Gastric adenocarcinoma

Last revised by Mohammadtaghi Niknejad on 30 Nov 2022

Gastric adenocarcinoma, commonly, although erroneously, referred to as gastric cancer, refers to a primary malignancy arising from the gastric epithelium. It is the most common gastric malignancy. It is the third most common GI malignancy following colon and pancreatic carcinoma

Gastric cancer is rare before the age of 40, but its incidence steadily climbs after that (from 50 to 70 years) and peaks in the seventh decade of life with males predominating at 2:1 2,10. The median age at diagnosis of gastric cancer in the United States is 70 years for males and 74 years for females. 

It often produces no specific symptoms when it is superficial and potentially surgically curable, although up to 50% of patients may have nonspecific gastrointestinal complaints such as dyspepsia 2.

Patients may present with anorexia and weight loss (95%) as well as abdominal pain that is vague and insidious. Nausea, vomiting, and early satiety may occur with bulky tumors that obstruct the gastrointestinal lumen or infiltrative lesions that impair stomach distension 2.

Several nodal metastases with eponymous names associated with gastric cancer have been described:

Adenocarcinoma is by far the most common gastric malignancy, representing over 95% of malignant tumors of the stomach 1. There are two types of gastric adenocarcinoma, intestinal or well-differentiated and diffuse or undifferentiated that have distinct morphologic, pathogenesis, and genetic traits 11.

Gastric cancer continues to be one of the leading causes of cancer-related death. A significant development in the epidemiology of gastric carcinoma has been the recognition of the association with Helicobacter pylori infection (~55% risk; range 46-63% 11). Most gastric cancers occur sporadically, whereas 8-10% have an inherited genetic component. A low vitamin A and C diet, large amounts of smoked foods consumption, and contaminated drinking water also increase the risk of gastric cancer. High body mass index (BMI), high-calorie foods, and gastro-esophageal reflux are associated with an increased risk of the esophageal distal segment, gastric proximal segment, and gastro-esophageal junction adenocarcinoma 11.

Endoscopy is regarded as the most sensitive and specific diagnostic method in patients suspected of harboring gastric cancer. Endoscopy allows direct visualization of tumor location, the extent of mucosal involvement, and biopsy (or cytologic brushings) for tissue diagnosis 3. But radiological methods are often the initial examination that raises suspicion for gastric carcinoma, besides being used in the staging of the disease.

Early gastric cancer (elevated, superficial, shallow):

  • type I: elevated lesion, protrudes >5 mm into the lumen (polypoid)

  • type II: superficial lesion (plaque-like, mucosal nodularity, ulceration)

  • type III: shallow, irregular ulcer crater with adjacent nodular mucosa and clubbing/fusion/amputation of radiation folds 4

Advanced gastric cancer:

  • polypoid cancer can be lobulated or fungating

  • lesion on a dependent or posterior wall; filling defect in barium pool

  • lesion on non-dependent or anterior wall; etched in white by a thin layer of barium trapped between edge of mass and adjacent mucosa

  • ulcerated carcinoma (penetrating cancer): 70% of all gastric cancers 4

Not useful, unless a large epigastric mass is present or in an endoscopic ultrasound study.

CT is currently the staging modality of choice because it can help identify the primary tumor, assess for the local spread, and detect nodal involvement and distant metastases 1.

Demonstration of lesions facilitated by negative contrast agents (water or gas):

  • a polypoid mass with or without ulceration

  • focal wall thickening with mucosal irregularity or focal infiltration of the wall

  • ulceration: gas-filled ulcer crater within the mass

  • infiltrating carcinoma: wall thickening and loss of normal rugal fold pattern 4

Calcifications are rare but when present, they are usually mucinous adenocarcinoma.

It is an aggressive tumor with a 5-year survival rate of less than 20%. Prognosis is correlated to the stage of the tumor at presentation. Therefore, accurate staging of gastric cancer is essential because surgical resection is the treatment for localized disease 1

Peritoneal metastases (gastric carcinomatosis) can occur especially in advanced stage gastric cancer and is frequently considered to be an incurable disease 12-13

  • perforation with peritonitis: rare (thought to occur in ~2% of cases) 5,6

The imaging differential can be broad and includes:

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Cases and figures

  • Figure 1: gastric carcinoma
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  • Case 1
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  • Case 2
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  • Case 3
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  • Case 4: on Barium meal
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  • Case 5: adenocarcinoma
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  • Case 6: adenocarcinoma of antrum
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  • Case 7: with wall thickening on ultrasound
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  • Case 8
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  • Case 9: mucinous adenocarcinoma
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  •  Case 10
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  • Case 11: adenocarcinoma of antrum
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  • Case 12: mucinous adenocarcinoma
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  • Case 13
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  • Case 14
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  • Case 15
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  • Case 20
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  • Case 21
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  • Case 22: gastric cardia adenocarcinoma
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  • Case 23: metastatic antral cancer
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  • Case 28
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  • Case 29: metastatic
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  • Case 30: metastatic
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  • Case 31: in a patient with situs inversus
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  • Case 32
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  • Case 33
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  • Case 34: metastatic
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  • Case 35: with local invasion
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  • Case 46
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  • Case 47: esophagogastric cancer
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  • Case 48
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  • Case 50
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  • Case 51: metastatic
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  • Case 53: metastatic
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  • Case 58: metastatic
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  • Case 59
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  • Case 60: metastatic
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  • Case 61: causing gastric outlet obstruction
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  • Case 62: metastatic esophagogastric cancer
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  • Case 63: Gastric adenocarcinoma
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  • Case 64: esophagogastric adenocarcinoma
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  • Case 65: esophagogastric adenocarcinoma
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  • Case 66: with peritoneal carcinomatosis
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  • Case 67
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  • Case 68: metastatic
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  • Case 69: metastatic
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  • Case 70: pseudoachalasia
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  • Case 71: locally advanced gastroduodenal adenocarcinoma
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  • Case 72: metastatic
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  • Case 73
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  • Case 74: causing gastric outlet obstruction
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  • Case 75
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