LAPORAN KASUS Pembimbing

CA GASTER dr. Jean E. Pello, Sp.B

ABSTRACT
Gastric cancer was the fourth most common cancer in the world.
Worldwide there are 930,000 new cases and 700,000 deaths
per year. Sixty percent of new cases occur in developing
countries.
There is tremendous geographic variation, with the highest
death rates in Chile, the former Soviet Union, China, and Japan.
EPIDEMIOLOGY
In New York State there were an average of 1955 cases
annually between 1998-2002, with 1070 deaths.
Male to female ratio of 2:1 in the US; 3:2 in New York.
Median age at diagnosis is 65 years (40-70). Incidence
increases with age, peaking in the 7th decade.
RISK FACTORS
Diet
 Salted meat or fish
 High nitrate consumption
 High complex carbohydrate
 Low fruit & vegetables consumption (B carotene, selenium, Alpha tocopherol
 ↓ risk)

Key TJ, scatzkin A, Willlet W, et al. Diet, nutrition, and the prevention of cancer. 2010. Public health nutrition, 7(1A), 187-200.
RISK FACTORS
Environment
 Poor food preparation (smoked/salted)
 Lack of refridgeration
 Poor drinking water (well water)
 Smoking
RISK FACTORS
Social
 Low social class (except in Japan)

Medical
 Prior gastric surgery
 H. pylori infection
 Gastric atrophy and gastritis
 Adenomatous polyps
 Male gender
RISK FACTORS
Helicobacter pylori
 Presence of IgG to H. pylori in a given population correlates with local
incidence and mortality from gastric cancer.
 Different strains elicit different antibody responses. The cagA strain causes
more mucosal inflammation and thus a higher risk of gastric cancer than
cagA-negative strains.
RISK FACTORS
Adenomatous polyps
 10-20% risk of developing cancer, especially in lesions greater than 2 cm.
 Multiple lesions increase the risk of developing cancer.
 Presence of polyps increase the chance of developing cancer in the
remainder of mucosa.
 Endoscopic surveillance is required after removal of polyps.
ANATOMY
Most of the blood supply to the stomach is from the celiac
artery.
Four main arteries:
 Left and right gastric along the lesser curvature
 Left and right gastroepiploic along the greater curvature.
ANATOMY
Venous drainage parallels the arterial supply
 Left and right gastric veins drain into the portal vein
 Right gastroepiploic drains into the SMV
 Left gastroepiploic drains into the splenic vein
ANATOMY
Lymphatic drainage is into four zones:
 Superior gastric
 Suprapyloric
 Pancreaticolienal
 Inferior gastric/subpyloric

All four drain into the celiac group of nodes and into the
thoracic duct.
Gastric cancers drain into any of these groups regardless of
location of the tumor.
ANATOMY
Innervation:
 Parasympathetic via the vagus.
 Left anterior and right posterior.
 Sympathetic via the celiac plexus.
ANATOMY
Stomach has five layers:
 Mucosa
 Epithelium, lamina propria, and muscularis mucosae*
 Submucosa
 Smooth muscle layer
 Subserosa
 Serosa
CLINICAL PRESENTATION
Symptoms are often absent in early stages, and when present
are often ignored, missed, or mistaken for another disease
process.
 Vague discomfort and/or indigestion
 Epigastric pain that is constant, non-radiating, and unrelieved by food
ingestion.

Proximal tumors may present with dysphagia.

