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Chapter 12: Gastric Cancer

Jonas W. Feilchenfeldt; Manish A. Shah

INTRODUCTION

Epidemiology

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Epidemiology
Incidence: 22,220 (male: 13,730; female: 8,490. Estimated new cases for 2014 in the United States) Stage at Presentation
Localized 24%
Regional 30%
10.4 per 100,000 male, 5.3 per 100,000 female Distant 35%
The incidence of gastric cancer varies with different geographic regions    
Deaths: Estimated 10,990 in 2014 (male: 6,720; female: 4,270)    
Median age: 69 years    
Male to female ratio: ~2:1    

Kamangar F et al. J Clin Oncol 2006;24:2137–2150

Siegel R et al. CA Cancer J Clin 2014;64:9–29

Surveillance, Epidemiology and End Results (SEER) Program, available from http://seer.cancer.gov (accessed in 2013)

Work-up

  1. Multidisciplinary evaluation

  2. History and physical examination

  3. CBC and chemistry profile

  4. CT abdomen with contrast; CT/ultrasound pelvis in women pelvis

  5. Chest imaging✫

  6. Esophagogastroduodenoscopy (EGD)

  7. PET-CT or PET scan (optional)

  8. Endoscopic ultrasound (EUS) (optional)

  9. Helicobacter pylori test† (optional)

 

Locoregional (M0):

  1. Medically fit (medically able to tolerate major abdominal surgery), potentially resectable

  2. Medically fit (medically able to tolerate major abdominal surgery), unresectable

  3. Medically unfit. Laparoscopy is performed to evaluate for peritoneal spread when considering chemoradiation or surgery. Laparoscopy is not indicated if a palliative resection is planned

 

Stage IV (M1):

  1. No further work-up necessary

Note: PET-CT may have a role for monitoring chemotherapy response

Pathology

Borrman Classification

Gross appearance is the basis for the first classification system of stomach cancers. Any of the 4 types may coexist:

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Type I: Polypoid
Type II: Fungating
Type III: Ulcerated
Type IV: Infiltrative

 

Lauren Classification

Pattern of local invasion based on histologic features:

  1. Intestinal: composed of cohesive neoplastic cells that form glands and tubular structures

  2. Diffuse: scattered neoplastic cells that invade individually with minimal intercellular cohesion

  3. Unclassified

 

World Health Organization Classification

  1. Intraepithelial neoplasia—adenoma

  2. Carcinoma

  3. Adenocarcinoma (intestinal type, diffuse type)

  4. Papillary adenocarcinoma

  5. Tubular adenocarcinoma

  6. Mucinous adenocarcinoma

  7. Signet ring cell carcinoma

  8. Adenosquamous carcinoma

  9. Squamous cell carcinoma

  10. Undifferentiated carcinoma

  11. Others

 

Stemmermann GN et al. Gastric cancer: pathology. In: Kelsen DP et al. eds. Gastrointestinal Oncology: Principles and Practice. Baltimore, MD: Lippincott Williams & Wilkins, 2008:257–274

Pathologic Staging

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Pathologic Staging

Primary Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ: intraepithelial tumor without invasion of the lamina propria
T1 Tumor invades lamina propria, muscularis mucosae, or submucosa
T1a Tumor invades lamina propria or muscularis mucosae
T1b Tumor invades submucosa
T2 Tumor invades muscularis propria
T3 Tumor penetrates subserosal connective tissue without invasion of visceral peritoneum or adjacent structures✫,†,‡
T4 Tumor invades serosa (visceral peritoneum) or adjacent structures†,‡
T4a Tumor invades serosa (visceral peritoneum)
T4b Tumor invades adjacent structures

✫A tumor may penetrate the muscularis propria with extension into the gastrocolic or gastrohepatic ligaments, or into the greater or lesser omentum, without perforation of the visceral peritoneum ...

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