSTEM FOR GASTRIC CA

Stage TNM Features No. of Cases % 5 year

survival, %

0 TisN0M0 Node negative; 1 90

Limited to mucosa
IA T1N0M0 Node negative; 7 59
Invasion of lamina propria or
submucosa
IB T2N0M0 Node negative; 10 44
Invasion of muscularis
propria
II T1N2M0 Node positive; invasion 17 29
T2N1M0 beyond mucosa but within
wall
T3N0M0 Node negative, extension
through wall
IIIA T2N2M0 Node positive; invasion of 21 15
T3N1-2M0 muscularis propria or
through wall
IIIB T4N0-1M0 Node negative; adherence to 14 9
surrounding tissue
IV T4N2M0 Node positive; adherence to 30 3
surrounding tissue
T1-4N0-2M1 Distant metastases
 Staging
Spread of
of Gastric
gastric Cancer
cancer

T1Direct
laminaSpread
propria & submucosa
Lymphatic spread
T2 muscularis & subserosa
T3Tumor penetrates the
serosa
muscularis, serosa &
What is important here is
Virchows node
T4Adjacent
Adjacentorgans organs (Trosiers sign)
(Pancreas,colon &liver)
N0 no lymph node
N1 Blood-borne
Epigastric node Transperitoneal
metastasis spread
N2 main arterial trunk
Usually with extensive This is common
M0Disease
No distal metastasis
where liver 1st Anywhere in peritoneal cavity
(Ascitis)
M1Involved
distal
Bone
then lung &
metastasis Krukenberg tumor (ovaries)
Sister Joseph nodule
(umbilicus)
 COMPLICATIONS
Peritoneal and pleural effusion

Obstruction of gastric outlet or

small bowel

Bleeding

Intrahepatc jaundice by
hepatomegaly
 I H
A S
K
A
R IM
TE