Gastric cancer

Last updated: September 21, 2023

Summarytoggle arrow icon

Gastric cancer is the fifth most common cancer worldwide. Although the incidence is declining in the United States, it remains high in some Asian countries, most notably Japan, South Korea, and Mongolia. The main risk factor for developing gastric cancer is infection with Helicobacter pylori. Other risk factors include GERD, a diet high in salts and nitrates, and tobacco use. Adenocarcinoma accounts for 95% of gastric cancer and is further classified as intestinal or diffuse type. Less frequent gastric cancers include gastric lymphomas, gastrointestinal stromal tumors, and neuroendocrine tumors. Early on, patients are commonly asymptomatic or have nonspecific symptoms (e.g., dyspepsia, epigastric pain). Later on patients may develop signs of metastatic disease or complications (e.g., gastric outlet obstruction, GI bleeding, ascites). Diagnosis is confirmed with upper endoscopy and biopsy. Staging via imaging or diagnostic laparoscopy helps inform the treatment. Early nonmetastatic disease is typically treated with surgery and perioperative chemotherapy. Unresectable or metastatic disease is treated with systemic chemotherapy or chemoradiation. Targeted therapy can be added based on tumor molecular characteristics. Palliative care is the mainstay of therapy for patients with frailty and an advanced cancer stage. The prognosis varies according to tumor stage, but the overall 5-year survival rate is low as the diagnosis is often made late once symptoms progress.

Epidemiologytoggle arrow icon

  • Incidence
    • An estimated 27,600 new cases were diagnosed in the US in 2020. [1][2]
    • Highest incidence in South Korea, Mongolia, and Japan [3]
  • Sex: > [2]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Exogenous risk factors [2]

Endogenous risk factors [2]

Clinical featurestoggle arrow icon

Early stages of gastric cancer

  • Often asymptomatic
  • Loss of appetite, nausea

Late stages of gastric cancer

Diagnosticstoggle arrow icon

Gastric cancer is frequently diagnosed during the endoscopic evaluation of nonspecific symptoms or findings (e.g., heartburn, dyspepsia, anemia, weight loss). Patients typically need repeat endoscopic tissue sampling for histopathologic studies and imaging studies for cancer staging.

Diagnostic approach [10][11][12]

Over half of patients with gastric cancer in the US present with advanced disease (stage III or higher) at the time of diagnosis. [14]

EGD with biopsy [15][16]

  • Indications include:
    • Clinical features suspicious for gastric cancer
    • Incidental finding of gastric cancer on previous EGD
  • Procedure
    • Visual identification and biopsy of suspicious lesions
    • Frequently combined with EUS
  • Findings

Staging investigations [10][11][13]


Diagnostic laparoscopy [10][13][20]

The peritoneum is the most common site of metastasis in gastric cancer. Curative gastrectomy is typically not attempted if diagnostic laparoscopy or peritoneal cytology indicate peritoneal metastasis. [13][21]

Additional diagnostics [10][12][13]

Stagestoggle arrow icon

pTNM classification of gastric cancer [33]
Intent AJCC/UICC TNM Tissue invasion Lymph node metastases Distant metastasis
  • Stage 0
  • None
  • None
  • Stage IA
  • T1, N0, M0
  • Stage IB
  • T1, N1, M0
  • T2, N0, M0
  • Muscularis propria
  • None
  • Stage IIA
  • T1, N2, M0
  • T2, N1, M0
  • Muscularis propria
  • T3, N0, M0
  • Subserosal tissue
  • None
  • Stage IIB
  • T1, N3a, M0
  • T2, N2, M0
  • Muscularis propria
  • T3, N1, M0
  • Subserosal tissue
  • T4a, N0, M0
  • None
  • Stage IIIA
  • T2, N3a, M0
  • Muscularis propria
  • T3, N2, M0
  • Subserosal tissue
  • T4a, N1, M0
  • T4a, N2, M0
  • T4b, N0, M0
  • Adjacent organs/structures
  • None
  • Stage IIIB
  • T1, N3b, M0
  • T2, N3b, M0
  • Muscularis propria
  • T3, N3a, M0
  • Subserosal tissue
  • T4a, N3a, M0
  • T4b, N1, M0
  • Adjacent organs/structures
  • T4b, N2, M0
  • Stage IIIC
  • T3, N3b, M0
  • Subserosal tissue
  • T4a, N3b, M0
  • T4b, N3a, M0
  • Adjacent organs/structures
  • T4b, N3b, M0
  • Stage IV
  • Any T, any N, M1
  • Any structure
  • Any number
  • Yes

Pathologytoggle arrow icon

Gastric adenocarcinoma

General features

  • Accounts for ∼ 95% of cases [34]
  • Most commonly located on the lesser curvature
  • Arises from glandular cells in the stomach

