Pathology of

Gastric cancer
Moderater Dr
Mehateme

Bezawit Demoz
 Outline
Epidemology
Etiology
Premalignant lesion
Pathology
Pathologic classification
Mode of Spread
Clinical presentation
Evaluation
Objective
To have a better understanding about
Gastric Ca
Epidemology

Most common Ca worldwide

Higher rates in Japan & Some part of S.America

and lower rates western Europe & US

occur predominantly in b/n 5th & 7th decade

M>F, Black>whites

Dramatic decrease in incidence is related to distal

stomach
Etiology
Family history
Diet
◦ Smoked foods
◦ Heavily salted food
◦ High level of nitriates (eg food preservatives)
Familial polyposis
Gastric adenomas
Cigaret smoking
Blood group A
Hereditary nonpolyposis colorectal ca
H. pylori infection
Previous gastrectomy or gastrojejunostomy
(>10yr ago)
Tobacco use
Menetrier's disease
DECREASE RISK
Asprin
Diet ( fresh fruit & vegetable intake)
Vitamin C
Premalignant conditions
Chronic atrophic gastritis
◦ 2 subgroups
◦ Type A - autoimmune, associated with pernicious
anemia, predominantly fundus & body
◦ Type B - affects the antrum, related to H. pylori
infection
 Benign gastric ulcer
◦ Suggested that regenerating gastric mucosa around
an ulcer is prone to become malignant
◦ Generally all gastric ulcer are cancers untill proven
otherwise with adequqte biopsy & follow up
Cont`d

Gastric polps
◦ 5types inflammatory, hamartomatous,
heterotopic, hyperplasic & adenoma
◦ adenomatous polyps, occationally hyperplastic
polpyps & familial adenomatous polyps

Previous gastric surgery

H. pylori infection
◦ causes atrophic gastritis which leads to Intestinal
metaplasia

Menetrier's disease
 Pathology
Dysplasia
◦ Universal precursor of gastric ca
Early gastric ca
◦ limted to mucosa &/or submucosa regardless of LN
status
◦ 10% of pt will have LN metastsis
◦ 70% is well differentiated & 30% poorly differentiated
◦ cure rate with adequate resection & lymphadenectomy
is 95%
◦ includes types and subtypes
Late gastric ca
◦ involves muscularis layer
Classification of early gastric
ca
 Type 1 - exophytic lesion
extending in to gastric lumen
Type 2 - superficial variant
2a - height no more than the
thickness of adjacent mucosa
2b - flat lesions
2c - with eroded but not
deeply ulcerated apperance
Type 3 - extending in to the
muscularis propria
Classification of late gastric ca
Borrman classification
◦ Type 1 polypoid and fungating
lesion

◦ Type 2 ulcerating lesion

surrounded by elevated borders

◦ Type 3 ulcerating lesion with

infiltration in to gastric wall

◦ Type 4 diffusely infiltrating

lesion ( Linitis plastica )
WHO Histologic types of Gastric ca
Adenocarcinoma (90%)
◦ Papillary adenocarcinoma
◦ Tubular adenocarcinoma
◦ Mucinous adenocarcinoma
◦ Signet-ring cell carcinoma
Adenosquamous carcinoma
Squamous cell carcinoma
Small cell carcinoma
Undifferentiated carcinoma
Others
 Cont`d
Lauren classification
◦ Intestinal type (53%)
 M>F, environmental, less aggressive
 Increase incidence with age, hematogenous spread
 associated with chronic atrophic gastritis, intestinal
metaplasia & dysplasia
◦ Diffused type (33%)
 F>M, familial occurrence( BG A)
 Younger age group, transmural/lymphatic spread
 Poorly differentiated, metastasize early, less favorable
prognosis
◦ Unclassified (14%)
Cont`d
Borders classification
◦ According to degree of differentiation
◦ Independent of morphology
◦ Ranges from 1 (well differentiated) to 4 (anaplastic)

