GASTRIC CARCINOMA

Gastric cancer is a common and important tumour. It is often diagnosed too late
for curative procedures in the UK, although it is detected earlier in countries such
as Japan, where it is more common. The main surgical treatment modalities are
partial and total gastrectomies.
Incidence of gastric carcinoma
Third most common cause of cancer death in men in the UK
In the UK, 10 000 new cases per annum
Very common in Japan
Incidence falling in Europe and USA
80% are aged >65 years
Distal carcinomas are more common in lower social classes
Proximal (cardia) tumours are more common in higher social classes
More common in men than women (2M:1F)
Aetiology of gastric carcinoma
Chronic gastritis
There is a known association between chronic gastritis and gastric cancer
Of superficial cancers, 94% are found in areas of gastritis
Pernicious anaemia
The incidence of gastric cancer is raised in patients with chronic atrophic
gastritis
One type (autoimmune type A) is associated with pernicious anaemia caused by
anti-parietal cell antibodies
There is a fivefold increased risk of gastric cancer in young patients with
pernicious anaemia
Another type of chronic atrophic gastritis is environmental type B, related to:
H. pylori
Toxic and dietary agents
Previous surgery leading to bile reflux
Of all patients with pernicious anaemia 10% develop gastric cancer in 1020
years
Family history
Genetic factors are implicated by variations in races, which persist despite
emigration
Risk of stomach cancer in relatives of an affected patient is four times greater
than that in those with no affected relative
Gastric cancer is most common in people with blood group A
Napoleon and his father and grandfather all died of gastric cancer
Environmental factors
Diet, alcohol and tobacco are implicated in the development of gastric cancer but
links have not been proved.
H. pylori infection
There is undoubtedly a higher prevalence of H. pylori in patients with gastric
cancer when compared with the normal population, but a causative link has not
been proved.
Previous gastric surgery
Studies show an increased risk of gastric cancer after surgery for benign disease.
The risk seems to be related to intestinal metaplasia at the anastomosis
spreading into the gastric remnant.

Premalignant conditions
Gastric polyps
Adenomatous gastric polyps (25%) have a chance of malignant change, unlike
hyperplastic polyps (75%), which rarely become malignant
Gastric ulcers
The appearance of a gastric cancer in a chronic gastric ulcer has been recorded,
but it is thought that this is usually due to an error in diagnosis
Hypertrophic gastropathy (Mntriers disease)
This is a rare disorder involving rugal-fold hypertrophy, hyperplasia of mucusproducing cells, parietal cell atrophy producing hypochlorhydria and proteinlosing enteropathy
Of reported cases, 15% developed gastric cancer
Site of gastric cancers
There has been a change in the anatomical subsite distribution of gastric cancer:
Increased incidence in the proximal stomach, particularly around the cardia
Decreased incidence in the distal stomach
This leads to an increasing incidence of cancers around the GOJ, and it can be
difficult to tell which are oesophageal and which are gastric
Siewert classified tumours of the GOJ:
Type I is true lower oesophageal adenocarcinoma, usually arising from Barretts
oesophagus
Type II is true junctional tumour
Type III is an upper gastric tumour
Pathology of gastric cancers
Gastric cancers have four macroscopic appearances:
1. Malignant ulcer: with raised, everted edges
2. Polypoid tumour: proliferating into the stomach lumen
3. Colloid tumour: massive gelatinous growth
4. Linitis plastica (leather-bottle stomach): caused by submucosal infiltration of
tumour with marked fibrous reactions producing a small, thickened, contracted
stomach
Microscopic pathology
Tumours are all adenocarcinomas with varying degrees of differentiation. One
method of classification (Lauren classification) divides these adenocarcinomas
into two types.
Intestinal type
Poor prognosis
Composed of malignant glands

Diffuse type
Better prognosis
Composed of single or small groups of malignant cells

