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Key Features

Essentials of Diagnosis

  • Dyspeptic symptoms with weight loss in patients age > 40

  • Iron deficiency anemia; occult blood in stools

  • Abnormality on upper gastrointestinal series or endoscopy

General Considerations

  • There are two main histologic variants of gastric cancer

    • Intestinal-type

    • Diffuse

  • Intestinal-type gastric cancer resembles intestinal cancers in forming glandular structures

    • Accounts for 70–80% of cases

    • Occurs twice as often in men as women

    • Primarily affects older people (mean age 63 years)

    • More strongly associated with environmental factors

  • Diffuse gastric cancer is poorly differentiated, has signet-ring cells, and lacks glandular formation

    • Accounts for 20–30% of cases

    • Affects men and women equally

    • Occurs more commonly in young people

    • Not as strongly related to Helicobacter pylori infection

    • Has a worse prognosis than the intestinal-type

    • Most diffuse gastric cancers are attributable to acquired or hereditary mutations in the genes regulating the E-cadherin cell adhesion protein

  • In addition to the hereditary diffuse gastric cancer, there are other hereditary cancer predisposition syndromes that account for 3–5% of gastric cancers

    • Lynch syndrome

    • Juvenile polyposis syndrome

    • Peutz-Jeghers syndrome

    • Familial adenomatous polyposis

  • Most gastric cancers arise in the body and antrum

  • Chronic H pylori gastritis is the major risk factor

  • Other risk factors for intestinal-type gastric cancer

    • Pernicious anemia

    • Partial gastric resection > 15 years previously

    • Smoking

    • Diets that are high in nitrates or salt and low in vitamin C

Demographics

  • Gastric adenocarcinoma is the most common cancer worldwide

  • Incidence in the United States has declined rapidly over last 70 years

  • In 2017 in the United States, there were an estimated 28,000 new cases and 10,960 deaths

  • Incidence is higher in Asian Americans, Hispanics, African Americans and American Indian/Alaska Natives

Clinical Findings

Symptoms and Signs

  • Generally asymptomatic or nonspecific symptoms until advanced disease

  • Dyspepsia, vague epigastric pain, anorexia, early satiety, and weight loss

  • Acute upper gastrointestinal bleeding with hematemesis or melena

  • Postprandial vomiting suggests pyloric obstruction

  • Progressive dysphagia suggests lower esophageal obstruction

  • Physical examination rarely helpful

  • Gastric mass is palpated in < 20%

  • Signs of metastatic spread include

    • Left supraclavicular lymph node (Virchow node)

    • Umbilical nodule (Sister Mary Joseph nodule)

    • Rigid rectal shelf (Blumer shelf)

    • Ovarian metastases (Krukenberg tumor)

Differential Diagnosis

  • Benign gastric ulcers

  • Lymphoma

  • Ménétrier disease

Diagnosis

Laboratory Tests

  • Iron deficiency anemia or anemia of chronic disease

  • Liver biochemical test abnormalities, particularly elevation of alkaline phosphatase, if there is metastasis to liver metastatic spread

  • Tumor markers

    • Do not have established clinical validity in screening, diagnosis, or management of gastric cancer

    • However, can assist in monitoring treatment response when checked serially

Imaging Studies

  • Upper gastrointestinal series may not detect small or superficial lesions and cannot reliably distinguish benign from malignant ulcerations

  • Preoperative evaluation with CT of chest and abdomen and ...

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