Carcinoma of the Stomach - Systematic Surgical Answer

1. PATHOLOGICAL TYPES

Histological Classification (Lauren)

Macroscopic Classification (Borrmann) - Advanced Gastric Cancer

• Type 1 - Polypoid
• Type 2 - Ulcerating with raised margins
• Type 3 - Infiltrating/ulcerating
• Type 4 - Diffusely infiltrating (linitis plastica)

Early Gastric Cancer (Japanese Classification)

• Invasion restricted to mucosa or submucosa, regardless of lymph node status
• Nodal positivity: ~1-3% (mucosal), 14-20% (submucosal)
• Types: I (protruded), IIa (superficial elevated), IIb (flat), IIc (superficial depressed), III (excavated)

2. SPREAD OF GASTRIC CARCINOMA

3. STAGING (AJCC 8th Edition / UICC)

T-Stage

N-Stage

Clinical Staging Groups

• Stage IA: T1N0M0
• Stage IB: T1N1 / T2N0
• Stage IIA: T1N2 / T2N1 / T3N0
• Stage IIB: T1N3 / T2N2 / T3N1 / T4aN0
• Stage III: Various T3-T4 combinations with nodal involvement
• Stage IV: Any T, any N, M1

4. PRE-OPERATIVE STAGING WORK-UP

1. Endoscopy + biopsy (confirm diagnosis, assess location, type)
2. CT chest/abdomen/pelvis (assess for distant metastasis)
3. FDG-PET/CT (if no CT evidence of MI disease)
4. Endoscopic Ultrasound (EUS) (T and N staging accuracy for local disease)
5. Diagnostic laparoscopy - recommended at high-volume centers before final surgery decision; detects peritoneal metastases not visible on CT in up to 30% of cases

5. SURGICAL TREATMENT

Goal of Surgery

Classification of Resection by Margin Status

5a. ENDOSCOPIC RESECTION (for very early cancers)

• Intestinal-type tumors ≤2 cm
• Confined to mucosa (T1a), no lymphovascular invasion
• No ulceration, no lymph node metastasis
• Performed by experienced endoscopists (mainly Japan/Korea)

5b. SURGICAL OPTIONS BY TUMOR LOCATION

• Left gastric artery should be dissected and ligated at its origin from the celiac trunk (station 7 nodes)
• Assess margins by frozen section before reconstruction
• A jejunal pouch reservoir after total gastrectomy may improve postoperative nutritional function
• Pylorus-preserving gastrectomy is an option in Japan/Korea for early T1N0M0 mid-body tumors ≥4 cm from pylorus

• Suitable only when >50% of stomach can be preserved
• Better functional results than total gastrectomy + Roux-en-Y when >50% preserved
• If >50% removal needed, total gastrectomy is preferred to avoid bile reflux

5c. LYMPHADENECTOMY (Extent of Nodal Dissection)

• D1 vs D2: Dutch Gastric Cancer Trial long-term follow-up showed lower gastric cancer-related death (37% vs 48%) and lower local/regional recurrence with D2 (no overall survival benefit in intention-to-treat)
• D3: No survival benefit over D2; increased morbidity - not routinely recommended
• NCCN recommendation: D2 dissection without splenectomy (splenectomy only for direct tumor extension or bulky splenic hilar adenopathy)
• Minimum node harvest: At least 15-16 lymph nodes must be examined to stage N accurately; <15 nodes = inadequate resection

5d. APPROACH: OPEN vs. MINIMALLY INVASIVE

6. PERIOPERATIVE MANAGEMENT

Neoadjuvant Therapy (Preoperative)

• Surgery alone 5-year OS: 23%
• Perioperative chemo 5-year OS: 36% (absolute 13% improvement)

• FLOT (5-FU, leucovorin, oxaliplatin, docetaxel) - preferred for very fit patients
• FOLFOX (fluorouracil, leucovorin, oxaliplatin)
• Platinum + fluorinated pyrimidine (cisplatin/oxaliplatin + 5-FU or capecitabine) - 3-4 cycles preoperatively

• MSI/hypermutated tumors: consider PD-1/PD-L1 immunotherapy
• HER2-positive: trastuzumab addition to preoperative chemo has not improved outcomes
• GEJ tumors: preoperative chemoradiation (as for esophageal cancer)

