Carcinoma of the Stomach
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Direct answer
Gastric carcinoma in India is predominantly intestinal-type and distal (per most Indian series, though patterns vary), arising on a background of Helicobacter pylori-associated chronic atrophic gastritis following the Correa cascade of gastritis, atrophy, intestinal metaplasia, dysplasia and cancer. Lauren intestinal-type tumours form glands and ulcers, while diffuse-type (including signet-ring and linitis plastica) infiltrate the wall, spread submucosally and carry a worse outlook; hereditary diffuse cancer follows germline CDH1 (E-cadherin) mutation. Diagnosis is endoscopy with multiple biopsies, staging is with CT and laparoscopy for peritoneal disease, and treatment of resectable disease is a D2 radical gastrectomy — distal subtotal for antral tumours, total for proximal or diffuse — with perioperative chemotherapy per current practice.
What you must remember
- Correa cascade: H. pylori gastritis (a class 1 carcinogen) progresses through atrophy, intestinal metaplasia and dysplasia to adenocarcinoma; smoked, salted and nitrite-preserved foods, smoking, pernicious anaemia, prior partial gastrectomy and CDH1, Lynch and FAP syndromes add risk.
- Lauren classification: intestinal (gland-forming, better prognosis, distal) versus diffuse (poorly cohesive signet-ring cells, linitis plastica with a leather-bottle stomach, worse prognosis).
- Early gastric cancer is confined to mucosa or submucosa regardless of nodal status, has an excellent prognosis after resection, and is detected by population screening in Japan.
- Named metastatic sites: Virchow (Troisier) node in the left supraclavicular fossa, Krukenberg tumour in the ovary, Blumer shelf in the rectovesical or rectouterine pouch, Sister Mary Joseph nodule at the umbilicus, and the Irish node in the left axilla.
- D2 gastrectomy removes the greater and lesser omentum with the relevant tier of nodes (stations along the hepatic, left gastric, splenic and coeliac arteries) and is standard practice in India and Japan; D1 alone is inadequate for cure in fit patients.
- Perioperative chemotherapy (for example FLOT) or postoperative chemoradiotherapy is offered for locally advanced resectable disease; hereditary CDH1 carriers may choose prophylactic total gastrectomy.
- Palliation of advanced disease: stenting for gastric outlet obstruction, and occasionally a bypass or feeding jejunostomy for nutrition.
Common confusion
Students confuse early gastric cancer with 'stage I' only. Early gastric cancer is defined purely by depth (mucosa or submucosa) irrespective of nodes, and it is the depth-based definition that explains its excellent prognosis and the possibility of endoscopic resection. A second confusion is linitis plastica appearing 'normal mucosa' on endoscopy — biopsies may be falsely negative, and imaging showing a non-distending stomach should raise diffuse-type suspicion.
Exam-focused takeaway
Eponyms are near-guaranteed marks: Virchow node, Krukenberg, Blumer shelf, Sister Mary Joseph and Irish node all indicate advanced disease. Other tested facts: the Correa sequence, H. pylori as class 1 carcinogen, Lauren types, the definition of early gastric cancer, and D2 as the standard lymphadenectomy. Stems show wasting with a mass and iron-deficiency anaemia or a leather-bottle stomach on imaging, asking the histological type or the operative standard.
Frequently asked questions
What is the Correa cascade?
The multistep path from Helicobacter pylori-associated chronic gastritis through atrophy, intestinal metaplasia and dysplasia to intestinal-type gastric adenocarcinoma.
How do Lauren types differ in behaviour?
Intestinal tumours form glands, ulcerate, and spread to nodes relatively late, whereas diffuse tumours infiltrate the wall as signet-ring cells, causing linitis plastica and transperitoneal spread with worse survival.
What is a D2 gastrectomy?
A radical gastrectomy clearing the first and second tier of perigastric nodes along the coeliac axis branches (hepatic, left gastric, splenic stations) with omentectomy — the standard curative operation in India for fit patients.
What is early gastric cancer and why does it matter?
Cancer confined to the mucosa or submucosa regardless of lymph node status, carrying excellent survival and, in selected intramucosal cases, eligibility for endoscopic submucosal dissection.