Antral tumors may present with outlet obstruction.
CLINICAL PRESENTATION
Up to 15% of patients develop hematemesis and 40% are
anemic at presentation.
CLINICAL PRESENTATION
Unfortunately most patients present in later stages of disease,
with evidence of metastatic or locally advanced tumor.
 Palpable abdominal mass, supraclavicular or periumbilical lymph nodes.
 Obstruction from tumor invasion into transverse colon.
 Hepatomegaly, jaundice, ascites, and cachexia.
DIAGNOSIS
Endoscopy is the diagnostic method of choice.
 With multiple biopsies (seven or more) the diagnostic accuracy approaches
98%.
 Cytologic brushings can also be obtained.
 Size, morphology, and location of tumor can be documented, as well as any
other mucosal abnormalities.
ENDOSCOPY
DIAGNOSIS
Double contrast barium
swallow has 90% accuracy
and is cost effective.
 No ability to distinguish
between malignant and
benign ulcers.
DIAGNOSIS
Endoscopic Ultrasound (EUS) is a newer modality that is being
used in some center to help stage the tumor.
Extent of wall invasion and lymph node involvement can be
assessed.
Overall accuracy is 75%.
 Poor for T2 tumors (38%)
 Better for T1 (80%) and T3 (90%)

Remains operator dependent.

PREOPERATIVE WORKUP
Once diagnosis of gastric cancer has been made, CT scan is
useful for evaluation of any distant disease.
 Limited in detecting early primary and small (<5mm) metastatic tumors.
 Accuracy of lymph node staging ranges from 25 to 86%.

If CT scan is negative, then laparoscopy is recommended as the

next step in evaluation.
PREOPERATIVE WORKUP
Laparoscopy detected metastatic disease in 23 to 37% of
patients deemed eligible for curative resection by CT scan.
Laparoscopy improves palliation in these patients by avoiding
unnecessary laparotomy in about one fourth of patients
presumed to have local disease on CT scan.
 AJCC Cancer Staging Manual, Sixth Edition

Stomach
(Lymphomas, sarcomas, and carcinoid tumors are not included.)
 AJCC Cancer Staging Manual, Sixth Edition

Stomach
(Lymphomas, sarcomas, and carcinoid tumors are not included.)
 AJCC Cancer Staging Manual, Sixth Edition

Stomach
(Lymphomas, sarcomas, and carcinoid tumors are not included.)
 THERAPY

NEO
OPERATIVE ADJUVANT
ADJUVANT
SURGICAL TREATMENT
Aggressive resection of gastric cancer is justified
in the absence of distant metastatic spread.
The surgery is tailored mainly to the location of
the tumor and known pattern of spread.
R0 resection should be achieved, with a minimum
of 6cm margins from gross tumor.
Minimum of 15 nodes should be removed.
SURGICAL TREATMENT
Tumors in the cardia and proximal stomach account for 35-50%
of gastric adenocarcinomas. For these tumors a total
gastrectomy should be performed, as opposed to proximal
gastric resection which is associated with higher morbidity and
mortality rates.
Distal tumors may be removed by distal gastrectomy as long as
adequate margins are achieved.
SURGICAL TREATMENT
The extent of lymphadenectomy remains
controversial.
The JGCA classifies the lymph node basins into 16
basins, and are grouped according to the location
of the primary tumor as either D1, D2, or D3
nodes. In general:
 D1 – removal of group 1 nodes along the lesser and
greater curvature.
 D2 – D1 plus group 2 nodes along the left gastric,
common hepatic, celiac, and splenic arteries.
 D3 – D2 plus para-aortic and distal lymph nodes
LYMPH NODE STATIONS
SURGICAL TREATMENT
A 1993 survey by the ACS showed a 77.1% resection
rate in 18,365 patients, with a postoperative
mortality rate of 7.2% and 5-year survival rate of
19%. Of these only 4.7% were D2 dissections.
In comparison, the Japanese routinely perform D2
dissections, with 5-year survival rates above 50%.
Although earlier detection accounts for much of the
survival benefit, when comparing cancers in the same
stage, the Japanese continue to have improved
survival.
SURGICAL TREATMENT
Based on this and other retrospective data, four randomized
studies comparing D1 to D2 dissections have been conducted.
All four trials, including two large ones from the Netherlands
and Britain all show the same data; that D2 dissection
significantly increases morbidity and mortality without any
significant increase in survival.
SURGICAL TREATMENT
Splenectomy and pancreatectomy were found to be important
risk factors for morbidity and mortality after D2 dissection.
In the DGCT trial a subgroup analysis of patients who
underwent D2 without splenectomy and/or pancreatectomy had
a significantly improved survival benefit.
A randomized British trial also supported these findings in stage
II and III disease.
SURGICAL TREATMENT
Choice of reanastamosis depends on extent of resection.
Very distal gastrectomies may be reanastamosed via a Billroth
I, II, or Roux-en-Y.
Subtotal gastrectomies will require a Billroth II or Roux-en-Y.
Total gastrectomies are best served with a Roux-en-Y
anastamosis.
SURGICAL TREATMENT
SURGICAL TREATMENT
SURGICAL TREATMENT
In the U.S. 20 to 30% of patients present with stage IV disease.
Palliative treatment should be geared toward relief of
symptoms with minimal morbidity, usually non-operative.
Laser recanulization and endoscopic dilatation with or without
stent placement has shown success in relieving outlet obstruction.
OUTCOMES

