AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Background

Gastric carcinoma is the most common cancer in the world after lung cancer and is a major cause of mortality and morbidity. Though a marked reduction has been observed in the incidence of gastric carcinoma in North America and Western Europe in the last 50 years, 5-year survival rates are less than 20%, as most patients present late and are unsuitable for curative, radical surgery.

Pathophysiology

The accepted pathway involves transitions from gastritis, to gastric atrophy, to metaplasia, to dysplasia, and, finally, to cancer.

Several dietary and environmental factors may influence this pathway.

• Dietary nitrates: Bacteria in the stomach break down nitrites to compounds (eg, N-nitroso compounds) that are carcinogenic in animals.
• Hypochlorhydria: This condition occurs in gastric atrophy and promotes bacterial colonization of the stomach. It leads to increased nitrite formation, which may have a mutagenic effect on the atrophic gastric mucosa.
• Helicobacter pylori: Antral gastritis caused by H pylori has been linked to the development of gastric cancer. Patients with H pylori gastritis are 3-6 times more likely to develop gastric cancer than individuals without the infection.
• Certain foods: Starch, pickled vegetables, salted fish and meat, smoked foods, and salt have all been implicated in the development of gastric carcinoma.
• Cigarette smoking: Those who smoke more than 30 cigarettes per day have a 5-fold increased risk of gastric carcinoma.

Several precancerous conditions are recognized:

• Chronic atrophic gastritis (see Image 1)
• Pernicious anemia
• Previous partial gastrectomy
• Ménétrier disease
• Gastric dysplasia
• Adenomatous polyps (20% of all gastric polyps)
• Hereditary factors

Adenocarcinomas account for approximately 95% of all malignant gastric neoplasms. The remaining 5% of tumors are lymphomas, leiomyosarcomas, carcinoids, or sarcomas.

Gastric adenocarcinomas are divided into 2 types:

• An intestinal type (type 1), with well-formed glandular structures: This type is more likely to involve the distal stomach and occur in patients with atrophic gastritis. It has a strong environmental association.
• A diffuse type (type 2), with poorly cohesive cells that tend to infiltrate the gastric wall: Tumors of this type may involve any part of the stomach, especially the cardia, and have a worse prognosis than the intestinal type. Unlike type 1 gastric cancers, type 2 cancers have similar frequencies in all geographic areas.

With gastric carcinomas, advanced lesions will have already invaded the muscularis propria. They are associated with metastases to regional lymph nodes or to local or distant structures.

Early gastric lesions are confined to the mucosa or submucosa. Patients with these tumors have a 5-year survival rate of 90%. Most reports are from Japan as a result of mass screening in that country.

Before 1950, most gastric tumors detected were located in the antrum. Since then, the location has gradually shifted from the antrum to the body and fundus because of the rapidly increasing incidence of carcinoma in the gastric cardia and lower esophagus. Today, 30% of gastric lesions are found in the antrum, 30% are in the body, and 40% are in the fundus and cardia.

Frequency

United States

The incidence decreased from 33 cases per 100,000 population in 1930 to 3.7 cases per 100,000 population in 1990. In 1996, about 22,800 new cases of gastric adenocarcinoma occurred. In Western countries, the incidence of carcinoma of the cardia has increased rapidly in the last 20 years, in contrast to the decline in gastric cancer as a whole, particularly in tumors of the body and antrum.

International

Worldwide, gastric adenocarcinoma is the second most common cancer (second to lung cancer). The global incidence of gastric cancer varies 10-fold. The highest incidence (>30 cases per 100,000 population) is in Japan, Russia, China, South America, and Eastern Europe. The lowest incidence ( <3.7 cases per 100,000 population) is in North America, Western Europe, Australia, and New Zealand.

Mortality/Morbidity

• In 1996, gastric cancer caused approximately 14,000 deaths in the United States.
• Worldwide, gastric cancer is second only to lung cancer as the most common cause of cancer deaths.
• Most patients present late, and the 5-year survival rate is approximately 20%.

