Gastric Cancer

DR HASSAN ABBAS.
Objectives

 Epidemiology
 Clinical Presentation
 Diagnosis
 Staging
 Treatment
 Screening
Objectives

 Epidemiology
 Clinical Presentation
 Diagnosis
 Staging
 Treatment
 Screening
Epidemiology

 Incidence: 21,260 cases in 2007

– ~7 per 100,000
 11,210 cancer deaths in 2007
 Mortality significantly decreased in past 75
years (unknown reasons)
Gastric tumors

 85% adenoocarcinomas
 15% lymphomas and gastrointestinal stromal
tumors (GIST)
Adenocarcinoma Cancer types

 “Intestinal type” (more common)

– Morphologically similar to intestinal
adenocarcinomas.
 Diffuse-type
– Lack of intercellular adhesions (germline mutation
in protein E-cadherin)
Spectrum of gastric cancer

 Proposed progression:
 chronic gastritis -->
– chronic atrophic gastritis -->
 intestinal metaplasia -->
– dysplasia -->
 adenocarcinoma
Risk Factors for gastric cancer

 Diet
– nitroso compounds
– low fruit/vegetable, high fried foods/processed meat
– High salt intake
 Obesity
 Smoking (HR 2-3)
 ? Alcohol
 H. Pylori
 Low socioeconomic status
 Hereditary diffuse gastric cancer
– 40-67% lifetime risk for men, 60-83% for women
 Immigrants from endemic areas
– maintain native country risk, risk to offspring similar to new homeland
Objectives

 Epidemiology
 Clinical Presentation
 Diagnosis
 Staging
 Treatment
 Screening
Presentation

 Approximately 50% of cases present with

symptoms and have disease extending
beyond locoregional confines
 Of locoregional cases, only ½ can undergo a
potentially curative resection
Symptoms at presentation
Symptoms (cont’d)

 Dysphagia: more common with proximal

gastric tumors
 Occult GI bleeding very common, overt
bleeding <20%.
Less Common Symptoms

 Pseudoachalasia: if Auerbach’s plexus

involved
 Colonic obstruction: if cancer spreads (direct
extension) to colonic wall
Signs

 Palpable abdominal mass: most common

physical finding
 If cancer spreads via lymphatics…
– Left supraclavicular node (Virchow’s)
– Periumbilical node (Sister Mary Joseph)
– Left axillary node (Irish)
– Enlarged ovary (Krukenberg's tumor)
– Ascites
Objectives

 Epidemiology
 Clinical Presentation
 Diagnosis
 Staging
 Treatment
 Screening
Diagnosis

 EGD
– Gold standard
– Single biopsy from ulcer -> sensitivity ~ 70%
– Seven biopsies from ulcer -> sensitivity >98%
– Brush cytology increases sensitivity of single
biopsies, aid in multiple biopsies unclear
Barium studies

 False negative in as many as 50% of cases

 Sensitivity as low as 14% in early cases
 May be superior to EGD for linitis plastica
– EGD may be normal while “leather-bottle” will be
apparent on radiograph
Linitis Plastica

 Diffuse-type gastric cancer

 Tumor often infiltrates the submucosa and
muscularis propria
 Superficial biopsies may be falsely negative
 Combination of strip and bite biopsy needed
if suspicious for linitis plastica
Linitis Plastica, “leather bottle stomach”
Objectives

 Epidemiology
 Clinical Presentation
 Diagnosis
 Staging
 Treatment
 Screening
Staging of Gastric Cancer

 Two systems:
– Japanese classification (more elaborate and
anatomic based)
– Western: developed by American Joint Committee
on Cancer (AJCC) and International Union Against
Cancer (UICC) -- more widely used
 Tumors at GE junction of in cardia of stomach
within 5cm of GE junction
– Classified using esophageal staging
Other caveats

 T stage: dependent on depth of tumor

invasion NOT size of lesion
 Nodal stage: based on # of positive LN rather
than location of LNs (proximity to tumor)
Staging workup

