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CARCINOMA OF THE STOMACH

(A Concise Textbook of Surgery)

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1. INCIDENCE

• One of the major causes of cancer mortality
• UK/USA: 10-15 per 1,00,000/year | Japan: 70 per 1,00,000/year
• China (small area): double that of Japan
• Men > Women; increases with age
• Incidence falling at ~1%/year (body & distal stomach decreasing, proximal stomach increasing)
• Low socioeconomic group: body & distal stomach carcinoma more common
• Higher socioeconomic group: proximal gastric cancer more common
• H. pylori - associated with body & distal stomach cancer, NOT proximal

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2. AETIOLOGY

A. Diet

• Positively correlated: starch, pickled vegetables, salted fish, fresh vegetables, Vit C, refrigeration
• Increased salt intake → associated with stomach cancer
• High nitrate intake → high risk populations
• Cigarette smoking - well established association

B. Environmental

• High incidence: Japan, Iceland, Chile, Hawaii
• Smoked fish & meat → carcinogenic hydrocarbons
• Peculiar spirits (China, Japan) → gastritis → long-term cancer
• Excessive salt + N-nitroso compounds

C. Age & Sex

• Rare < 30 years
• Peak age: 50-70 years (both sexes, ~59)
• Males > Females (3:1 in some reports)

D. Heredity

• Blood group A → more frequent in gastric cancer patients
• First-degree relatives: 2x risk
• Reported in monozygotic twins

E. H. pylori ⭐

• Associated with body & distal stomach cancer
• Causes: gastritis → gastric atrophy → intestinal metaplasia → malignancy

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3. PREDISPOSING CONDITIONS ⭐

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4. DISTRIBUTION (Fig. 44.18)

• Antrum: 50% (most common site)
• Body: 18%
• Cardia: 10%
• Fundus: 12%
• Diffuse: 7%
• Multiple: 3%
• Commonest site = pyloric & antral regions, along lesser curvature

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5. PATHOLOGY

A. MACROSCOPIC TYPES ⭐

B. MICROSCOPIC TYPES ⭐

1. Adenocarcinoma - 95% of all gastric cancers; columnar/cuboidal/round cells; tubular, acinar, colloid, signet-ring cell types; undifferentiated type also seen
2. Squamous cell epithelioma - lower oesophagus grows into stomach
3. Adenoacanthoma - admixture of glandular + squamous elements (rare)

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6. SPREAD ⭐

1. Direct Spread

• In stomach wall: upward along lesser curvature toward cardia (submucous coat - 5 cm ahead of visible edge)
• To adjacent organs: colon, pancreas, liver, gallbladder, omentum, spleen, upper jejunum

2. Lymphatic Spread

• Via embolism or permeation
• Virchow's node = left supraclavicular fossa (pathognomonic of stomach cancer)
• Spread along ligamentum teres → umbilical nodules

3. Blood Spread

• Via portal vein → Liver (most common organ affected - large, white, hard, umbilicated tumours)
• Also: lungs, pleura, bones
• Subcutaneous nodules possible

4. Transperitoneal Spread

• Cancer cells → peritoneal cavity → carcinomatosis peritonei
• Krukenberg's tumour = bilateral ovarian metastases (premenopausal women); transcoelemic implantation

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7. CLINICAL FEATURES

Symptoms (in order of frequency):

Groups of Presentation ⭐

Signs of Metastasis:

• Virchow's node (Troisier's sign) - left supraclavicular node
• Trousseau's sign - phlebothrombosis of superficial veins
• Sister Mary Joseph nodule - umbilical metastasis
• Krukenberg's tumour - bilateral ovarian metastases

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8. INVESTIGATIONS ⭐

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9. TREATMENT

General Rule:

When gastric carcinoma is diagnosed → laparotomy should always be performed (except absolute contraindications)

Contraindications to Laparotomy:

• Unfit to stand operation
• Disease beyond scope (signs: growth fixed in pelvis, palpable metastasis even in-situ, multiple liver metastasis, palpable metastasis in left supraclavicular nodes [Troisier's sign], jaundice, lung/bone metastasis)

Exploration - Contraindications to Radical Surgery:

• Fixation to pancreas/posterior abdominal wall
• Fixation of involved lymph nodes
• Secondaries all over peritoneal cavity
• Multiple liver secondaries (except solitary resectable nodule)

Radical Operations:

1. Total Radical Gastrectomy - for growths involving mid-stomach or whole stomach (Linitis plastica); upper left paramedian incision
2. Upper Radical Partial Gastrectomy - upper 1/3 growths
3. Lower Radical Partial Gastrectomy - antrum/pylorus growths

Prognosis:

• Only 50% of cases will be qualified for exploration
• Of those, 50% not suitable for radical operation
• Only 5% of radical operation cases survive >5 years

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HIGH-YIELD EXAM POINTS ⭐⭐

1. Most common site = Pylorus & antrum (50%)
2. Most common macroscopic type = Ulcerative (most malignant)
3. Most common microscopic type = Adenocarcinoma (95%)
4. Most common organ for blood spread = Liver (via portal vein)
5. Krukenberg's tumour = bilateral ovarian metastases (transcoelemic)
6. Virchow's node = left supraclavicular (Troisier's sign)
7. H. pylori = body & distal stomach cancer ONLY (not proximal)
8. Leather-bottle stomach = Linitis plastica (fibrous, scirrhous)
9. Best investigation = Flexible endoscopy with biopsy
10. Irregular filling defect on barium = favours carcinoma
11. Serum pepsinogen I = marker for intestinal metaplasia
12. Laparoscopic USG = best to detect liver metastasis
13. Blood group A = higher risk
14. Occult blood in stool = ~80% of cases
15. Pyloric ulcer = always suspect malignancy (20% are primarily malignant)

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