Patients who have undergone a potentially curative resection

have an average 5-year survival of 24 to 57%.
More useful survival rates are stratified by stage of disease.
OUTCOMES
Recurrence rates remain high, from 40 to 80% depending on
the series being quoted.
Surveillance is important. Patients should be followed every 4
months for the first year, then 6 months for 2 more years. Yearly
endoscopy should be performed for subtotal gastrectomies.
LAPORAN KASUS
IDENTITAS PASIEN
Nama : Ny. MM
Usia : 42 tahun
TL : 18/09/1975
JK : Perempuan
Alamat : Oesapa
No. MR : 482738
Tanggal MRS :14/02/2018
KRS : 26/03/2018
RIWAYAT PENYAKIT SEKARANG
KU : Perut membesar ± 1 bulan SMRS
RPS :
Pasien mengeluhkan perut membesar sejak ± 1 bulan SMRS hingga
membuat pasien merasa kesulitan bernafas yang dirasakan 3 hari
SMRS. Perut membesar disertai rasa nyeri pada perut dan dada,
nyeri berlangsung terus menerus.
Pasien juga mengeluh muntah setiap sehabis makan dan minum
terutama pada pagi hari dengan volume makanan atau minuman
yang dimuntahkan ± ½ dari volume yang dimakan. muntah didahului
rasa mual dan warna muntah dikatakan jernih dan tidak tampak
merah atau kehitaman. Muntah tidak bergantung pada jenis makanan
atau minuman yang dimakan. Pasien mengalami penurunan nafsu
makan dan penurunan berat badan. BAB 1 kali/3hari konsistensi cair,
lendir (-), kadang-kadang berwarna hitam. BAK normal.
Pasien juga mengeluh kedua kakinya bengkak.
RIWAYAT PENYAKIT
Pasien mengaku memiliki riwayat penyakit maag sejak remaja
akan tetapi tidak berat dan hanya muncul sesekali apabila
pasien telat makan.
Pasien mengatakan makanan yang ia makan cukup berimbang
dan disesuaikan dengan lauk yang ada. Pasien mengatakan
jarang makan di luar dan biasanya selalu memasak
sendiri.Pasien menyangkal adanya riwayat merokok dan minum
– minuman beralkohol.
Pasien pernah dirawat di RSU Siloam dengan keluhan yang
sama dipasang DJ Stent kanan dilepas tanggal 17/1/2018
Riw Keluarga : tidak ada keluarga yg mengalami gejala yang
sama. Riwayat Ca di keluarga (-)
PEMERIKSAAN FISIK
(26/02/2018)
Keadaan umum : tampak sakit sedang
Kesadaran compos mentis
TD : 120/70 mmHg, N : 80x/m, S: 36.80, RR : 20x/m, SpO2 98%
Kepala : normocephal
Mata : conjuctiva anemis +/+, sklera ikterik -/-
Hidung : rhinorrhea -/-
Telinga : otorrhea -/-
Mulut : mukosa bibir kering, tampak pucat dan pecah-pecah
Leher : p.KGB (-)
Thoraks : Ekstremitas :
 I : pengembangan dada simetris
 P : nt (-), FV D=S Akral hangat, CRT<2”, edema
 P : sonor pada kedua lap. Paru tungkai pitting +/+
 A : Ves menurun/+, Rh -/-, Wh -/-

