Gastric Cancer

Background / Epidemiology

  • Fourth leading cause of cancer death worldwide; poor prognosis (30% 5-year
  • Incidence in the UK is ~12/100,000 in men (more common in Eastern Asia; Eastern Europe and South America); more common in men than women (2:1)


  • H pylori infection associated with chronic atrophic gastritis/mucosal atrophy (thought to be involved in 60-70%)
    • H pylori usually located in the stomach body (cf peptic ulcer disease where H pylori is usually situated in the antrum) causing decreased acid production
      • However, the majority of tumours are found in the antrum (50%) rather than the body (20-30%)
  • Other risk factors include smoking, alcohol excess, poor diet (salt rich; vitamin deplete)
    • Patients with pernicious anaemia (autoimmune gastritis); Menetrier’s disease; FAP and other inherited conditions e.g HDC1 mutations; CDH1 mutations
  • Majority of tumours are adenocarcinoma (from mucous secreting cells of gastric crypts)- see below for other types


  • Upper abdominal pain and/or dyspepsia with weight loss
    • Occasionally nausea, dysphagia and malaena
    • Enlarged Virchow’s node is actually quite rare; although lymphadenopathy is a red flag
  • Some patients will also present with signs of anaemia (an unexplained iron-deficiency anaemia should be investigated with scopes)
  • Persistent vomiting, jaundice, odynophagia are other red-flag to consider


  • All patients >55 with new onset dyspepsia and weight loss (or other red flags) should have urgent upper GI endoscopy
    • Any lesions should be biopsied and (if malignant) staged
      • Staged by depth of invasion
        • T1- superficial to the muscularis propria
        • T2- invades muscularis propria
        • T3- invades subserosal connective tissue
        • T4- through serosa (visceral peritoneum) or adjacent structures
    • CT and laparoscopy for staging


  • Surgical resection/gastrectomy (radical curative treatment) + chemotherapy
  • Palliative chemotherapy can prolong survival

MALT (Mucosa associated lymphoid tissue) Lymphoma

  • Also associated with H pylori
  • Characteristic histopathology- lymphoid tissue
  • Presents similarly to adenocarcinoma
  • Low grade tumours can be observed conservatively (+ H pylori eradication); High grade tumours should be treated as high grade lymphoma i.e. rituximab, chemo/radiotherapy, or surgery

Gastrointestinal stromal cell tumours (GIST)

  • Arise from connective (stromal) tissue of the stomach
  • Many asymptomatic but may cause dyspepsia, ulceration, and GI bleeding
  • Can be removed by endoscopy if small and surgery if large (>2cm)
    • Very large tumours may be treated with imatinib (these tumours express tyrosine kinase receptors- imatinib antagonises the receptor and inhibits action); either palliatively or neo-adjuvantly

Carcinoid tumours

  • Associated with long-standing pernicious anaemia
  • Benign tumours of neuro-endocrine cells (may be multiple but rarely invasive)
  • Generally have a good prognosis

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