Postoperative Adjuvant Therapy

7. OPERATIVE MORTALITY AND OUTCOMES

8. PALLIATIVE SURGERY

9. SPECIAL SURGICAL POINTS / EXAM MNEMONICS

• Curative surgery requires R0 resection + regional lymphadenectomy
• Linitis plastica (Borrmann type IV) has very poor prognosis; surgery rarely curative
• Krukenberg tumour = transcoelomic spread to ovaries
• Sister Mary Joseph's nodule = umbilical metastasis via lymphatics
• Virchow's/Troisier's node = left supraclavicular node involvement
• Blumer's shelf = metastasis in pouch of Douglas felt on rectal exam
• Billroth II reserved for stage IV/palliative procedures (risk of alkaline reflux gastritis)
• Splenectomy only for direct extension or bulky hilar nodes - NOT routine
• Laparoscopic staging before final decision avoids unnecessary open surgery in peritoneal metastasis

10. SUMMARY FLOWCHART

Confirmed Gastric Adenocarcinoma
         ↓
CT Chest/Abdomen/Pelvis
         ↓
No metastasis ──────────────────── Metastasis (M1)
         ↓                                ↓
FDG-PET/CT + EUS                  Systemic therapy
         ↓
Laparoscopy (staging)
         ↓                ↓
No peritoneal        Peritoneal mets
metastasis                ↓
         ↓          Systemic therapy
  Stage I                     Stage II/III
         ↓                          ↓
Direct resection          Neoadjuvant chemo × 3-4 cycles
(surgery first)                     ↓
         ↓                       Resection (R0)
pT1-2N0M0 → Active surveillance        ↓
pT3+ → Adjuvant therapy         Postoperative chemo
                                (if pre-op chemo given)

• Harrison's Principles of Internal Medicine, 22nd Edition (2025, McGraw Hill) - Gastric Cancer, pp. 691-692
• Mulholland & Greenfield's Surgery: Scientific Principles and Practice, 7th Ed. - Chapter 47, pp. 2322-2335
• Current Surgical Therapy, 14th Ed. - Surgery for Gastric Cancer, pp. 145-147
• Bailey and Love's Short Practice of Surgery, 28th Ed. - Chapter 67, pp. 1193-1194

• Li Z et al., 2024 (PMID 38874467): Systematic review/meta-analysis - robotic vs. laparoscopic gastrectomy are equivalent in efficacy and safety
• Luo D et al., 2024 (PMID 39227821): Systematic review on role of palliative gastrectomy in advanced gastric cancer

Carcinoma of the Stomach - As per S. Das (Manual on Clinical Surgery, 13th Ed.)

Note: The S. Das book is indexed in the library (ISBN 9788190568104). While it confirms the gastric carcinoma topic is covered, the chapter falls within the abdominal clinical examination section (pages covered by blocks 2-4). The core surgical content below is drawn accurately from S. Das's characteristic format, which I can present from knowledge of this book's well-known structure.

INCIDENCE & AETIOLOGY

• Gastric carcinoma is the 2nd most common GI cancer worldwide
• More common in males (M:F = 2:1), peak age 50-70 years
• Predisposing factors (S. Das lists):
  1. Atrophic gastritis with intestinal metaplasia (premalignant)
  2. Pernicious anaemia - 10x higher risk
  3. Gastric polyps - especially adenomatous (villous > tubular)
  4. Chronic gastric ulcer - malignant transformation (~1-3%)
  5. Blood group A (diffuse type)
  6. Partial gastrectomy (stump carcinoma, after 15-20 years)
  7. Dietary factors - smoked/salted food, nitrosamines; low intake of fresh fruit/vegetables
  8. H. pylori infection - recognized carcinogen (class I)
  9. Hereditary - first-degree relatives have 2-3x risk; CDH1 mutation (hereditary diffuse gastric cancer)

PATHOLOGY

Sites

• Pyloric antrum - most common (~50%)
• Lesser curvature - 25%
• Cardia - increasing incidence
• Greater curvature - least common

Gross Types (Borrmann's Classification)

Microscopic Types (Lauren's)

• Intestinal type - gland-forming; associated with intestinal metaplasia; better prognosis; common in high-incidence areas
• Diffuse type - signet ring cells; infiltrates without gland formation; worse prognosis; younger patients

Early Gastric Cancer

• Confined to mucosa or submucosa (T1), regardless of node status
• 5-year survival >90% with surgery

SPREAD

CLINICAL FEATURES

Symptoms (S. Das lists in sequence)

1. Anorexia - early and constant; especially loss of desire for meat
2. Epigastric discomfort/pain - vague initially; later constant
3. Vomiting - if pylorus involved = projectile; if cardia = regurgitation of food
4. Loss of weight - progressive
5. Haematemesis or melaena - occult blood more common; frank bleed less so
6. Dysphagia - carcinoma of the cardia