 COR : S1S2 tunggal reguler, murmur

(-), gallop (-)

Abdomen :
 I : cembung, undulasi (+), venektasi (-)
 A : BU (+) kesan menurun
 P : LP = 83cm, nyeri tekan (+) pada
seluruh regio, massa & hepar lien sde
 P : pekak pada seluruh regio
abdomen
PEMERIKSAAN PENUNJANG
PEMERIKSAAN PENUNJANG (USG
ABDOMEN)
PEMERIKSAAN PENUNJANG (CT SCAN
ABD KONTRAS)
BACAAN CT-SCAN KONTRASABD
KONFIRMASI USG ABD
 Cholelythiasis halus ringan dengan sludge
Massa intramural pada gaster, bagian terbesar massa pada
curvatura mayor-cardia disertai penyempitan lumen bagian
distal ec pendesakan oleh masa. Curiga massa menginfiltrasi
tunica serosa, tidak tampak massa di intralumen
 nephrolithiasis bilateral disertai hydronephrosis grade 1
bilateral (kanan sedikit lebih prominent dari kiri. Curiga ec
batu kecil di ureter distal.
 suspek cystitis
 ascites
Efusi pleura ringan dextra
PEMERIKSAAN PENUNJANG (LAB)
14/02/2018 17/03/2018
Hb : 10.7 g/dl
Hb : 10,4 g/dl
MCV : 52,4 fl
MCH : 14,4 pg MCV : 75,6 fl
Leu : 11.04 x 103/UL MCH : 21,8 pg
Trom : 717 x 103/UL
Leu : 10.03x 103/UL
Ur/Kr : 25.68/0.68 mg/dl
SGOT/PT : 12/8 U/L Trom : 469 x 103/UL
Albumin :3,2 mg/L Albumin :2,9mg/L
Elektrolit dbn
HIV one step non reaktif

IVFD, PRC, Ceftriaxone, Inbumin

Konsul dr. SpOG  Keganasan Ginekologi dicurigai Ca
Ovarium  Sitologi Cairan Ascites  sel keganasan (-) 
laparatomy eksplorasi
Konsul Sp.U  Keganasan Urologi (-)
Konsul dr. Sp.PD  Terapi Hipoalbumin
LAPORAN OPERASI 08/03/2018
 Disinfeksi lapangan operasi kemudian drapping  insisi kulit
midline  diperdalam sampai ke peritoneum  keluar cairan
kuning jernih + 5L, dievaluasi : tampak gaster membesar,
teraba menebal massa berbenjol-benjol pada cardia dan
sepanjang dinding sampai pylorus tebal, permukaan licin/rata,
omentum majus melengket, jarak gaster dan colon transversum
pendek
 Usus halus sampai colon permukaan putih dan bernodul-nodul
Permukaan dinding peritoneum dan cavum pelvis berbenjol-
benjol
Dilakukan biopsi pada dinding gaster dan omentum  PA
HASIL PA 21/03/2018
Terdapat sel-sel atipik curiga ganas pada jaringan gaster dan
omentum. Cairan ascites terdapat sebaran limfosit, neutrofil
disertai debris, sel atipik (-).
DIAGNOSIS
Ca Gaster T4NxM1 (Stadium IV)
Hipoalbumin
Anemia MH
PLANNING
 Terapi palliative  Chemotherapy
THANKYOU 