Gastric tumors :

Gastric tumors (benign\malignant): abnormal mass originates from the components of the stomach,
mainly the layers of the stomach (generally: mucosa, submucosa, muscularis propria, subserosa and
serosa)
Benign
-more common than malignant tumors, but
-infrequently cause clinical problems;
-reported in 5-25% of autopsies
-types:
Polyps.
GI Stromal tumors (GIST): spindle
cell tumors(most common ).
Lipomas, hemangiomas, granular
cell tumors, heterotopic
pancreatic rests(pancrearic

Malignant
Carcinomas

Lymphomas

Sarcomas (malignant GI stromal tumors)

tissue founded in the stomach)

Gastric polyps :

nodules or masses that project above the level of

the surrounding mucosa
- they are result either from neoplastic or non-neoplastic
Type
Hyperplastic

Fundic

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Notes
-- the most common (75 %)
- usually affect age 50 -60
reults from inflammation
- chronic gastritis(H.pylori) reaction in the mucosa hyperplasia
-treatment of H.pylori may lead to regression
-The development of dysplasia in those polyps is 0% if small in size.
BUT, if size of polyp is more than 1.5 cm, a significant increase in risk is there.
- less common ( 10 %)
-Fundus and body
-Sporadic or syndromatic
- associated with familial adenomatous polyposis multiple polyps in the
colon
- associated with PPI use increase gastrin hyperplasia of the fundic
glands

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-No neoplastic potentials in both pathways BUT however the polyps with
more than 1.5cm diameter have an association with dysplasia should be
resected
MULTIPLE
Associated with Peutz-Jeghers syndrome.
HAMARTOMATOUS
Rare
POLYPS
Neoplastic
- 10 % overall
polyps(adenomas) - Almost always occur on a background of chronic gastritis with atrophy and
intestinal metaplasia
- two forms : tubular (rounded ) , villous (villi stretching , cabbage-like)
-associated with dysplasia : may be low grade ,or high grade ( higher risk for
transformation to adenocarcinoma)
-Neoplastic polyps contain dysplastic epithelium, have 50% chance of
malignant transformation
30% association in malignancy in the
surrounding tissue.
-Risk of Adenocarcinoma increases dramatically if size of adenoma is more
than 2 cm.
-Carcinoma may be present in up to 30% of gastric adenomas.
Location: Antrum

- gastric adenocarcinoma :

-Approximately 90% of gastric malignancies , 3% of all malignancies

Variable geographic distribution: 20 times more in Japan, Latin America than in rest of world.

Mass endoscopic screening

35% of newly detected cases are early gastric cancer, or tumors limited to the mucosa and
submucosa.

Detection of early tumors

the overall 5-year survival is from 5-15% only depend on the stage

Two types of gastric adenocarcinoma , differ in histology and location :

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1) Intestinal type

2) Gastric diffuse type

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Intestinal type
- more common
- Arise from gastric mucous cells that have
undergone intestinal metaplasia.
- Proliferation of well formed glands
- Expanding growth
- Well or moderately differentiated
- Associated with risk factors :
-1)Diet: nitrites, smoked & pickled food, salt, ...
-2)Gastric disease: H. pylori atrophy intestinal
metaplasia
3)Altered anatomy: post-subtotal
gastrectomy(Favors reflux of bilious, alkaline
intestinal fluid )
4) Partial gastrectomy (as trt for PUD):
increases risk

Diffuse type
- less common
-Arise de novo from native gastric mucous
cells
Proliferation of signet-ring cells : discohesive cells with large mucin vacuoles
that expand the cytoplasm and push the
nucleus to the periphery, giving a ring-like
structure
- Infiltrative growth evoke a demoplastic
reaction that
stiffens the gastric wall and may cause diffuse
rugal flattening and a rigid, thickened wall that
imparts a leather bottle appearance

termed linitis plastica.

Poorly differentiated

Usually >50 yrs; M>F

Undefined risk factors

Decreasing in frequency

Usually <50 yrs; M=F

Increasing in frequency

- general risk factors :

1) ENVIRONMENTAL RISK FACTORS
Infection by H. pylori (discussed) and modified later on.
Diet (discussed)
Low socioeconomic status
Cigarette smoking
2) HOST FACTORS
Chronic gastritis:
Hypochlorhydria: favors colonization with H. pylori
Intestinal metaplasia is a precursor (precancerous) lesion
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 Partial gastrectomy
Gastric adenomas:
a) 40% harbor cancer at time of diagnosis
b) 30% have adjacent cancer at time of diagnosis
Barrett esophagus: may lead to increased risk of gastroesophageal
junction tumors.
3) GENETIC FACTORS:
Slightly increased risk with blood group A
Family history of gastric cancer
Hereditary nonpolyposis colon cancer syndrome
Familial gastric carcinoma syndrome (E-cadherin mutation)
Pathogenesis :
1) Mutations : Germline mutations in CDH1, which encodes E-cadherin, a protein
that contributes to epithelial intercellular adhesion. Thus, the loss of E-cadherin function seems
to be a key step in the development of diffuse gastric cancer. (Loss of adhesion= diffused single cells).
Mutation in APC (adenomatous polyposis coli) gene, have an
increased risk for developing intestinal type gastric cancer.
TP53 mutations are present in a majority of sporadic gastric cancers
of both histological types (intestinal & diffuse)
2)H.pylori :

