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Chapter 16: Gastric Cancer

Jonas W. Feilchenfeldt; Manish A. Shah

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INTRODUCTION

Epidemiology

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Epidemiology
Incidence:

27,600 estimated new cases for 2020 in United States

 Stage at Presentation

Localized

28%

Male: 16,980; Female: 10,620

Regional

26%

9.3 per 100,000 male, 5.3 per 100,000 female (2016 figures)

Distant

36%

Unknown

10%

The incidence of gastric cancer varies with different geographic regions

  
Deaths: Estimated 11,010 in 2020 (male: 6650; female: 4360)
Median age: 68 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 2020;70:7–30

Surveillance, Epidemiology and End Results (SEER) Program, available from http://seer.cancer.gov [accessed in 2020]

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

  5. Chest imaging✫

  6. Esophagogastroduodenoscopy (EGD)

  7. PET-CT or PET scan (optional)

  8. Endoscopic ultrasound (EUS) (optional)

  9. Helicobacter pylori test† (optional)

 

✫A combined CT scan of chest and abdomen is a pragmatic option

†Chey WD et al. Am J Gastroenterol 2007;102:1808–1825

 

Locoregional (stages cT1b-cT4a; cM0):

Laparoscopy is performed to evaluate for peritoneal spread when considering chemoradiation or surgery.

Laparoscopy is not indicated if a palliative resection is planned. Laparoscopy allows patients to be categorized into one of the following groups:

  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

Stage IV (cT4b; cM1):

  1. No further work-up necessary

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

Pathology

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

 

Borrmann Classification

Based on gross appearance

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

Staging

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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, high-grade dysplasia
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/organs

✫A tumor may penetrate the muscularis ...

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