Cancer of the Stomach
Charles F. Babbs, MD, PhD
Definition
An invasive, life-threatening proliferation
of epithelial cells derived from gastric
mucosa. Cancer of the stomach is slow-
growing tumor that is difficult to diagnose.
It tends to produce the kind of slow,
painful demise that we have come to fear
from cancer.
Dietary factors
• Dietary factors: nitrosamines derived from
nitrates used to preserve hot dogs, bacon,
and sausage; 3,4-benzopyrene in smoked
fish (high incidence in Japan, Iceland,
Finland) [Anna Liebelt’s mouse studies]
• A high fat (yes) diet and green veggies
protect against gastric cancer.
Causes: gastric
cancer and
heliobacter
pylori
Helicobacter pylori as the
universal stomach pathogen
www.vwmin.org
How
helicobacter
might cause
gastric cancer
Wadhwa, et al., Nature
Reviews Clinical Oncology
10, 643–655 (2013)
Stomach mucosa and muscular wall
(normal)
1 cm
1 cm
medcell.med.yale.edu
Normal stomach mucosa
Normal function of gastric lining
• Mucus neck cells
make mucus
• Parietal cells make
acid
• Chief cells make the
digestive enzyme,
pepsinogen (converted
to pepsin in lumen)
ANATOMY OF STOMACH
CANCER
Gastric cancer
Normal gastric glands
Qiao's Pathology: Gastric Adenocarcinoma
Loss of normal
structure
(dysplasia)
More dysplasia
Highly dysplastic lesion
Gross pathology
… superficial type
… fungating type
Linitis
plastica
(leather bottle stomach)
Directional spread options
Spread of gastric cancer
Spread to Osler’s node in the neck
Pathophysiology and late
manifestations
• Reduced gastric compliance and/or intraluminal masses
may cause early satiety, obstruction, and vomiting
• Chronic bleeding can lead to iron deficiency anemia
• Loss of appetite and weight loss can result from pain or
from factors released by the tumor
(Professor Roger Maickel at Purdue)
• Milk-alkali syndrome is possible with painful ulcerating
cancers
• Liver metastases can cause obstructive jaundice
• Compression of veins in the liver or abdomen, or tumor
seeding of peritoneum, can promote ascites
Diagnosis
may not
be red
Why early symptoms are ignored
• The stomach is distensible
• Anemia from bleeding causes subtle
weakness, takes 1-2 years to develop
• Weight loss is viewed as a good thing
• Pain responds to antacids initially
• Fullness and bloating is blamed on food
choice
• Vomited blood is not bright red
(“coffee grounds”)
Physical findings
(usually stage 3-4)
• Adult > 40 years old
• Abdominal mass or masses
• Enlarged lymph nodes (lymphadenopathy)
• Bowel obstruction
• Fluid in the abdomen (ascites)
• Enlarged liver (hepatomegaly)
Differential diagnosis
• Cancer of the pancreas -- jaundice appears earlier
and is more prominent
• Benign ulcer of the stomach -- negative biopsy
• Cancer of the lower third of the esophagus --
endoscopy
• Gastritis -- alcohol or steroid use, endoscopy
• Gastric lymphoma or lieomyosarcoma -- biopsy
Endoscopy of normal stomach
Endoscopy of fungating gastric cancer
Endoscopy and biopsy for diagnosis
Gastric mucosa is the “organ of origin”
Magnetic resonance imaging for staging
The Role of Computed Tomographyin the Imaging of Gastric Carcinoma
Marco Moschetta, et al. www.intechopen.com
Treatment is predominantly surgical
Surgery: total or partial gastrectomy
image.slidesharecdn.com
Billroth II procedure improves drainage
and is recurrence resistant
Ancillary treatments
• Chemotherapy and radiation are of minimal
value in gastric cancer (pending new research)
• Treatment for stage 3 or 4 may include
surgery (incurable inoperable)
• Correction of anemia and malnutrition to
make the patient feel better
• Ultimately hospice care is helpful
Special section on early detection
(a public health approach)
Gastric cancer screening in Japan
• Gastric cancer is the leading cause of death
from cancer in Japan. In 2004, there were
50,562 deaths from gastric cancer; they
accounted for 15.8% of the total number of
cancer deaths. Since 1983, under the Health
Service Law for the Aged, gastric cancer
screening has been conducted nationwide
for all residents aged 40 years and over.
Jpn J Clin Oncol. 2008 Apr;38(4):259-67.
Screening endoscopy in Japan
• 1 in 700 ‘scopes positive
• 1 in 1400 ‘scopes finds early cancer
• 5-year survival ~ 90 percent!
Why not screen in USA?
• Stomach cancer incidence 1/10th that of
breast cancer
• Need to screen ~ 10 times as many people to
find one case
• For women between the ages of 40 and 49
years undergoing annual screening
mammography, the number needed to screen
is about 300 (~ 700 for Ca stomach in Japan)
• At $1000/’scope that’s 3000 scopes x $1000
= $3,000,000 / case
Can BME help?
acquired by Medtronic
(VP Teri Whitman is
Purdue BME grad)
Capsule endoscopy
(used mostly for esophagus, small bowel, and colon)
Wearable receiver and recorder
Self-propelled capsule
endoscopy for stomach
Ryukoku University and Osaka College of
Medicine, Japan
Capsule endoscopy of
the stomach
• It can be done
• What are the problems?
• How can you help?
Endoscopic images Copyright © Atlanta South
Gastroenterology, P.C.
Pill-cam images too fuzzy?
Look what Katie Bouman did!
Imaging the Unseen: Taking the First Picture of a Black Hole -
Katie Bouman - 6/7/2019Imaging
the Unseen: Taking the First Picture of a Black Hole - Katie B
ouman - 6/7/2019
Future work
is available
