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TUMOR LAMBUNG

Disusun oleh: Hendianto 030.08.116

Pembimbing: Dr. Rofi Yuldi Saunar, Sp.B(K)BD


KEPANITERAAN KLINIK ILMU BEDAH RSUP FATMAWATI PERIODE 26/02/2013 4/05/2013

Epidemiologi
Kanker gaster merupakan kanker keempat yang paling sering terjadi di dunia. Sekitar 600,000 kasus baru terdiagnosa setiap tahunnya, dan hampir dua pertiga dari pasien meninggal dikarenakan kanker gaster.

Insidens Tumor Gaster yang tinggi ditemukan di Jepang, Cina,Korea dan Chili, di Jepang dalam rentang waktu 1980-2003 terjadi 34,5 per 100.000 pada pria dan 13,2 per 100.000 pada wanita. Tumor gaster banyak ditemukan pada orang tua (50-70 tahun), Perbandingan laki-laki : wanita = 2:1.

Epidemiologi
Insiden kanker lambung di banyak pusat penelitian Indonesia pada tahun 1996. Kejadian kasus yang tertinggi dari kanker lambung berada di Medan: Laki-laki (5,6%), Perempuan (2,22%), Jakarta: Laki-laki (4%), Perempuan (1,39%), Palembang:Laki-laki(4,75%),Perempuan (0,11%) Denpasar:Laki-laki (2,97%),Perempuan (0,24%) Surabaya: laki-laki(1,38%),Perempuan(0,35 %).7

FAKTOR RESIKO
Diet Faktor Penjamu:
-Gastritis Kronis - Infeksi H. pylori - a cofactor - Polip gaster

Genetik
- Golongan Darah A - Riwayat Keluarga - Ras

Etiologi
H. pylori Faktor Genetik

Kanker Lambung

Faktor Lingkungan

Kondisi Precancer

Faktor Lingkungan
Status Ekonomi Kurang Mampu
Kerusakan Mukosa

Makanan Berpengawet Kurangnya Konsumsi makanan segar


Kebiasaan Merokok Zat Karsinogenik

GC

Kurang Antioxidant

Makan makanan yang diasap atau diasinkan

Kondisi Pracancer
Diartikan sebagai kondisi dimana beresiko tinggi untuk berlanjutnya proses menjadi keganasan. Gastritis Atrofik Kronis Riwayat reseksi/gastrektomi Anemia pernisiosa Ulkus Gaster Kronik Polip Gaster

Klasifikasi Patologis
Borrmanns Laurens WHO Gross Morphology Histopathology (cohesiveness) Histopathology (grade dan pertumbuhan) Histopathology (pertumbuhan dan pola) Histhopathology (atypia & musin)

Ming
Goeski

Klasifikasi Kanker Lambung


Kedalaman Invasi
EARLY GASTRIC CA - mucosa & submucosa ADVANCED GASTRIC CA berada di/lebih dalam dari muscularis propria

Pola Pertumbuhan Makroskopis


Expanding Infiltrative - "linitis plastica"

Tipe Histologi
Intestinal Diffuse (gastric); poorly differentiated; "signet ring" cells

Klasifikasi Pato-histologis
Adenocarcinoma 90% Lymphoma 5% Stromal 2% Carcinoid <1% Metastasis <1% Adenosquamous/squamous <1% Miscellaneous <1%

Stages
Stege Awal Terbatas pada mukosa dan submukosa tak terkait apakah sudah atau belum terdapat metastasis ke KGB Klasifikasi dari: Japanese Society for Gastric Cancer Stage Lanjut Berinvasi melebihi submucosa Klasifikasi dari: Bormann classification

Origin (Lauren)
Intestinal type dikaitkan paling sering dengan faktor resiko lingkungan memiliki prognosis yang lebih baik. tidak menunjukan keterlibatan riwayat keluarga.

Diffuse type terdiri dari sel scattered yang terbatas dan berprognosis buruk.

Klasifikasi TNM (UICC)

TX-tumor primer tidak dapat ditemukan ;T0- Tidak ada bukti adanya tumor primer. Tis- mencapai intraephitelial tanpa invasi ke lamina propria;T1-tumor menginvasi lamina propria atau submukosa T2- tumor menginvasi muscularis propria;T3-tumor penetrasi ke serosa tanpa menginvasi struktur ....................;T4- Tumor menginvasi struktur...................