Race

• Overall, gastric carcinoma is 1.5-2.5 times more common in African Americans, Hispanics, and American Indians than in whites.
• Among Japanese who immigrate to the United States, the incidence gradually decreases (to 25% of their original incidence). The rate further decreases in their children, and their grandchildren have a rate comparable to that of the general population in the United States.
• The incidence of adenocarcinoma of the cardia is highest among white men.

Sex

Gastric carcinoma is 2 times more common in men than in women. Moreover, carcinoma of the cardia of the stomach is up to 7 times as common in men as in women.

Age

Gastric carcinoma has a peak incidence in those aged 50-70 years; however, approximately 5% of patients with gastric cancer are younger than 35 years, and 1% are younger than 30 years. Younger patients have more aggressive lesions with a worse prognosis.

Anatomy

The stomach consists of the cardia (adjacent to the gastroesophageal junction), the fundus, the body, the antrum, and the pylorus. The fundus is dome-shaped and extends above and to the left of the cardia, toward the left hemidiaphragm. The body extends from the fundus to the lower end of the lesser curve, known as the incisura angularis. The antrum extends from the incisura to the pyloric canal.

The stomach is lined by peritoneum. The lesser omentum and greater omentum are double layers of peritoneum that extend from the lesser curve and greater curve, respectively.

The right and left gastric, right and left gastroepiploic, and short gastric arteries supply the stomach. These arteries originate from all 3 branches of the celiac trunk. The venous drainage is into the portal vein or one of its branches. The lymphatic drainage is into the celiac lymph nodes surrounding the celiac trunk.

Clinical Details

Presentation

Most patients present with advanced disease because they are often asymptomatic in the earlier stages. Common presenting features include epigastric pain, bloating, early satiety, nausea, vomiting, dysphagia, anorexia, weight loss, and upper GI bleeding (hematemesis, melena, iron deficiency anemia, positive results with fecal occult blood tests).

Differential diagnosis

Because peptic ulcers and gastritis cause similar findings, diagnosis is often delayed. Jaundice and hepatomegaly may be due to hepatic metastases. Pelvic masses may be the result of ovarian metastases (Krukenberg tumors).

Prognosis and staging

The prognosis is related to the stage of the disease at the time of diagnosis and to the histologic grade of the carcinoma.

Pathologic staging is based on tumor stage, nodal stage, and metastasis stage (TMN).

• T stage - Extent of penetration through the gastric wall
  • Tis - Carcinoma in situ, intraepithelial tumor
  • T1 - Tumor extension to submucosa
  • T2 - Tumor extension to the muscularis propria or subserosa
  • T3 - Tumor penetration of the serosa
  • T4 - Tumor invasion of the adjacent organs
• N stage - Number and site of draining lymph nodes involved (see also N staging in the CT Scan, Findings section, below)
  • N0 - No lymph nodes involved
  • N1 - Metastases in 1-6 regional lymph nodes
  • N2 - Metastases in 7-15 regional lymph nodes
  • N3 - Metastases in >15 regional lymph nodes
• M stage - Presence of metastases
  • M0 - No distant metastases
  • M1 - Distant metastases

Staging and 5-Year Survival Rates

*Tx indicates any T stage; Nx, any N stage.

Preferred Examination

• Begin the evaluation with history taking and physical examination.
• Perform blood tests, including a full blood count determination and liver function tests.
• Inspect the stool, and test for occult blood.
• Perform either fiberoptic endoscopy or a double-contrast study (barium and gas) of the upper GI tract.
  • Endoscopy has become the diagnostic procedure of choice for patients with suspected gastric carcinoma. Biopsy samples obtained during endoscopy enable histologic diagnosis. However, endoscopy is more invasive and more costly than a double-contrast study.
  • Double-contrast examinations of the upper GI tract remain a useful alternative to endoscopy and have similar sensitivity in the detection of gastric cancer.
• CT, MRI, and endoscopic ultrasonography (EUS) are used in staging but not usually in the primary detection of gastric cancers (see the CAT Scan, MRI, and Ultrasound sections).

