Carcinoma stomach

Carcinoma
stomach
© 2004, 2002 Elsevier Inc. All rights reserved.

Epidemiology
 2.5% of all cancer related death.
 Overall incidence decreasing.
 Incidence varies with geographic areas.
Highest in Japan, Chile, Cosat rica.
20 fold higher than…..
 SE Asia, North America, North Europe,
Africa.

Epidemiology
 Mass endoscopy program is high
yielding in case of high incidence areas,
where 35% of newly detected cases are of
Early Gastric Cancer.
 Environment plays a important risk
factor in causation of Gastric ca.

Early gastric carcinoma

Risk factors…
 H. pylori infection
 Gender
 Aging
 Smoking
 Ethnicity
 Diet
 Tobacco
 Obesity
 Previous gastric
surgery
 Pernicious anaemia
 Menetrier’s disease
 Inherited cancer
syndrome
 Family history +
 Type A blood group
 EBV infection

Cancer of gastric Cardia…
 Is on rise…
 Probably related to Barrett esophagus
as also chronic GERD and obesity.
 Clinical behavior similar to distal
esophageal adenocarcinoma.

Is there anyone to protect…?
 Green leafy vegetables
 Citrus food

Classification
 Gastric carcinoma (microscopically
Laurenn’s classification)
– Intestinal type
– Diffuse type
 Gastric carcinoma (macroscopically
Bormann’s classification)
– Type I (polypoid)
– Type II (fungating)
– Type III (ulcerated)
– Type IV (infiltrative)

WHO classification
 Adenocarcinoma
– intestinal type
– diffuse type
 Papillary
 Tubular
 Mucinous
 Signet ring cell
 Adenosquamous
 Squamous cell
 Small cell
 Undifferentiated

Pathogenesis..
 Multistep progression, from chronic
gastritis to intestinal metaplasia,
dysplasia, and carcinoma

Pathogenesis…..diffuse type
 CDH1 mutation : E-cadherin
– Familial
– 50% of sporadic type
 Methylation of CDH1 promoter.
 BRCA2 mutation.

Pathogenesis…..intestinal type
 FAP individual in Japan
 Mutation in β-catenin.
 MSI
 Hyper-methylation of several genes like
TGFβ RII, BAX, IGFRII, p16/INK4a.

Others are also there…
Genetic variants of pro-inflammatory and
immune response genes specially in
H.pylori
 IL-1β
 TNF
 IL-10
 IL-8
 Toll-like receptor 4 (TLR4)

Morphology -Location
 Gastric antrum.
 Lesser curvature.

Type
 Intestinal
 Diffuse

Intestinal type- gross

Intestinal type- microscopy

Intestinal type
 Composed of
glandular structures.
 Columnar and mucin
secreting.
 Grow along broad
cohesive fronts to
form either an
– Exophytic mass.
– Ulcerated area.
 Calcification
 Stroma of the tumor
is heavily infiltrated
by neutrophils or
histiocytes

Diffuse type- gross

Diffuse type- microscopy

Diffuse type-microscopy
 Extensive fibrosis
 Inflammation
 Most tumor cells
grow individually
 Mucin is
intracytoplasmic, 
typical signet ring.

Linitus plastica- leather bottle
stomach..
 Desmoplastic
Diffuse rugal
flattening and
a rigid,
thickened wall

C /Feature
 Median age- 55 years
 Male: female :: 2 : 1
 remarkable decrease in gastric cancer
incidence applies only to the intestinal
type
 weight loss, abdominal pain, nausea,
vomiting.

Spread
 supraclavicular nodes (Virchow’s node)
 periumbilical region --- subcutaneous
nodule---- Sister Mary Joseph nodule.
 Locally invades
– esophagus, duodenum
– colon, pancreas, spleen
– omentum,
– seeding of peritoneum , lung/liver

Virchow’s node

Sister Mary Joseph nodule

Kruckenberg tumor
 metastases of diffuse or signet ring types
to one or both ovaries

Prognosis depends on..
 Depth of invasion
 Extent of nodal involvement
 Distant metastasis

GASTRIC
LYMPHOMA

Epidemiology
 Extra-nodal lymphomas --- GI tract
--- the stomach
 Allogeneic bone marrow transplant
 Organ transplant recipients
– MALTomas
– Diffuse large b-cell lymphoma

Pathogenesis
 Preexisting MALT
 Pro-lymphomatous lesion like Chronic
H.pylori infection
 Eradication of the infection with
antibiotics
 MALToma may turn into DLBCL

Translocations
Translocations are
 11;18
 1;14
 14;18
activation of NF-κB
 In DLBCL
transformation p53,
p16 inactivation are
there.

Microscopy
 Dense lymphocytic
infiltrate in the
lamina propria
 The neoplastic
lymphocytes infiltrate
the gastric glands
focally to create
diagnostic
Lymphoepithelial
Lesions

GIST

Morphology

Carney’s triad
 gastric GIST, paraganglioma, and
pulmonary chondroma

Carcinoma stomach

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