Lauren classification of gastric adenocarcinoma

  • Intestinal type gastric carcinoma
    • Typically localized
    • Polypoid, glandular formation
    • Similar to an ulcerative lesion with clear raised margins
    • Commonly located on the lesser curvature
  • Diffuse type gastric carcinoma
    • No clear border
    • Spreads earlier in the course of disease
    • Infiltrative growth
    • Diffuse spread in the gastric wall
    • Linitis plastica: gastric wall thickening and leather bottle appearance
    • Composed of signet ring cells: round cells filled with mucin, with a flat nucleus in the cell periphery
    • Associated with E-cadherin mutation [35]
  • Intermediate type (the least common type): should be treated as the diffuse type, as the extent of tumor infiltration is difficult to assess

Differential diagnosestoggle arrow icon

See also “Approach to dyspepsia” and “Acute abdominal pain.”

Gastric conditions

Other types of cancer

Gastrointestinal stromal tumor (GIST) [36]

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

Approach [10][13]

Provide multidisciplinary care where available (e.g., tumor board) and base treatment plan on patient fitness, disease characteristics, and goals of care (see “Principles of cancer care” for more information).

  • Localized, resectable disease
    • Stages 0 and IA (≤ T1 and ≤ N0): surgical or endoscopic resection
    • Stage IB or higher (≥ T2 and/or N > 0): surgical resection plus perioperative chemotherapy or adjuvant chemoradiotherapy
  • Specific molecular markers present: Consider adding targeted therapy and/or immunotherapy.
  • Metastatic or unresectable cancer: Provide palliative care.

The mainstay of treatment for nonmetastatic gastric cancer is surgical resection with perioperative chemotherapy.

Resection [13][14]

Margin-free resection (R0 resection) is the only potentially curative therapy. However, it is only possible in 30% of patients and is associated with a high recurrence rate. [32][38]


The following procedures are typically combined with radical lymphadenectomy and reconstructive procedures (e.g., Roux-en-Y anastomosis). [10]


Reconstructive procedures [40][41][42]

Chemotherapy and radiotherapy [10][13]

A combination of preoperative and postoperative chemotherapy significantly improves survival in resectable disease. [45]

Personalized treatment [10][12][13]

Gastric cancers are genetically diverse and have multiple possible genetic mutations amenable to therapeutic manipulation. Systemic therapy may be modified based on the presence of specific molecular markers.

For the forms of cancer associated with HER2 gene overexpression and the medication used for treatment, think: TRUST HER, GaBriel (TRUSTuzumab; HER2; Gastric cancer; Breast cancer).

Supportive and palliative care [46]

Complicationstoggle arrow icon

Metastatic disease

The Skeleton (bones), Liver, Lung, and Brain are the structures most commonly affected by hematogenous spread of gastric cancer: Zombie SKELETONs don't LIVE LONG (lung) without eating BRAINs.

Paraneoplastic syndromes

Paraneoplastic syndromes may be signs of visceral malignancies, especially GI carcinomas. These syndromes include:

Always rule out malignancy in patients with acanthosis nigricans.

Gastric outlet obstruction (GOO) [46][51]

Postgastrectomy complications


Small intestinal bacterial overgrowth (SIBO)

Efferent loop syndrome

  • Definition: kinking or anastomotic narrowing of the efferent loop that causes emesis and/or a feeling of fullness
  • Management

Afferent loop syndrome

  • Definition
    • Biliary and pancreatic obstruction due to stenosis, kinking, or incorrect anastomosis of the afferent loop
    • Chyme enters the afferent loop instead of the efferent loop and causes loss of appetite, a feeling of fullness, and bilious vomiting with subsequent relief of nausea.
  • Management: surgical treatment

Dumping syndrome

  • Definition: rapid gastric emptying as a result of defective gastric reservoir function, impaired pyloric emptying mechanisms, or anomalous postsurgery gastric motor function

Early dumping

Late dumping

Suspect late dumping syndrome in a patient with previous gastric surgery and hypoglycemia.

Remnant gastric cancer [57][58][59]

We list the most important complications. The selection is not exhaustive.

Prognosistoggle arrow icon

  • Because there are no early signs, gastric cancer is often diagnosed very late. Around 50% of cancers have already reached an advanced stage that does not allow for curative treatment due to tissue invasion and metastases. [33]
  • If diagnosed at a very early stage, the 5-year survival rate is 95%. [60]
  • Late-stage disease with distant metastases and/or peritoneal carcinomatosis has a poor prognosis (5-year survival rate of ∼ 5%). [61]

Referencestoggle arrow icon

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