Gastric Cancer Screening and Diagnosis

Il Ju Choi

doi:10.4166/kjg.2009.54.2.67

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Choi: Gastric Cancer Screening and Diagnosis

Review

Korean J Gastroenterol 2009;54(2):67-76.

Published online: 21 February 2009

DOI: https://doi.org/10.4166/kjg.2009.54.2.67

Gastric Cancer Screening and Diagnosis

Il Ju Choi, M.D., PhD.

Center for Gastric Cancer, National Cancer Center, Goyang, Korea

Correspondence to: Il Ju Choi, M.D. Center for Gastric Cancer, National Cancer Center, 111, Jungbalsan-ro, Ilsandong-gu, Goyang 410-769, Korea Tel: +82-31-920-2282, Fax: 82-31-920-1127 E-mail: cij1224@hanmail.net

Abstract

Gastric cancer is the most common cancer in Korea and has overall survival rate of around 50%. Gastric cancer detected in early stage can be cured by endoscopic resection or less invasive surgical treatment and the subsequent prognosis is excellent. National cancer screening program for gastric cancer has been available for several years. The evaluation for efficacy of our screening strategy is strongly needed in terms of mortality reduction and cost-effectiveness. Accurate diagnosis and staging evaluation is important for proper management and prediction of a patient's prognosis. It is recommended to understand the advantages and limitations of currently available guidelines and diagnostic modalities. The 7th edition of gastric cancer staging system from AJCC may have significant effect on our knowledge and patient management.

Keywords: Gastric cancer, Screening, Diagnosis, Staging

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Fig. 1.

Subtypes of advanced gastric cancer (Type 1-4). Type I, fungating type; Type II, ulcerofungating type; Type III, ulcer-oinfiltrative type; Type IV, infiltrative type.

Fig. 2.

Subtypes of early gastric cancer (Type 0). Type 0-I, protruded type; Type 0-IIa, superficial elevated type; Type 0-IIb, flat type; Type 0-IIc superficial depressed type; Type 0-III, excavated type.

Fig. 3.

Schematic view of tumor location. Stomach is longitudinally divided into three equal parts, and cross-sectionally divided into four parts.

Table 1.

Summary of Case-control Studies and Cohort Studies Evaluated Screening Effect on Mortality of Gastric Cancer Performed in Japan by Photofluorography

Reference	Population	Follow-up	Age	No of subject	Results
Case-Control study					Odds ratio
Oshima et al.⁹	Osaka		40＋	91 case	M: 0.60 (0.34-1.05)
				261 control	F: 0.38 (0.19-0.79)
Fukao et al.¹⁰	Miyagi		50＋	198 case	0.41 (0.28-0.61)
				577 control
Abe et al.¹¹	Chiba		30＋	820 case	M: 0.37 (0.34-1.05)
				2,413 control	F: 0.46 (0.26-0.80)
Cohort study					Relative risks
Oshima et al.¹⁴	Osaka	1967-1975 (6 yr)	All age	32,789	0.91^∗
Hisamichi and	Miyagi	1960-1977 (18 yr)	40-69	7,008	61.9 (p＜0.005)^†
Sugawara¹²					28.1 (p＜0.01)^‡
Inaba et al.¹⁵	Gifu	1992-1995 (40 month)	40＜	24,134	M: 0.72 (0.31-1.66)
					F: 1.46 (0.43-4.90)
Mizoue et al.¹⁶	Inaba (JACC)	1988-1997 (8 yr)	50-69	87,312	M: 0.65 (0.45-0.95)
					F: 0.75 (0.42-1.34)
Lee et al.¹³	JPHC	1990-2003 (13 yr)	40-59	42,150	0.52 (0.36-0.74)
Miyamoto et al.⁸	Miyagi	1990-2001 (11 yr)		41,394	0.54 (0.38-0.77)

M, male; F, female. ∗ Ratio of observed to expected number of cases (O/E ratio) for mortality.