Limitations of Techniques

Endoscopy with biopsy has a sensitivity of 95%. Multiple biopsy specimens are needed to avoid sampling errors. Endoscopy is less reliable in the diagnosis of scirrhous tumors (35-70%). False-negative biopsy results may delay diagnosis.

Single-contrast barium studies have an overall sensitivity of 75%, but double-contrast barium examinations have a sensitivity of 90-95% in the detection of gastric cancer, comparable to endoscopy.

DIFFERENTIALS

Section 3 of 11  

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• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Other Problems to be Considered

• Gastric lymphoma
• Gastric metastases
• Gastritis
• Gastric varices
• Gastric polyps
• Peptic ulcers

RADIOGRAPH

Section 4 of 11  

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• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

Early gastric cancer

Double-contrast barium upper GI examination is widely recognized as the radiologic technique of choice for diagnosing early gastric cancers. These lesions are confined to the mucosa or submucosa and are classified into 3 types:

• Type I lesions are elevated and protrude more than 5 mm into the lumen.
• Type II tumors are superficial lesions that are elevated (IIa), flat (IIb), or depressed (IIc).
• Type III early gastric cancers are shallow, irregular ulcers surrounded by nodular, clubbed mucosal folds.

In Western counties, early gastric cancers account for only 5-20% of all gastric cancers. In Japan, they represent 25-46% owing to the population-screening program that was implemented to combat the high incidence of the disease.

Advanced carcinoma

Gastric carcinomas are occasionally seen on plain abdominal radiographs as abnormalities in the gastric contour or as soft-tissue masses indenting the gastric contour. Rarely, mucin-producing carcinomas may show areas of punctate calcification.

On barium studies, gastric carcinomas may be polypoidal, ulcerative, or infiltrating lesions.

Polypoid carcinomas are lobulated masses that protrude into the lumen (see Image 2). They may contain 1 or more areas of ulceration.

With ulcerated carcinomas, an irregular crater is located in a rind of malignant tissue. Seen en face, tumor nodules may be in the adjacent mucosal folds; the mucosal folds that converge to the edge of the ulcer may be blunted, nodular, or clubbed from tumor infiltration. Seen in profile, these lesions are intraluminal, whereas benign ulcers project beyond the contour of the stomach. The radiating folds associated with a benign ulcer are regular and extend close to the ulcer margins (see Image 3). Endoscopy and biopsy are generally required to confirm or rule out malignancy in most cases of gastric ulcers.

Infiltrating carcinomas result in irregular narrowing of the stomach, with nodularity or spiculation of the mucosa (see Image 4).

Special considerations

• Scirrhous carcinomas typically cause irregular narrowing and rigidity of the stomach, giving rise to the typical linitis plastica, or "leather bottle" appearance (see Image 5). Although some are lobulated lesions in the fundus or body, others consist of thickened, irregular mucosal folds and nodularity without significant narrowing.
• Carcinomas of the cardia are often missed during single-contrast examinations. In double-contrast studies, normal anatomic landmarks are obliterated and replaced by a plaquelike lesion with nodularity or ulceration. The distal esophagus is often involved (see Images 6-7).
• Submucosal spread of tumors may result in pseudo-achalasia or secondary achalasia with tapered, beaklike narrowing of the distal esophagus (see Image 8) and infiltration of the gastric cardia (see Image 9).

Degree of Confidence

Single-contrast studies have a sensitivity of 70%, but double-contrast examinations have a sensitivity of 90%.

Equivocal lesions should always be confirmed or ruled out by means of endoscopy and biopsy.

