Overview

The stomach is part of the digestive system. It is located in the upper abdomen, between the esophagus
and the small intestine. Stomach cancer is also called gastric cancer.
Most (85%) cases of gastric cancer are adenocarcinomas that occur in the lining of the stomach
(mucosa). Approximately 40% of cases develop in the lower part of the stomach (pylorus); 40% develop
in the middle part (body); and 15% develop in the upper part (cardia). In about 10% of cases, cancer
develops in more than one part of the organ.
Stomach cancer can spread (metastasize) to the esophagus or the small intestine, and can extend
through the stomach wall to nearby lymph nodes and organs (e.g., liver, pancreas, colon). It also can
metastasize to other parts of the body (e.g., lungs, ovaries, bones).
Incidence
According to the National Cancer Institute (NCI), approximately 760,000 cases of stomach cancer are
diagnosed worldwide and more than 24,000 cases are diagnosed in the United States each year.
Incidence is highest in Japan, South America, Eastern Europe, and parts of the Middle East. Worldwide,
stomach cancer is the second leading cause of cancer-related deaths
Risk Factors and Causes
The cause of stomach cancer is unknown. Age and gender are risk factors and the disease is more
common in men over the age of 55.
A diet high in salt and nitrates and low in vitamins A and C increases the risk for stomach cancer. Other
dietary risk factors include food preparation (e.g., preserving food by smoking, salt-curing, pickling, or
drying) and environment (e.g., lack of refrigeration, poor drinking water). A diet high in raw fruits and
vegetables, citrus fruits, and fiber may lower the risk for stomach cancer.
Medical conditions that increase the risk for the disease include pernicious anemia (vitamin B-12
deficiency), chronic inflammation of the stomach (atrophic gastritis), and intestinal polyps (noncancerous
growths).

Genetic (hereditary) risk factors include hereditary nonpolyposis colon cancer (HNPCC) syndrome and
Li-Fraumeni syndrome (conditions that result in a predisposition to cancer), and a family history of
gastrointestinal cancer. People with type A blood also have an increased risk for stomach cancer.
Acquired (not present at birth) risk factors include the following:
Signs and Symptoms of Gastric Cancer
Early stomach cancer usually does not cause symptoms (i.e., is asymptomatic). Symptoms usually
indicate advanced disease and include the following:
• Abdominal discomfort or pain
• Blood in stool
• Bloating (especially after eating)
• Diarrhea or constipation
• Fatigue
• Diagnosis
• Diagnosis of stomach cancer involves taking a medical history and performing a physical
examination and laboratory tests. A palpable (i.e., able to be felt with the fingers) tumor or mass
may indicate advanced disease. Tests may include fecal occult blood test, complete blood count
(CBC), upper GI series (also called barium swallow), gastroscopy, and imaging tests.
• Fecal occult blood test is used to detect microscopic blood in the stool, which may indicate
stomach or other gastrointestinal (GI) cancers (e.g., colorectal cancer).
• Complete blood count (CBC) is a simple blood test used to measure the concentration of white
blood cells, red blood cells, and platelets.
 • In an upper GI series, or barium swallow, the patient drinks a thick, chalky liquid (barium) that
coats the esophagus and stomach and makes it easier to detect abnormal areas on x-ray.
In double-contrast barium swallow, air is blown into the esophagus and stomach to help the
liquid coat the wall of the organs more thoroughly
• Gastric Cancer Staging
• Staging is a method of judging the progress of the cancer in a patient. That is, once doctors know
how far along the cancer is, they can decide on the best course of treatment. The staging process
looks at the tumor and the extent to which it has spread to other parts of the body. There are a
number of aspects to staging.
• A simplified approach puts patients into six groups or stages based on how far the cancer has
advanced:
Stage 0 Cancer has just begun to affect the inner
stomach.
Stage I Cancer has begun to penetrate toward the
outer layer of stomach. Nearby lymph
nodes may be involved.
Stage II Cancer has progressed farther through
tissue layers of stomach or more distant
lymph nodes may be involved.
Stage III Cancer has penetrated all tissue layers of
stomach or distant lymph nodes may be
involved.
Stage IV Cancer has affected nearby organs and
tissues. Cancer may even have been carried
through the lymph system to distant parts
of the body. This is known as metastasis.
Recurrent Patient with previous gastric cancer was
cancer free, but cancer returned.
Surgical Treatment for Gastric Cancer
Treatment for stomach cancer depends on the size, location, and extent of the tumor; the stage of the
disease; and the patient's age and overall health. The goal of treatment for early-stage stomach cancer is
to cure the disease. In advanced cases, when a cure is unlikely, the goal is to reduce pain and restore
some quality of life (called palliative treatment).
Surgical removal (resection) is the only curative treatment. Chemotherapy and radiation therapy may be
used in addition to surgery (adjuvant treatment) or as palliative treatment.
Gastric Surgery
The extent of surgery depends on the extent of the disease. Endoscopic mucosal resection may be used
to treat early stomach cancer (i.e., tumor smaller than 3 cm that has not invaded beyond the innermost
layer of the stomach lining [submucosa]). This procedure involves removing only the tumor and
surrounding tissue.
Gastrectomy is the most common treatment for stomach cancer. In this surgery, the entire stomach (total
gastrectomy) or part of the stomach (partial or subtotal gastrectomy) is removed. Parts of nearby tissues
or organs (e.g., the spleen) may also be removed. In most cases, surrounding lymph nodes also are
removed (lymph node dissection). Surgery for cancer of the upper stomach (cardia) may require removal
of the stomach and part of the esophagus (called esophagogastrectomy).
Following total gastrectomy, the esophagus is attached directly to the small intestine. When a large
section of the stomach is removed during partial gastrectomy, the surgeon reattaches the stomach to the
esophagus or small intestine. The connection between these organs is called an anastomosis.
Gastrectomy requires a large incision. Most patients experience postsurgical pain, weakness, fatigue, and
loss of appetite. Recovery from the procedure varies depending on the patient’s age and overall health,
the type of surgery, and the stage of the disease.
Complications of surgery include the following:
• Anastomosis failure
• Blood clots
• Bowel obstruction (ileus)
• Inflammation of the gall bladder (cholecystitis) or pancreas (pancreatitis)
• Pneumonia
Chemotherapy
Chemotherapy involves using drugs to destroy cancer cells. This treatment may be used after stomach
cancer surgery to destroy remaining cancer cells and prevent recurrence (adjuvant
treatment). Chemotherapy drugs may be administered orally or through an IV (i.e., through a vein) and
treatment often is administered on an outpatient basis.
Chemotherapy drugs target rapidly dividing cells and travel throughout the body via the bloodstream
(called systemic treatment). Side effects may be severe and include the following:
• Diarrhea
• Fatigue
• Hair loss
Stomach Cancer
• Increased risk for infection (suppressed immune system)
• Loss of appetite
• Nausea and vomiting
• Reduced red blood cell count (anemia)
• Prevention
• Stomach cancer cannot be prevented in all cases. With most cancers, prevention involves
moderating the lifestyle and environmental exposure factors that seem to be associated with it. In
the case of gastric cancer, this may be difficult, since all the causes are not well understood.
• Dietary risk factors can be managed. Individuals, especially those in risk groups, should eat an
adequate amount of fruits, vegetables, and whole grains.
• In addition, high-fat foods and animal proteins should only be consumed moderately. Most
importantly, individuals should minimize their intake of dried, salty foods.