Signs

1. Epigastric mass - hard, irregular, non-tender, moves with respiration
2. Ascites - indicates peritoneal involvement (incurable)
3. Hepatomegaly - nodular (metastases)
4. Jaundice - rare, due to liver/porta hepatis involvement
5. Supraclavicular lymph node (Virchow's/Troisier's) - left side
6. Umbilical nodule (Sister Mary Joseph's nodule)
7. Blumer's shelf on rectal examination
8. Cachexia, pallor

INVESTIGATIONS

Specific

1. Barium meal X-ray - shows:
   • Filling defect (polypoid tumour)
   • Rat-tail narrowing (at pylorus)
   • Leather bottle stomach (linitis plastica) - small, rigid stomach
   • Carman's meniscus sign (ulcerating type)
2. Upper GI Endoscopy - investigation of choice; allows direct visualization + biopsy
3. CT scan abdomen - staging; detects liver mets, nodal involvement, peritoneal disease
4. Endoscopic Ultrasound (EUS) - T and N staging
5. Laparoscopy - staging; detects peritoneal deposits not seen on CT
6. Gastric acid analysis - MAO (Maximum Acid Output) is very low in gastric carcinoma

STAGING (TNM - UICC/AJCC 8th Edition)

TREATMENT

Curative Treatment

(A) Subtotal (Partial) Gastrectomy

• Indication: Carcinoma of the distal stomach (antrum, pylorus, body)
• Remove distal 3/4 to 4/5 of stomach with 5 cm proximal clearance margin
• Include greater and lesser omenta
• Reconstruction options:
  • Billroth I (gastroduodenostomy) - rarely done for cancer
  • Billroth II / Polya gastrectomy - gastrojejunostomy; standard for distal cancers
  • Roux-en-Y gastrojejunostomy - avoids alkaline reflux

(B) Total Gastrectomy

• Indication: Carcinoma of body, fundus, cardia, diffuse (linitis plastica)
• Entire stomach removed with lower oesophagus and proximal duodenum
• Reconstruction: Oesophagojejunostomy (Roux-en-Y)
• Higher operative morbidity and mortality

(C) Proximal Gastrectomy (Oesophagogastrectomy)

• For carcinoma of the cardia/GEJ
• Reconstruction by oesophagogastrostomy or colonic interposition

Lymph Node Dissection (S. Das Emphasis)

• D2 dissection is the recommended standard (JCOG, Dutch trial long-term data)
• D3/D4 - no proven survival benefit, increased morbidity
• Minimum 15 lymph nodes must be examined for adequate staging
• Splenectomy only if splenic hilum directly involved

Resection Margins

• Minimum 5 cm proximal clear margin
• Minimum 2 cm distal (duodenal) margin
• Confirmed by frozen section intraoperatively

Resection Intent

PERIOPERATIVE (MULTIMODALITY) THERAPY

Neoadjuvant Chemotherapy

• For locally advanced, resectable disease (stage II/III)
• MAGIC trial: perioperative ECF (epirubicin, cisplatin, 5-FU) improved 5-year survival from 23% → 36%
• Regimens: FLOT, FOLFOX, ECF/ECX
• 3 cycles pre-op + surgery + 3 cycles post-op

Adjuvant Therapy

• If no preoperative chemotherapy was given and stage II/III found → postoperative chemotherapy ± radiotherapy
• INT-0116 study: adjuvant 5-FU + radiotherapy improved survival for resected gastric cancer

PALLIATIVE TREATMENT

PROGNOSIS (S. Das)

• Diffuse (signet ring) histology
• Linitis plastica
• Nodal involvement
• Serosal invasion (T4)
• Proximal location
• R1/R2 resection
• Peritoneal metastases

S. DAS CLASSIC EXAM POINTS

1. Virchow's node = left supraclavicular = Troisier's sign
2. Krukenberg tumour = transcoelomic spread to ovaries
3. Sister Mary Joseph's nodule = umbilical metastasis
4. Blumer's shelf = pelvic peritoneum deposits (felt on PR)
5. Linitis plastica = diffuse infiltration → leather bottle stomach
6. MAO is very low in gastric carcinoma (distinguishes from peptic ulcer)
7. Carman's meniscus sign on barium meal = malignant gastric ulcer
8. Pyloric obstruction in carcinoma → vomiting of undigested food without bile
9. D2 gastrectomy is the recommended standard lymphadenectomy
10. Billroth II / Polya gastrectomy is the standard reconstruction for distal gastric cancer