Ming classification
◦ Expanding (67%)
 Produces nodules
 Similar to Lauren's intestinal type
◦ Infiltrative (33%)
 Does not form masses
 Cont`d
Location
◦ Distal (40%)
◦ Middle (30%),
◦ Proximal (30%)
 Worst prognosis
 Mostly diffuse types
 Increased incidence
American joint cancer commission (AJCC) TNM
staging system

T - Primary tumor - Depth of invasion

◦ T0 - No evidence of primary tumor
◦ Tis - Carcinoma-in-situ
◦ T1 - Mucosa & submucosa
◦ T2 - invades muscularis propria
◦ T3 – invades serosa (visceral peritoneum)
without invading adjacent structures
◦ T4 – invades adjacent structures
 Cont`d

Nodal (N)
◦ N0 - No regional lymph node metastasis
◦ N1 - Metastasis in 1-6 regional lymph
nodes
◦ N2 - Metastasis in 7-15 regional lymph
node
◦ N3 - Metastasis in more than 15 regional
lymph nodes
Cont`d
 Metastasis (M)
◦ M0… No distant metastasis
◦ M1… Distant metastasis (peritoneum and
distant lymph nodes)
Stage T N M
0 Tis N0 M0
IA T1 N0 M0
T1 N1 M0
IB
T2 N0 M0
T1 N2 M0
II T2 N1 M0
T3 N0 M0
T2 N2 M0
IIIA T3 N1 M0
T4 N0 M0
IIIB T3 N2 M0
T4 N1-3 M0
IV
T1-3 N3 M0
Any T Any N M1
Mode of spread of gastric ca
Direct spread
◦ Pancreas, colon and liver
Lymphatic spread
◦ Supraclavicular nodes (Virchow`s node) and
axilary
Blood-borne metastases
◦ First to the liver then to the lung and bone
Transperitoneal spread
◦ Anywhere in the peritoneal cavity
◦ Ovaries (Krukenberg’s tumours)
◦ Umbilicus (Sister Joseph’s nodule)
 Clinical features
Most common symptoms
◦ Weight loss
◦ Anorexia
◦ Early satiety
◦ Abdominal pain ( not sever and often ignored)
◦ Nausea & Vomiting
◦ Bloating
◦ Chronic occult blood loss
◦ Dysphagia
Unusual symptoms
◦ Acute GI bleeding (5%)
Cont`d
Paraneoplastic syndrome
◦ Trousseau`s syndrome ( thrombophlebitis)
◦ Acantosis nigrican (hyper pigmentation of
axilla & groin)
◦ Peripheral neuropathy
 Cont`d

Physical examination
◦ Signs of weight loss
◦ cervical supraclavicular (virchow's node ) &
axillary lymphadenopathy
◦ Metastatic pleural effusion or aspiration
pneumonitis
◦ Abdominal mass ( indicate large primary tumor)
◦ Palpable umbilical nodules ( Sister Joseph's
nodule)
◦ Signs of ascites
◦ Rectal examination
 Hard nodularity extraluminally and anteriorly
 Investigation
Routine investigations
Diagnostic investigations
o Tumor markers
o Carcinoembryonic antigen (CEA)
o Cancer antigen (CA) 19-9
o CA 724 carbohydrate antigen
o Double contrast barium meal (75% sensitive)
o Abdominal Ultrasound
o Endoscopy + biopsy +/- Brush cytology – GOLD standard
o Pt >45yrs old who have new onset dyspepsia
o Pt with dyspepsia & alarming sing ( wt loss, recurrent vomiting,
dysphagia, evidence of bleeding or anemia)
o Pt with family history of gastric ca
Cont`d
Staging Investigations
◦ Endoscopic Ultrasound
◦ CT scan
◦ MRI
◦ Chest X-Ray
◦ Laparoscopy
◦ Peritoneal cytology
◦ Abdominal ultrasound
◦ Positron Emission Tomography Scanning
References
Schwartz’s Principles of surgery,
Seymour I. Schwartz, 9th edition
Oxford Textbook of Surgery, Peter J.
Morris – 2nd edition, 2000
Bailey and Love’s short practice of
surgery, 25th edition
Sabiston textbook of surgery, 18 th edition
Uptodate 20.3
Thank you