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Etiology of stomach cancer is multifactorial, butHelicobacter pylori plays a

significant role. Symptoms include early satiety, obstruction, and bleeding but
tend to occur late in the disease. Diagnosis is by endoscopy, followed by CT
and endoscopic ultrasound for staging. Treatment is mainly surgery;
chemotherapy may provide a temporary response. Long-term survival is poor
except for those with local disease.

Stomach cancer accounts for an estimated 21,000 cases and over 11,000
deaths in the US annually. Gastric adenocarcinoma accounts for 95% of
malignant tumors of the stomach; less common are localized gastric lymphomas
(see Lymphomas) and leiomyosarcomas. Stomach cancer is the 2nd most
common cancer worldwide, but the incidence varies widely; incidence is
extremely high in Japan, China, Chile, and Iceland. In the US, incidence has
declined in recent decades to the 7th most common cause of death from cancer.
In the US, it is most common among blacks, Hispanics, and American Indians.
Its incidence increases with age; > 75% of patients are > 50 yr.

Etiology
Helicobacter pylori infection is the cause of most stomach cancer. Autoimmune
atrophic gastritis (see Gastritis and Peptic Ulcer Disease: Autoimmune
Metaplastic Atrophic Gastritis) and various genetic factors (see Tumors of the GI
Tract: Gastrointestinal Stromal Tumors) are also risk factors. Dietary factors
have not proven to be a cause.

Gastric polyps can be precursors of cancer. Inflammatory polyps may develop in

patients taking NSAIDs, and fundic foveolar polyps are common among patients
taking proton pump inhibitors. Adenomatous polyps, particularly multiple ones,
although rare, are the most likely to develop cancer. Cancer is particularly likely
if an adenomatous polyp is > 2 cm in diameter or has a villous histology.
Because malignant transformation cannot be detected by inspection, all polyps
seen at endoscopy should be removed. The incidence of stomach cancer is
generally decreased in patients with duodenal ulcer.