TNM staging
Regional lymph nodes (N) NX-regional lymph nodes cannot be assessed N0- no regional lymph node metastasis N1- metastasis in 1-6 regional LN N2- metastasis in 7-15 regional LN N3- metastasis in more than15 regional LN Distant metastasis(M) MX cannot be assessed M0 no distant metastasis M1- distant metastasis

Morphology---early stage

Morphology---early stage

Morphology---early stage

Morphology ---advanced stage

Clinical manifestation
Signs and Symptoms
Early Gastric Cancer Asymptomatic or silent Peptic ulcer symptoms Nausea or vomiting Anorexia Early satiety Abdominal pain Gastrointestinal blood loss Weight loss Dysphagia

80% 10% 8% 8% 5% 2% <2% <2%

<1%

Signs and Symptoms


Advanced Gastric Cancer Weight loss 60% Abdominal pain 50% Nausea or vomiting 30% Anorexia 30% Dysphagia 25% Gastrointestinal blood loss 20% Early satiety 20% Peptic ulcer symptoms 20% Abdominal mass or fullness 5% Asymptomatic or silent <5%
Duration of symptoms Less than 3 month 40% 3-12 months 40% Longer than 12 month 20%

Special signs & terms


Linitis plastica:
diffusely infiltrating with a rigid stomach

Virchows node:
Irishs node:

supraclavicular lymphadenopathy (left)

axillary lymphadenopathy

Sister Mary Josephs node:

umbilical lymphadenopathy

Sister Mary Josephs node

Laboratory tests
Iron deficiency anemia

Fecal occult blood test (FOBT) Tumor markers (CEA, Ca19-9)

Diagnosis
Endoscopic diagnosis --- biopsy needed for definitive diagnosis Radiologic diagnosis Detection of early gastric cancer

Endoscopic diagnosis
In patients with signs and symptoms suggestive of GC,
and/or with compatible risk factors or paraneoplastic conditions, the diagnostic procedure of choice could be an endoscopic examination The diagnostic criteria for early or advanced gastric cancer under endoscopy are based on the JRSGC and Bormanns classification

Endoscopic features of gastric cancer

Radiologic diagnosis
For reasons of cost and availability, radiography may sometimes be the first diagnostic procedure performed Classic radiography signs of malignant gastric ulcer asymmetric/distorted ulcer crater ulcer on the irregular mass irregular/distorted mucosal folds adjacent mucosa with obliterated /distorted area gastricae nodularity, mass effect, or loss of distensibility

Radiologic diagnosis
Distal GC

Proximal GC

Linitis plastica

Detection of early gastric cancer


Endoscopic screening general population or high risk persons
Careful observation Japan is the only country that had conducted large nationwide mass population screening of asymptomatic individuals for gastric malignancy

Differential diagnosis

Gastric Cancer

Gastric Ulcer

Complications
GI bleeding 5%

Pylorus/cardia obstruction
Perforation ulcer type

Treatment
Surgical resection
EMR Adjuvant therapy Palliative therapy

Endoscopic mucosal resection


Gastric cancer lesion confined to mucosa layer

Endoscopic ultrasound (EUS) is helpful in stageing GC

Endoscopic mucosal resection

Endoscopic mucosal resection

Chemotherapy
Adjuvant chemotherapy may increase 5 years survival rates and decrease the relapse rates Combination chemotherapy are recommended

Chemotherapy
Regimen Fluorouracil +doxorubicin + mitomycin (FAM) Fluorouracil + doxorubicin + Semustine (FAMe) Fluorouracil + doxorubicin + cisplatin (FAP) Etoposide + doxorubicin + cisplatin (EAP) Etoposide + leucovorin + fluorouracil (ELF) Fluorouracil +doxorubicin + methotrexate (FAMTX) Approximate Response rate 30% 30% 30% 40% 30% 40% Survival Benefit No No No No No Unconfirmed

Side effects of chemotherapy


Mucositis

Alopecia

Pulmonary fibrosis Nausea/vomiting

Diarrhea
Cystitis Sterility Myalgia

Cardiotoxicity
Local reaction Renal failure

Myelosuppression
Phlebitis

Neuropathy

Prognosis
The TNM classification/staging of gastric cancer is the best prognostic indicator The 5 years survival rate depends on the depth of gastric cancer invasion Patients in whom tumors are resectable for cure also have good prognosis

Prevention

Eradication of H. Pylori infection in those high risk population family history of gastric cancer chronic gastritis with apparent abnormality (atrophy, IM) post early gastric cancer resection gastric ulcer Management of dietary risk factor intake adequate amount of fruits, vegetables minimize their intake of salty/smoked foods Tightly follow up those with precancerous condition Endoscopic or radiologic screening

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