^† Standardized mortality rate for men.

^‡ Standardized mortality rate for women.

Table 2.

Gastic Cancer Staging System (AJCC 6th ed)

Primary tumor
TX	Primary tumor cannot be assessed
T0	No evidence of primary tumor
Tis	Carcinoma in situ: intraepithelial tumor without invasion of the lamina propria
T1	Tumor invades laminar propria or submucosa
T2	Tumor invades muscularis propria or subserosa
T2a	Tumor invades muscularis propria
T2b	Tumor invades subserosa
T3	Tumor penetrates serosa (visceral peritoneum) without invasion of adjacent structures
T4	Tumor invasdes adjacent structures
Regional lymph nodes (N)
NX	Regional lymph nodes cannot be assessed
N0	No regional lymph node metastasis
N1	Metastasis in 1 to 6 regional lymph nodes
N2	Metastasis in 7 to 15 regional lymph nodes
N3	Metastasis in more than 15 regional lymph nodes
Distant metastasis (M)
MX	Distant metastasis cannot be assessed
M0	No distant metastasis
M1	Distant metastasis

Table 3.

Gastic Cancer Stage Grouping (AJCC 6th ed)

Stage 0	Tis	N0	M0
Stage IA	T1	N0	M0
Stage IB	T1	N1	M0
	T2a/b	N0	M0
Stage II	T1	N2	M0
	T2a/b	N1	M0
	T3	N0	M0
Stage IIIA	T2a/b	N2	M0
	T3	N1	M0
	T4	N0	M0
Stage IIIB	T3	N2	M0
Stage IV	T4	N1-3	M0
	T1-3	N3	M0
	any T	any N	M1

Table 4.

A Standardized Pathology Reporting Format for Gastric Cancer⁵²

Stomach, (subtotal, total, proximal) gastrectomy, (endoscopic mucosal resection):
(Multiple, Early, Advanced) gastric carcinoma
1. Location:
[ ] esophagus, [ ] upper third, [ ] middle third, [ ] lower third, [ ] duodenum
Center at (cardia, fundus, body, antrum)
(lesser curvature, greater curvature, anterior wall, posterior wall, circle)
2. Gross type:
EGC type (I, IIa, IIb, IIc, III, _____________),
Borrmann type (1, 2, 3, 4, unclassifiable)
3. Histologic type:
Papillary adenocarcinoma,
tubular adenocarcinoma,
(well-, moderately-, poorly-) differentiated,
mucinous adenocarcinoma, signet-ring cell carcinoma,
small cell carcinoma, undifferentiated carcinoma,
other ______________________
4. Histologic type by Lauren : (intestinal, diffuse, mixed, indeterminate)
5. Size : ____×____×____ cm
6. Depth of invasion:
Carcinoma in situ (pTis),
invades mucosa (lamina propria, muscularis mucosa) (pT1a),
invades submucosa (sm1, sm2, sm3, sm) (pT1b), [depth of sm invasion : _____ cm]
invades proper muscle (pT2a), invades subserosa (pT2b),
penetrates serosa (pT3), directly invades adjacent structure (pT4)
7. Resection margin: (involved by carcinoma, free from carcinoma)
Safety margin: distal ___ cm, proximal ___ cm
[anterior ___ cm, posterior ___ cm, deep ___ cm (sm only)]
8. Lymph node metastasis:
no metastasis in ___ regional lymph nodes (pN0)
metastasis to __ out of __ regional lymph nodes (pN_) (lesser curvature/, greater curvature /, LN /,)
9. Lymphatic invasion: (not identified, present)
10. Venous invasion: (not identified, present)
11. Perineural invasion: (not identified, present)
12. Pre-existing adenoma: histology, grade, size, resection
13. Associated findings: (ulceration, perforation, mesenteric metastasis)
14. Separate lesions: (peptic ulcer, adenoma, GIST, polyp, etc)
Contents in Italic font are reserved for EMR specimens.

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