Pathophysiology
Gastric adenocarcinomas can be classified by gross appearance: (1) Protruding
—the tumor is polypoid or fungating. (2) Penetrating—the tumor is ulcerated. (3)
Superficial spreading—the tumor spreads along the mucosa or infiltrates
superficially within the wall of the stomach. (4) Linitis plastica—the tumor
infiltrates the stomach wall with an associated fibrous reaction that causes a
rigid “leather bottle” stomach. (5) Miscellaneous—the tumor shows
characteristics of two or more of the other types; this classification is the largest.
Protruding tumors have a better prognosis than spreading tumors because they
become symptomatic earlier.

Stomach Cancer

Symptoms and Signs

Initial symptoms are nonspecific, often consisting of dyspepsia suggestive of
peptic ulcer. Patients and physicians alike tend to dismiss symptoms or treat the
patient for acid disease. Later, early satiety (fullness after ingesting a small
amount of food) may occur if the cancer obstructs the pyloric region or if the
stomach becomes nondistensible secondary to linitis plastica. Dysphagia may
result if cancer in the cardiac region of the stomach obstructs the esophageal
outlet. Loss of weight or strength, usually resulting from dietary restriction, is
common. Massive hematemesis or melena is uncommon, but secondary
anemia may follow occult blood loss. Occasionally, the first symptoms are
caused by metastasis (eg, jaundice, ascites, fractures).

Physical findings may be unremarkable or limited to heme-positive stools. Late

in the course, abnormalities include an epigastric mass; umbilical, left
supraclavicular, or left axillary lymph nodes; hepatomegaly; and an ovarian or
rectal mass. Pulmonary, CNS, and bone lesions may occur.

Diagnosis
• Endoscopy with biopsy
• Then CT and endoscopic ultrasound

Differential diagnosis commonly includes peptic ulcer and its complications.

Patients suspected of having stomach cancer should have endoscopy with

multiple biopsies and brush cytology. Occasionally, a biopsy limited to the
mucosa misses tumor tissue in the submucosa. X–rays, particularly double-
contrast barium studies, may show lesions but rarely obviate the need for
subsequent endoscopy.

Patients in whom cancer is identified require CT of the chest and abdomen to

determine extent of tumor spread. If CT is negative for metastasis, endoscopic
ultrasound should be done to determine the depth of the tumor and regional
lymph node involvement. Findings guide therapy and help determine prognosis.

Basic blood tests, including CBC, electrolytes, and liver function tests, should be
done to assess anemia, hydration, general condition, and possible liver
metastases. Carcinoembryonic antigen (CEA) should be measured before and
after surgery.

Screening: Screening with endoscopy is used in high-risk populations (eg,

Japanese) but is not recommended in the US. Follow-up screening for
recurrence in treated patients consists of endoscopy and CT of the chest,
abdomen, and pelvis. If an elevated CEA dropped after surgery, follow-up
should include CEA levels; a rise signifies recurrence.

Prognosis
Prognosis depends greatly on stage but overall is poor (5–yr survival: < 5 to
15%) because most patients present with advanced disease. If the tumor is
limited to the mucosa or submucosa, 5–yr survival may be as high as 80%. For
tumors involving local lymph nodes, survival is 20 to 40%. More widespread
disease is almost always fatal within 1 yr. Gastric lymphomas have a better
prognosis and are discussed in Lymphomas.

Treatment
 • Surgical resection, sometimes combined with chemotherapy, radiation, or both

Treatment decisions depend on tumor staging and the patient's wishes (some
may choose to forgo aggressive treatment—see Medicolegal Issues: Advance
Directives).

Curative surgery involves removal of most or all of the stomach and adjacent
lymph nodes and is reasonable in patients with disease limited to the stomach
and perhaps the regional lymph nodes (< 50% of patients). Adjuvant
chemotherapy or combined chemotherapy and radiation therapy after surgery
may be beneficial if the tumor is resectable.

Resection of locally advanced regional disease results in a 10–mo median

survival (vs 3 to 4 mo without resection).

Metastasis or extensive nodal involvement precludes curative surgery, and at

most, palliative procedures should be undertaken. However, the true extent of
tumor spread often is not recognized until curative surgery is attempted.
Palliative surgery typically consists of a gastroenterostomy to bypass a pyloric
obstruction and should be done only if the patient's quality of life can be
improved. In patients not undergoing surgery, combination chemotherapy
regimens (5– fluorouracil

, doxorubicin

, mitomycin

, cisplatin

, or leucovorin in various combinations) may produce temporary response but

little improvement in 5–yr survival. Radiation therapy is of limited benefit.