12/2/2010
TUMOR LAMBUNG
DR. MABEL HM SIHOMBING, SPPD-KGEH DR.ILHAMD SPPD
DIVISION OF GASTROENTERO-HEPATOLOGY DEPARTEMENT OF INTERNAL MEDICINE FACULTY OF MEDICINE / NORTH OF SUMATERA H. ADAM MALIK HOSPITAL
TUMOR LAMBUNG EPIDEMIOLOGY INSIDENSI : JAPAN :100/100000 USA : 6 /100000 TYPE : ADENO CARCINOMA GASTRIC LYMPHOMA LEIOMYOSARCOMAS CARCINOID TUMORS SYMPTOM : NOT SPECIFIC & FREQUENT VAGUE (EPIGASTRIC PAIN, HEARTBURN, ULCER PAIN, BB↓ ↓, MUAL, ANEMIA, HEMATEMESIS)
1
12/2/2010
2
12/2/2010
RISK FACTORS FOR GASTRIC ADENOCARCINOMA DEFENITE/SURVEILLANCE SUGGESTED FAMILIAL ADENOMATOUS POLIPOSIS (FAP), GASTRIC ADENOMA DYSPLASIA
DEFENITE HP INFECTION, CHRONIC ATROPHIC GASTRITIS, INTESTINAL METAPLASIA, HERED. NONPOLYPOSIS COLORECTAL CANCER (HNPCC) POSTGASTRECTOMY, FIRST-DEGREE RELATIVE WITH GASTRIC CANCER
PROBABLE PEUTZ-JEGHERS SYNDROME, CIGARETTE SMOKING, LOW ASPIRIN INTAKE, HIGH SALT INTAKE, LOW INTAKE OF FRESH FRUITS AND VEGETABLES, PERNICIOUS ANEMIA, LOW ASCORBATE INTAKE
POSSIBLE LOW SOCIOECONOMIC STATUS MENETRIER’S DISEASE, GASTRIC ULCER
QUESTIONABLE HIGH INTAKE OF ALCOHOL HYPERPLASTIC/FUNDIC POLYPS
3
12/2/2010
HELICOBACTER PYLORI
CARCINOGENIC NO. 1
NORMAL H PYLORI
CHRONIC ACTIVE GASTRITIS ATROPHIC GASTRITIS
P53 MICROSATELLITE INSTABILITY
INTESTINAL METAPLASIA LOW – GRADE DYSPLASIA HIGH - GRADE DYSPLASIA APC / β = CATENIN
GASTRIC CANCER
PROPOSED MULTISTEP PATHWAY IN THE PATHOGENESIS OF GASTRIC CANCER
4
12/2/2010
Dugaan : Pathogenesis of Gastric Carcinoma H. Pylori Acquisition
Normal Stomach
Autoimmunity
10 % 45 % NaCl
Cronic gastritis
DGCA Multifactorial 45 %
Atropic gastritis
Intestinal Metaplasia
IGCA
Bacterial over growth/Inflammation N-Nitroso-Compouns
Vitamin intake (c, carotene)
5
12/2/2010
INVESTIGATION : HISTORY PHYSICAL EXAMINATION BARIUM MEAL DOUBLE CONTRAST ENDOSCOPY BIOPSY CONFIMATIVE DIAGNOSTIC SCANNING
6
12/2/2010
TREATMENT CURATIVE (OPERATIVE) : SUBTOTAL GASTRECTOMY MORTALITAS ↓ & MORBIDITAS ↓ PALLIATIVE (OPERATIVE) : SUBTOTAL GASTRECTOMY BLEEDING ↓ & OBSTRUCTION ↓ & QOL ↑ (QUALITY OF LIFE ) CHEMOTHERAPY :
PENGOBATAN : # DINI : MUNGKIN MASIH DAPAT DILAKUKAN MUCOSAL RESECTION (EMR) # BEDAH : - CURATIVE - PALLIATIVE : - TANDA OBSTRUKSI - TANDA PERDARAHAN # KEMOTERAPI # RADIASI Prognosis : Sangat ditentukan oleh : 1. Derajat invasi dinding lambung 2. Adanya penyebaran ke kelenjar lymph 3. Anak sebar di peritoneum dan tempat lain
7
12/2/2010
COMPLICATION POST OPERATIVE (SUBTOTAL GASTRECTOMY) 1. MEGALOBLASTIC ANEMIA ← SUPP. VIT B 12 2. DUMPING SYNDROME : NAUSEA, VOMITING ABD. FULLNESS, TACHYCARDIA, WEAKNESS, DIZZINESS SMALL MEAL & LOW CHO 3. BUND LOOP SYNDROME REFRACTORY DIARRHEA ← BACTERIAL OVER GROWTH ← MALABSORBTION ANTIBIOTICS
INTRA OPERATIVE STAGING TUMOR
5 YEARS SURVIVAL
STAGE I
MUCOSA-SUBMUCOSA
85 %
STAGE II
PENETRASI SEROSA
45 – 55 %
STAGE III
REGIONAL LYMPH NODE (+) DISTAN METASTASIS
17 %
STAGE IV
<5%
8