False Positives/Negatives

The appearance of gastric carcinomas on barium studies must be distinguished from the appearances of benign gastric ulcers and polyps, gastric lymphomas, and focal gastritis. Malignant stromal tumors may also cause confusion. Although linitis plastica is usually caused by gastric carcinoma, it can also be caused by metastatic breast cancer.

In rare cases, radiation therapy, Crohn disease, tuberculosis, sarcoidosis, and syphilis may simulate gastric carcinoma, and primary esophageal adenocarcinoma may invade the stomach. Gastric varices and inadequate distention may mimic tumors of the gastric fundus.

CT SCAN

Section 5 of 11  

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• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

CT is used preoperatively primarily to determine the stage and extragastric spread of a gastric carcinoma. This information is vital in deciding between palliative surgery and curative radical surgery (ie, identifying patients who would not benefit from radical surgery). Additionally, CT is used to monitor a patient's response to treatment.

Detection of gastric carcinoma is improved by using thin-section sequences and helical or multidetector-row CT. When thin collimation is used, near-isotropic imaging of the stomach is possible, allowing high-quality multiplanar reformation and 3-dimensional reconstruction of gastric images. An intravenous contrast medium is used, along with water or gas as a negative intraluminal agent (see Image 10). Prone views improve visualization of tumors of the cardia and distal stomach.

Helical scanning allows for a biphasic technique. The early arterial phase is used to assess enhancement of the gastric wall; the later portal venous phase is used to assess the liver parenchyma for metastases.

CT scans may show the following:

• Polypoidal mass with or without ulceration
• Focal wall thickening with mucosal irregularity or ulceration
• Wall thickening with the absence of normal mucosal folds (infiltrative lesions)
• Focal infiltration of the gastric wall (see Image 11)
• Variable thickening of the wall and marked contrast enhancement (typical of scirrhous lesions)
• Mucinous carcinomas, which have low attenuation due to their high mucin content and which may contain calcification

T staging

The depth of tumor invasion is not accurately assessed with CT.

Tumor invasion of the perigastric fat is seen as soft-tissue stranding. Tiny 4- to 8-mm nodules may be observed. These may coalesce into sheets of tumor in advanced cases.

Direct extension of the tumor is relatively common. The pancreas is invaded via the lesser sac; the transverse colon, via the gastrocolic ligament; and the liver, via the gastrohepatic ligament.

Longitudinal spread to the distal esophagus occurs in as many as 60% of patients with carcinoma of the cardia (see Images 12-13). However, the duodenum is involved in only 5-20% of antral carcinomas.

Overall, the accuracy of determining the T-stage with CT is approximately 66%.

N staging

Lymph node metastases occur in approximately 80% of patients with gastric cancer (see Images 15-17). The frequency is related to the size and depth of the tumor; local perigastric nodes are involved first, followed by the regional (celiac, hepatic, left gastric, splenic) and distant (left supraclavicular and axillary) nodes.

CT depicts 75% of nodes larger than 5 mm in diameter, but it does not depict tumor in normal-sized nodes. CT is not useful in distinguishing between enlarged nodes due to reactive changes and those due to tumor.

The local nodes (N1) are located in the prepyloric region and in the gastrocolic and gastrohepatic ligaments. These nodes are removed by performing the standard gastrectomy procedure. The regional nodes (N2), located in the porta hepatis, hepatoduodenal ligament, and peripancreatic region, are not removed by the gastrectomy procedure; thus, their detection is more important.

In the new TNM tumor classification system, nodal staging is related to the number of regional nodes involved in the perigastric group and around the celiac axis. Enlarged nodes elsewhere (eg, in the retroperitoneum and mesentery) are classified as distant metastases. N1 indicates 1-4 nodes; N2, 7-15 nodes; and N3, more than 15 nodes.

M staging

Because the portal vein drains the stomach, the liver is the most common site for hematogenous metastases (see Image 12, Image 15). Less common sites are the lungs (see Image 19), adrenal glands, and kidneys. Bony and cerebral metastases are uncommon.