Spread of gastric cancers

Local spread
Often well beyond the visible tumour
Oesophagus may be infiltrated (spread to duodenum is rare)
Adjacent organs may be directly invaded
Lymphatic spread
Commonly along the nodes of the lesser and greater curves
Lymph drainage from the cardiac end of the stomach may invade the
mediastinal nodes and thence the supraclavicular nodes of Virchow on the left
(Troisiers sign)
At the pyloric end, involvement of the subpyloric and hepatic nodes may occur
The Japanese Research Society for Gastric Cancer has designated four tiers of
nodes likely to be involved according to the location of the main tumour
These are groups of nodes, the involvement of which indicates increasingly
advanced disease (which correlates with survival)
Bloodstream dissemination
Occurs via the portal system to the liver and thence occasionally to the lungs
and the skeletal system
Transcoelomic spread
May produce peritoneal seedlings and bilateral Krukenburgs tumours due to
implantation in both ovaries
Clinical features of gastric cancer
The diagnosis is commonly made only when the disease is advanced. Symptoms
are effects of the
tumour, of metastases or general features of malignant disease.
Local symptoms and signs
Epigastric pain: may radiate into the back, suggesting pancreatic involvement
Vomiting: especially with pyloric obstruction
Dysphagia: especially with tumours of the cardio
Perforation or haemorrhage
Mass in the upper abdomen on examination
Symptoms and signs of metastases
Jaundice
Abdominal distension due to ascites
More rarely, chest infections or bone pain suggesting metastases in the lungs or
skeleton

 Enlarged liver or nodes, jaundice or ascites on examination

General features of gastric cancer
Anorexia
Weight loss
Anaemia
Differential diagnosis of gastric cancer
There are five common diseases that give a similar clinical picture of a slight
lemon-yellow tinge,
anaemia and weight loss. These are:
Carcinoma of the stomach
Carcinoma of the caecum
Carcinoma of the pancreas
Pernicious anaemia
Uraemia
The principal differential diagnosis of gastric carcinoma is a benign gastric ulcer.
Investigating gastric cancer
Gastroscopy
This is the investigation of choice and the first investigation that should be carried
out in any patient suspected of gastric malignancy:
The advantage of fibreoptic endoscopy is that a suspicious lesion can be
biopsied. Biopsies from large malignant ulcers are notoriously difficult to take,
because there are large areas of benign inflamed and necrotic material within the
tumour. At least six to eight biopsy specimens should be taken from the edge of
the tumour
A gastric ulcer should not be considered benign just because it has responded to
medical treatment; it should be re-endoscoped and rebiopsied until it has
completely disappeared.
Computed tomography
Tumours at the cardia are best demonstrated following gastric distension with
600800 ml water
Distal body and antral tumours are best evaluated in the prone position
Endoscopic ultrasonography
Superior to CT for the local staging of gastric carcinoma
Higher-frequency transducers can evaluate the subgroups suitable for
endoscopic mucosal resection
The presence of direct invasion into adjacent structures can be assessed
Lymph nodes can be easily assessed
Management of gastric cancer
Preoperative optimisation
Optimising lung function and nutritional status are important in the preoperative
period:
Patients should give up smoking
High-risk patients should undergo preoperative physiotherapy
Consider placement of a nasojejunal or percutaneous jejunostomy feeding tube
if there is obstruction or malnourishment
A critical care bed may need to be arranged
The anaesthetist should be warned of any major problems and may require
further tests of pulmonary or cardiac function
Staging of gastric cancer

Full staging of the tumour is usually impossible until laparotomy (as shown in the
table).
Curative surgery for gastric cancer
This is only applicable to people without widespread metastases. Many patients in
this country present with advanced disease with little prospect of surgical cure,
but some have early T1 or T2 N0 lesions which may have been found by chance.
These patients have a good chance of survival postoperatively
Principles of curative surgery
Removal of the lesion by partial, subtotal or total gastrectomy
Removal of lymph nodes to a level determined by the site and extent of the
tumour
Restoration of the continuity of the GI tract
Creation of a reservoir in the case of total gastrectomy
Partial/subtotal gastrectomy
Possible methods of reconstruction include Billroth I, Polya and Roux-en-Y
Subtotal gastrectomy removes four-fifths of the stomach
As it is commonly for distal tumours, the entire pylorus is usually removed as
well
Extended gastrectomy
For GOJ tumours
Includes resection of the distal oesophagus
Total gastrectomy
Performed for middle-third tumours
Methods of reconstruction after a total gastrectomy include Roux-en-Y,
oesophagojejunostomy with or without a jejunal pouch, and variations of these
The 5-year survival rates for radical gastrectomy vary according to stage (see
table above)
Dissection 1 (D1) and dissection 2 (D2) gastrectomies
This has been one of the most controversial topics in the whole of surgery:
Studies demonstrate that nodal involvement indicates a poor prognosis and
more aggressive surgical approaches to remove involved lymph nodes are
gaining popularity
The Italian Gastric Cancer Study Group compared D1 (perigastric lymph nodes)
with D2 (hepatic, left gastric, coeliac and splenic arteries, as well as those in the
splenic hilum) in 2010. This RCT foundthat the postoperative morbidity rate (18%
versus 12%) and mortality rate (2.2% versus 3%) were no different between the
groups
D2 dissections are now generally recommended over D1 dissections. A
pancreas- and spleen preserving D2 lymphadenectomy is suggested because it
provides more staging information and may provide a survival benefit
Palliative surgery for gastric cancer
Many patients with gastric cancer can only be offered palliation. Symptoms most
commonly requiring palliative surgery are:
Obstruction
Haemorrhage
Pain