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3) EBV infection :
- 10% of gastric adenocarcinomas
- TP53 mutationsare uncommon in the EPV positive gastric tumors, thats why we consider the EBV
infection as a distinct pathogenesis
-Morphologically, EbV-positive gastric adenocarcinoma tend to occur in the
proximal stomach, most commonly have DIFFUSE morphology (associated
with diffuse-type adenocarcinoma) with a marked lymphocytic infiltrates
* pathology :
Sites: Pylorus & antrum 50-60%, cardia 25%, body & fundus 15-25%; lesser
40% & greater curvature 12% (lesser more that greater).
Gross appearance:
Exophytic
Flat or depressed (focal effacement of mucosa or linitis plastica)
Excavated (ulcer-like)

Depth of invasion (stage):

Early gastric carcinoma: confined to mucosa & submucosa regardless of
LN status, 90% of survival rate.

Advanced gastric carcinoma: extended beyond submucosa. Less than 20%

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CLINICAL FEATURES OF GASTRIC CARCINOMA

Important: the clinical manifestation in gastric carcinoma are very similar
to those in chronic gastritis, so as a physician, you have to consider this
when a patient come to you and have for example an abdomen pain.

Early gastric carcinoma is generally asymptomatic; usually discovered

by endoscopy while screening persons at high risk; excellent
prognosis
Advanced carcinoma may be asymptomatic; may cause abdominal
discomfort, weight loss, or obstructive symptoms; dismal prognosis
(poor quality or a low standard)
Spread to regional & distant lymph nodes; earliest lymph node
metastasis may be to supraclavicular termed : Virchows LN
Krukenberg tumor: intraperitoneal spread of gastric carcinoma to
both ovaries in females

gastric lymphoma :
- lymphoma usually occur on LNs , but when they are found outside LNs extranodal
lymphomas
- the GIT is common place for extranodal lymphoma
-The bowel also is the most frequent site for EBV positive B
cell lymphoproliferation, nearly 5% of all gastric malignancies are primary
lymphomas, the most common of which are indolent extranodal marginal zone B cell
lymphomas.
Gastric lymhoma
-May be primary or secondary.
GL represent 5% of all gastric malignancies.
Classification similar to nodal lymphoma; mostly B-cell type.
Stomach is the most common site of extra-nodal lymphomas (20%).
Patients: middle aged & elderly.
Clinical features depend on type, grade and stage of lymphoma.

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GIST :
benign tumors, mesenchymal neoplasms may arise in the stomach.
many are named according to cell type they most resemble, for example:
smooth muscle tumors are called leiomyomas or leiomyosarcomas, nerve
sheath tumors are called schwannomas, like this.
GISTs is the most common mesenchymal tumor in the abdomen, and more
than half of these tumors occur in the stomach.
more common in males, more common in aged persons.
75%-80% of GISTs patients have oncogenic mutations of gene encoding the
tyrosin kinase, c-KIT.
GISTs appear to share a common stem cell (interstitial cells of Cajal) which
are located in the muscularis propria
best treatment of this tumors is the surgery, however, the tumor may be
multiple located, in this situation, giving the kinase inhibitors is the best
option, like Imatinib.

Which of the following forms of stomach polyps is the most likely to become
cancerous?
a) Hyperplastic polyps
b) Fundic gland polyps
c) Adenomas
d) All of the above
e) None of the above
In gastric adenocarcinoma, Virchow node refers to the:
a) Right supraclavicular node
b) Left supraclavicular node
c) Right infraclavicular node
d) Left infraclavicular node
e) Submental node
Which of the following tumors would originate from the interstitial cells of Cajal
and thus affect peristalsis?
a) Gastric adenocarcinoma
b) Gastric lymphoma
c) Gastroinestinal stromal tumor
d) Gastric neuroendocrine cell (carcinoid) tumor
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e) Gastric gland hyperplasia

Peutz-Jeghers polyps fall under what category of small intestine and colonic
tumors?
a) Non-neoplastic polyps
b) Neoplstic epithelial lesions
c) Mesenchymal lesions
d) Lymphomas
is true regarding hyperplastic polyps of the stomach : Answer : The risk of development of dysplasia in
small sized polyps is very minimal

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