Intraperitoneal and omental metastases are common in advanced gastric cancer. They consist of nodules, localized fluid collections, and irregular thickening and stranding of the mesentery and omentum (see Images 17-18).

Ascites (see Images 16-18) and small-bowel obstruction may occur.

Gastric carcinoma is the most common primary tumor to metastasize to the ovaries. These ovarian metastases are usually bilateral and are known as Krukenberg tumors.

Degree of Confidence

For accuracy rates with CT, see Degree of Confidence in the Ultrasound section.

CT has several pitfalls.

• A pseudo-mass as a result of a normal gastroesophageal junction may be seen.
• Underdistention of the stomach may simulate wall thickening.
• T2 and T3 lesions may be difficult to distinguish.
• Loss of a fat plane between the gastric wall and the left lobe of the liver may be seen.
• Loss of a fat plane between the tumor and pancreas may be due to an inflammatory reaction.
• In cachectic patients, a loss of fat planes may simulate direct organ invasion.
• Small nodes may contain tumor.
• Large nodes may be due to inflammatory causes.
• Perigastric nodes may not be observed if the stomach is not well distended.
• CT may fail to depict tiny omental and peritoneal deposits.
• Small pelvic deposits may be overlooked.

MRI

Section 6 of 11  

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• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

Recent studies in which a breath-hold fast-imaging technique and water were used have shown accuracy rates comparable to those of helical biphasic CT scanning. The fast-imaging technique was superior to CT in detecting serosal invasion.

Degree of Confidence

In T staging, the accuracy of MRI is 73%, compared with 67% for CT. In N staging, the accuracy of MRI is 55%, compared with 59% for CT.

MRI is limited by respiratory and peristaltic artifacts, the lack of suitable oral contrast media, and higher cost, as compared with CT.

ULTRASOUND

Section 7 of 11  

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• Mri
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

The primary role of transabdominal ultrasonography (US) is to detect liver metastases. These metastases are usually hyperechoic, but they may be hypoechoic. CT scanning and endoscopic ultrasonography (EUS) are complementary. CT scanning is used first to stage the gastric carcinoma; if no metastases and no invasion of local organs are shown, EUS is used to refine the local stage. The depth of tumor invasion is not accurately assessed with CT, and the investigation of choice for this indication is EUS.

Gastric carcinomas are occasionally identified during US of the upper abdomen.

EUS has improved the accuracy of local staging of gastric carcinomas. Its role is to assess the depth of local invasion and the presence or absence of perigastric nodes. Unlike CT and MRI, EUS can depict individual layers of the gastric wall with a rotating high-frequency probe inserted via an endoscope. EUS is limited to an area 5 cm from the probe. It cannot be used to assess distant metastases or nodes more than 5 cm away from the probe.

The gastric wall is visualized as 5 concentric bands:

• Mucosa - echogenic
• Muscularis mucosa - hypoechoic
• Submucosa - echogenic
• Muscularis propria - hypoechoic
• Serosa – echogenic

A gastric tumor is demonstrated as a hypoechoic mass with varying mural invasion. Its depth may be overestimated, because of the inflammatory response around the tumor, or it may be underestimated, because of microscopic spread.

With T1 tumors, wall thickening is limited to the mucosa and submucosa. Regarding N staging, involved nodes are rounder and more hypoechoic than normal nodes.

Degree of Confidence

In the detection of liver metastases, sensitivities as high as 85% have been reported.

Overstaging is due to the peritumoral inflammatory response.

In T staging, EUS is 89-92% accurate, and CT is 43-65% accurate; however, the accuracy of CT increases with the use of the helical biphasic technique. In N staging, EUS is 60-85% accurate, and CT is 48-70% accurate. Inflammation may cause enlarged nodes. EUS has a high specificity (90%) but low sensitivity (53-80%) because it has a range of 5 cm from the gastric wall for nodes of normal size; thus, it does not permit assessment of the full extent of lymphadenopathy. Involved small nodes are not detected.