Principles of palliative surgery

Perform surgery only if it will significantly extend or improve quality of life
The procedure should be tailored to each patients symptoms and wishes
Theoretically the optimal operation is palliative resection if this is practicable,
because it is the
treatment of choice for obstruction and haemorrhage, and it is also effective for
ulcer-type pain (but not for pain related to extragastric extension and metastatic
disease)
However, this is rarely possible without considerable morbidity, so the modern
options of stents and palliative chemotherapy are often preferable to surgical
resection
Discussion with the oncologist beforehand at the multidisciplinary team (MDT)
meeting may identify other procedures that can be performed while the patient is
on the table, such as inserting a Hickman line for palliative chemotherapy or a
jejunostomy feeding tube
Apart from resection, other procedures available are bypass, intubation and
exclusion

Adjuvant therapy for gastric cancer

Adjuvant radiotherapy:
The British Stomach Cancer Group reported lower rates of local recurrence in
patients who received postoperative radiotherapy than in those who underwent
surgery alone
The Gastrointestinal Tumor Study Group revealed higher 4-year survival rates in
patients with
unresectable gastric cancer who received radiotherapy and chemotherapy than in
those who received chemotherapy alone (18% vs 6%)
Intraoperative radiotherapy:
Method of delivering radiotherapy allows for a high dose to be given while in the
operating room so that other critical structures can be avoided
A National Cancer Institute study showed that, although the median survival
duration was higher (21 months vs 10 months) in the IORT group, this was not
statistically significant
Adjuvant chemotherapy:
Recent meta-analyses compared 13 randomised trials and showed that
adjuvant systemic
chemotherapy was associated with a significant survival benefit (odds ratio for
death 0.80; 95% CI 0.660.97)
Subgroup analysis suggests that this effect is exaggerated in node-positive
patients

Adjuvant chemoradiotherapy:
The Intergroup 0116 study patients who received the adjuvant
chemoradiotherapy demonstrated improved disease-free survival rates (from
32% to 49%) and improved overall survival rates (from 41% to 52%) compared
with those who were observed
Neoadjuvant chemotherapy:
Attempts to downstage disease to increase resectability, determine
chemotherapy sensitivity, reduce the rate of local and distant
recurrences and improve survival
Both a European and a US RCT have demonstrated a survival benefit when
patients were treated with three cycles of preoperative chemotherapy followed by
surgery and then three cycles of postoperative chemotherapy, compared with
surgery alone
Postoperative management of gastric cancer
This older group of patients, often with comorbidity, undergo a laparotomy and
major surgery. They need careful postoperative care. Intensive care overnight is
often indicated because postoperative ventilation and sedation have benefits for
more frail patients. An epidural is invaluable for controlling pain and improving
outcome.
Look out for important immediate postoperative complications:
Chest infection
Pulmonary embolus
Anastomotic leak
Total gastrectomies are associated with adverse long-term nutritional effects:
Weight loss can be corrected by dietary supplementation
After total gastrectomy all patients become vitamin B12-deficient and need 3monthly injections within 612 months
Many patients develop iron deficiency anaemia after a total gastrectomy and
this will also have to be looked for
Malabsorption of fat and protein is common
Absorption of glucose usually increases, producing early hyperglycaemia and
late ypoglycaemia