 Biopsy
 Imaging
– CT: evaluates for metastases (M stage)
 20-30% with negative CT have intraperitoneal disease at
laparatomy
 Accuracy of 50-70% for T stage
 Slightly worse accuracy for N stage compared to EUS
– EUS: most reliable nonsurgical method to evaluate
depth of invasion
 More accurate than CT for T stage
 65-90% accurate for N stage
Staging workup

 PET
– More sensitive than CT for detection of distant
metastases.
– Also useful for detecting LNs
– Negative PET not helpful- even large tumors can
be falsely negative if metabolic activity low.
 Most diffuse gastric cancers (signet ring) are not FDG
avid
Staging workup

 Serologic markers
– CEA, CA-125, CA 19-9, CA 72-4 may be elevated
but have low sensitivity/specificity
– None are diagnostic
– Preoperative elevation in markers usually
pretends high risk of adverse outcome
– No serologic finding should exclude surgical
consideration
AJCC Staging System
AJCC Staging System
Objectives

 Epidemiology
 Clinical Presentation
 Diagnosis
 Staging
 Treatment
 Screening
Treatment

 Locoregional (stage I-III) disease

– Potentially curable
– Refer for multidisciplinary evaluation and
consideration of surgery
 Advanced (stage IV) disease
– Palliative therapy
– Studies indicate longer survival and better quality
of life with systemic treatment
Treatment

 Complete surgical resection with removal of

LNs (only chance of cure)
– Possible in < 1/3 of cases
 Subtotal gastrectomy for distal carcinomas,
total or near-total for proximal masses
 Reduction of tumor bulk (palliative)
– Chemotherapy (cisplatin + 5-FU or irinotecan)
 Partial response in 30-50% of patients
– Radiation (for pain control, no mortality benefit with
XRT alone)
Data from SEER. Patients diagnosed from 1991-2000 (n=14,097). Stage IA
(n=1194), stage IB (n=655), stage IIA (n=1161) stage IIB (n=1195), stage IIIA
(n=1031), stage IIIB (n=1660), stage IIIC (n=1053), stage IV (n=6148).
 Prognosis
% of % 5-year
Stage TNM Features Cases* survival*
0 TisN0M0 Node negative; limited to mucosa 1 90
Node negative; invasion of lamina propria or
IA T1N0M0 submucosa 7 59
Node negative; invasion of muscularis
IB T2N0M0 propria 10 44
T1N2M0 Node positive; invasion beyond mucosa but
II T2N1M0 within wall 17 29
T3N0M0 Node negative; extension through wall
T2N2M0 Node positive; invasion of muscularis propria
IIIA or through wall
21 15
T3N1-2M0
Node negative; adherence to surrounding
IIIB T4N0-1M0 tissue 14 9
Node negative; adherence to surrounding
IV T4N2M0 tissue 30 3
Any M1 Distant Metastases

** Data from American Cancer Society

Objectives

 Epidemiology
 Clinical Presentation
 Diagnosis
 Staging
 Treatment
 Screening/Follow-up
Screening

 Currently screening programs in Japan, Venezuela,

Chile due to high incidence
– Mostly barium studies, EGD is concerning findings
– Some use serum pepsinogen testing for high risk with EGD
confirmation
– H. pylori: sensitivity 88%, specificity 41% (Japan)
– Japan study: 5-year survival 74-80 in screened group, 46-
56% for non-screened group.
 Not cost effective in US due to relatively low
incidence (<10 per 100,000)
– Preventing incidence of 1 gastric cancer death estimated to
cost $247,600
Gastric Ulcers

 25% of patient with gastric cancer have history of a

gastric ulcer
 American Society of Gastrointestinal Endoscopy
recommendations:
– Follow-up EGD in 8-12 weeks to verify healing.
– Non-healing ulcers need repeat biopsies
 Question of cost-effectiveness of repeat
endoscopies; however, small (curable) lesions may
be missed without follow-up.
Take Home Points

 Most cases present in advanced stage

 Staging workup (CT vs PET vs EUS) to
evaluate extent of disease
 Staging laparoscopy indicated for medically
fit patients with >T1 lesion and without stage
IV disease
 Ensure follow-up of ulcers seen on EGD
 No effective screening in US patients
References

 Harrison’s Principles of Internal Medicine

 Up to Date