Intraoperative US and laparoscopy have an accuracy of 81% in T staging and an accuracy of 93% in N staging; however, the necessary equipment and expertise are not widely available.

NUCLEAR MEDICINE

Section 8 of 11  

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• References

Findings

Fluorodeoxyglucose–positron emission tomography (FDG-PET) may be useful in the staging and postoperative assessment of gastric carcinomas. FDG-PET depicts the primary tumor, but involved perigastric lymph nodes are not identified separately from the primary tumor. Thus, the role of PET is limited in staging. The use of combined PET-CT scanning may improve diagnostic accuracy.

Indium-111 (¹¹¹In)labeled monoclonal antibody has been used for intraoperative imaging to detect nodes, with an accuracy of 72%.

FDG-PET may be useful in evaluating patients with recurrent gastric cancer; findings can help localize the disease when CT findings are not diagnostic. Imaging evaluation with PET may also impact the clinical management of patients with recurrent gastric cancer.

INTERVENTION

Section 9 of 11  

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• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Inoperable obstructing gastric carcinomas can be treated with a covered metallic stent as an alternative to palliative surgery, especially for frail patients who are unable to tolerate surgery.

Stents are also used to treat recurrent tumors that obstruct the gastrojejunal anastomosis. Further surgery is often of little value in patients with this condition.

Complications from stents include stent migration, obstruction, perforation, and bleeding.

Medical/Legal Pitfalls

• Failure to recognize and investigate patients with signs and symptoms of gastric cancer
• Failure to monitor patients at high risk of developing cancer
• Failure to detect primary tumor by means of endoscopy or double-contrast barium study
• Failure to accurately stage the primary tumor by using CT scanning, leading to inappropriate surgical treatment

MULTIMEDIA

Section 10 of 11  

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• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Media file 1:  Atrophic gastritis.
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Media file 2:  Polypoid carcinoma of the body of the stomach.
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Media file 3:  Gastric ulcer with symmetrical, radiating mucosal folds. At histologic evaluation, no evidence of malignancy was observed.
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Media file 4:  Infiltrating carcinoma involving the greater curve of the stomach.
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Media file 5:  Linitis plastica.
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Media file 6:  Extensive carcinoma involving the cardia and fundus.
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Media file 7:  Carcinoma of the cardia with involvement of the distal esophagus (same patient as in Image 6).
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Media type:  X-RAY

Media file 8:  Secondary or pseudoachalasia due to infiltrating carcinoma of the cardia.
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Media type:  X-RAY

Media file 9:  Note malignant infiltration of the cardia (same patient as in Image 8).
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Media type:  X-RAY

Media file 10:  The stomach is distended by using water as a negative intraluminal contrast agent. Results of this examination are normal.
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Media type:  CT

Media file 11:  Carcinoma of the lesser curve. Note the focal mural thickening due to a tumor plaque.
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Media type:  CT

Media file 12:  Carcinoma of the cardia. Note the liver metastasis.
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Media type:  CT

Media file 13:  Tumor extension to the distal esophagus (same patient as in Image 12).
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Media type:  CT

Media file 14:  Carcinoma of the antrum. Note the circumferential mural thickening.
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Media type:  CT

Media file 15:  Celiac-axis nodes measure 8-12 mm and are from carcinoma of the cardia. Note the irregular liver metastasis and adjacent rounded cyst.
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Media type:  CT

Media file 16:  Carcinoma of the body of the stomach associated with regional lymphadenopathy and ascites.
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Media type:  CT

Media file 17:  Enlarged porta hepatis lymph nodes, ascites, and omental involvement (same patient as in Image 16).
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Media type:  CT

Media file 18:  Extensive mesenteric, omental, and peritoneal metastases (same patient as in Image 16).
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Media type:  CT

Media file 19:  Pulmonary metastases and left pleural effusion from a gastric carcinoma.
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Media type:  CT

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

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Article Last Updated: Oct 19, 2006