Carcinoma of the stomach

Epidemiology:

Third most common cause of death from cancer in men and fourth in women

More common in the Eastern world (China/Japan) than in the West

Peak age distribution is 50-70yrs, however 5% of pts are < 35yrs

Male > female (3:1)

Aetiology:

The cause is largely unknown. The most likely proximate pathological event is gastric atrophy which causes hypochlorhydria and is a consequence of:

• Prolonged H. pylori infection after initial active chronic gastritis
• Pernicious anaemia
• Gastric operations for peptic ulcer, particularly partial gastrectomy.

Pathological features:

• At time of presentation, most gastric cancers are both micro- and macroscopically advanced
• The great majority of tumours are adenocarcinomas
• The adenocarcinoma is a locally invasive tumour which directly infiltrates the full thickness of the gastric wall to involve the serosal layer and contiguous structures such as:
• Pancreas
• Transverse mesocolon
• Left lobe of the liver

• The tumour also spreads via the lymphatic system to local and regional lymph nodes

Symptoms of carcinoma of the stomach:

• Weight loss (72%)
• Pain (51%)
• Nausea/vomiting (40%)
• Anorexia (35%)
• Abdominal discomfort (22%)
• Dysphagia (22%)
• Upper GI bleeding (11%)

Signs:

• Weight loss
• Abdominal mass (17%)
• Abdominal tenderness (15%)
• Hepatomegaly (13%)
• Cervical lymphadenopathy (left supraclavicular fossa – Virchow’s node) (4%)
• Ascites (3%)

Carcinoma of the stomach

Investigations:

Faecal occult blood testing:

• Positive in 80%, but the ix is non-specific

Oesophagogastroscopy:

• Most sensitive procedure for determining the presence or absence of a gastric neoplasm

Imaging:

• Double contrast barium meal
• CT
• Ultrasound

Full blood count:

• Microcytic hypochromic anaemia

Laparoscopy:

• Detects irresectability, particularly by the detection of small liver or peritoneal metastases

Cure:

• The only curative procedure is surgical resection
• In the UK, only 30-40% of pts are suitable for an attempt at cure (although up to 70% of lesions may be resectable)

Palliation:

Surgical resection:

• May be done in spite of nodal or metastatic disease that makes cure impossible
• Often alleviates troublesome symptoms such as abdominal pain, dysphagia, blood loss and vomiting
• However, because of late dx and advanced disease, bypass of an obstructing lesion in the distal part of the stomach may be all that is possible

Laser ablation:

• For unresectable tumours at the cardia
• Can dramatically improve swallowing by using a laser through an endoscope so as to core out a passage through an obstruction