Gastric Cancer

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1- Introduction

2-Key Definitions

3- Clinical Features & Examination Tips

4- Investigations & Interpretation

5- Pathophysiology

6- Symptoms

7- Treatment

Introduction

Gastric cancer is the fifth most common cancer worldwide, with high mortality. Around 90% are adenocarcinomas, arising from the gastric mucosa, most often against a background of chronic atrophic gastritis and intestinal metaplasia. It presents late in Western countries but is often caught early in countries like Japan due to screening.

© image from Wikimedia Commons

Key Definitions

  • Adenocarcinoma: Malignant tumour of gland-forming epithelial cells.

  • Intestinal type: Well-differentiated, arises from intestinal metaplasia.

  • Diffuse type: Poorly differentiated, infiltrates stomach wall (e.g. linitis plastica).

  • Early gastric cancer: Confined to mucosa/submucosa.

 

  • CDH1 mutation: Associated with hereditary diffuse gastric cancer.

Clinical Features & Examination Tips

–Early disease is often asymptomatic, diagnosed via endoscopy for dyspepsia.
In advanced disease, symptoms include:

  • Weight loss (66%)

  • Epigastric pain (50%)

  • Anorexia, nausea

  • Early satiety

  • Anaemia (from occult bleeding)

  • Dysphagia (cardia involvement)

  • Haematemesis, melaena (less common)

–Examination findings:

  • Weight loss, pallor, epigastric mass

  • Virchow’s node (left supraclavicular)

  • Sister Mary Joseph nodule (umbilicus)

  • Krukenberg tumour (ovary metastasis)

  • Paraneoplastic signs: Trousseau’s sign, acanthosis nigricans

Investigations & Interpretation

–Initial test:

  • Upper GI endoscopy + multiple biopsies

–Staging:

  • CT, EUS (endoscopic ultrasound)

  • Laparoscopy for assessing peritoneal spread

-Consider testing for HER2 (for targeted therapy like trastuzumab)

Pathophysiology

  • Most cases arise after a long-term sequence:
    H. pylori infection → chronic gastritis → atrophy → intestinal metaplasia → dysplasia → carcinoma

  • H. pylori is a definite carcinogen (IARC class I) and may be responsible for ~70% of gastric cancers

  • Risk increases with dietary nitrites, smoked foods, autoimmune gastritis, family history, and CDH1 mutation

  • Intestinal-type arises from metaplastic mucosa; diffuse-type arises de novo and is often more aggressive

Symptoms

  • Persistent epigastric pain

  • Weight loss

  • Vomiting, nausea

  • Iron-deficiency anaemia

  • Early satiety (due to mass effect)

  • Dysphagia if near the gastroesophageal junction

Treatment

–Curative (Early Cancer):

  • Endoscopic resection (if limited to mucosa/submucosa)

  • Surgical resection (total/partial gastrectomy + lymphadenectomy)

    • Billroth I / Roux-en-Y reconstruction depending on location

–Perioperative chemotherapy:

  • ECF regimen: Epirubicin + Cisplatin + 5-FU

  • Post-op chemo or chemoradiotherapy if not given pre-op

–Palliative (Advanced/Metastatic):

  • Chemotherapy ± trastuzumab (if HER2+)

  • Endoscopic stenting, laser therapy for obstruction/bleeding

  • Palliative surgery in selected cases

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