Gastric Adenocarcinoma

• • Vague postprandial abdominal heaviness or fullness

  • Anorexia and weight loss

  • Upper GI endoscopic biopsy and histologic confirmation

Epidemiology

• • Ulcerating (25%): Ulcer-tumor that extends through all gastric layers

  • Polypoid (25%): Large, bulky intraluminal growths

  • Superficial spreading (15%): Confined to the mucosa and submucosa; also known as early gastric cancer

  • Linitis plastica (10%): Spreading tumor involving all gastric layers

  • Advanced (35%): Large tumors partly within and partly outside stomach

  • 40% in antrum, 30% in the body and fundus, 25% at the cardia, and 5% involve the entire organ

  • Helicobacter pylori infection carries a 3.6- to 18-fold increased risk of gastric cancer

  • Mean age at diagnosis is 63 years

  • Majority are adenocarcinoma; squamous cell arises from esophagus

  • Intestinal type histology has better prognosis than diffuse type

Symptoms and Signs

• • Postprandial abdominal heaviness

  • Anorexia develops early; weight loss averages about 6 kg

  • Vomiting, often containing blood, is a feature if pyloric obstruction occurs

  • Epigastric mass in 25% of cases

  • Hepatomegaly in 10% of cases

  • In 50% of cases, stool positive for occult blood; melena is seen in a few

  • Signs of distant spread

  • -Metastases to the neck (Virchow node)

    -Metastases anterior to rectum detectable on rectal examination (Blumer shelf)

    -Metastases to ovaries (Krukenberg tumors)

Laboratory Findings

• • Anemia is present in 40% of patients

  • Carcinoembryonic antigen (CEA) levels are elevated in 65% of patients, usually indicating extensive spread of the tumor

Imaging Findings

• • Large gastric carcinomas can usually be identified at endoscopy

  • All gastric lesions, whether polypoid or ulcerating, should be examined by taking multiple biopsy and brush cytologic specimens during endoscopy

• • Vague postprandial abdominal heaviness or fullness, along with anorexia and weight loss should prompt upper GI endocopy and biopsy

  • Any endoscopically evident gastric ulcer should be adequately biopsied to rule out carcinoma

Rule Out

• • Benign gastric ulcer

• • Upper GI endoscopy and biopsy will provide histologic diagnosis

  • CT scan for staging

When to Admit

• • High-grade gastric outlet obstruction preventing adequate enteral nutrition and hydration

  • Severe bleeding from ulcer

• • Resect tumor, adjacent margin of stomach (6 cm proximally) and duodenum, regional lymph nodes (no radical lymphadenectomy), and portions of adjacent organs if involved

Surgery

Indications

• • Curative resection if no metastases and reasonable operative risk

  • Palliative resection if the stomach is still movable and life expectancy is estimated to be more than 1-2 months

Contraindications

• • Limited life expectancy (< 1-2 months) and prohibitive operative risk

Medications