Tumours of the Stomach

Classification:
• I .Primary tumours

• A) Benign Tumours:

• From epithelial origin: Polyps

• From mesenchymal origin: Uncommon (leiomyoma, neurofibroma)

• B) Malignant tumours:
• From epithelial origin:
• 1. Carcinoma (90% - 95%).
• 2.Neuroendocrine tumours(3%).
• From mesenchymal origin:
• 1. Lymphoma (4%).
• 2. GIST (Gastrointestinal stromal tumor)
• 3. Sarcoma (2%).

II. Secondary tumours : Rare

Gastric Polyps

• A polyp is defined as any mass or nodule that projects above the level
of the surrounding mucosa.

• The use of this term in the gastro-intestinal tract is generally

restricted to masses arising from the mucosa.

• They occur in older persons.

• They are uncommon; and, constitute 0.4% in autopsies.

Morphology:
• Grossly,
• The polyps appear small, pedunculated and often multiple.

• They are three types:

• 1.Inflammatory and Hyperplastic polyps: Constitute 75% of gastric polyps. They are not true
neoplasms but are rather a reactive process, commonly to chronic gastritis. They are composed
of hyperplastic mucosa and inflammed edematous stroma. They have a very mild risk for
development of cancer.

• 2.Fundic gland polyps: Constitute 10% of gastric polyps. They are hamartomatous and not
neoplasms. They occur in association with chronic gastritis. They are composed of small
collections of dilated glands. They have no risk for malignant transformation.

• 3. Adenomatous polyps: Constitute 5% of gastric polyps. They are true neoplasms formed of
glandular structures showing varying degrees of dysplasia. They are potentially malignant
lesions, with a moderate risk for development of carcinoma, and the risk increases with the
increase in the size of the polyps.
Hyperplastic polyp
•usually arising in a
background of chronic
gastritis that initiates the
injury and reactive
hyperplasia of glands

•If size larger than 1.5

cm , risk for malignancy
Fundic gland polyps

Polyps associated with FAP (familial adenomatous polyposis): may show

dysplasia, but they almost never progress to become malignant.

.
Adenomatous polyp
1. Almost always occur on a background of chronic gastritis with atrophy and intestinal
metaplasia.
2. All gastrointestinal adenomas exhibit epithelial dysplasia, which can be classified as low- or
high-grade.
3. The risk for development of adenocarcinoma is related to the size of the lesion and is
particularly elevated with lesions greater than 2 cm in diameter.
Gastric carcinoma
• Adenocarcinoma is the most common malignancy of the stomach
comprising over 90% of all gastric cancers followed by lymphoma
then neuroendocrine tumour.

• Risk factors:
• Factors thought to affect diffuse gastric carcinoma are not identified.
• However there is a slightly increased association with blood group A
patients.
On the other hand risk factors defined for the intestinal type gastric carcinoma are:
• 1. Sex: Male to female ratio 2:1.
• 2. Race: More common in Japan, Chile, Colombia... (but it is due to environmental
rather than genetic factors)
• 3. Age: over 50 years.
• 4. Diet: -Nitrites derived from nitrates found in food and water, and used as
preservatives in prepared meat.
• - Smoked foods and pickled vegetables.
• - Excessive salt intake.
• - Decreased intake of fresh vegetables and fruits (Antioxidants in these foods may
be protective).
• 5. Infection with H. pylori leading to chronic gastritis with intestinal
metaplasia.
• 6. Altered anatomy after subtotal gastrectomy:
• 7. Pernicious anemia associated with chronic gastritis with intestinal
metaplasia
• 8. Adenomatous gastric polyp.
• 9. Changes in oncogenes and tumour-suppressor genes
Sites:
• The pylorus and antrum: 50% to 60% of cases,

• • The cardia: in 25%,

• • Body and fundus: in the remainder 25% .

• A favoured location is the lesser curvature of the antro-pyloric region.

• Although the greater curvature is much less affected than the lesser
curvature, yet, an ulcerative lesion on the greater curvature is more
likely to be malignant
• Classification of gastric carcinomas according to:

• a) Depth of invasion.

• b) Gross appearance.

• c) Histologic subtypes
A. According to depth of invasion:
• a. Early gastric carcinoma (EGC): is confined to the mucosa and
submucosa, regardless of the presence or absence of peri-gastric
lymph node metastases. It presents as a small flat mucosal thickening.
5 year survival rate:> 95%

• b. Advanced carcinoma : is a neoplasm that has extended beyond the

submucosa into the muscular wall and has perhaps spread more
widely. It may present as a fungating mass, excavating ulcer, or a
diffuse infiltrating lesion.
 Adenocarcinoma
► Early gastric carcinoma (EGC): i.e., tumors limited to the
mucosa and submucosa
Advanced Gastric Carcinoma
According
.
to depth of invasion: Advanced type

❖ I polypoid or fungating type.

❖ II ulcerating lesions
surrounded by elevated borders
❖ III ulcerating lesions with
invasion of the gastric wall
❖ IV diffusely infiltrating (linitis
plastica).
B. According to macroscopic growth pattern:
• a. Exophytic fungating mass, which protrudes inside the lumen of the stomach.
• b. Ulcerative mass, which may be in the form of a typical malignant ulcer with
everted edges and hard indurated base or an excavated ulcer with shallow or
deeply erosive crater in the wall of the stomach. It may resemble peptic ulcer,
although in advanced cases, it exhibits heaped-up margins. So any gastric ulcer
greater than 4 cm, on the greater curvature, with heaped-up margins and is
resistant to healing should be biopsied to rule out carcinoma.
• c. Diffuse infiltrating carcinoma (Leather bottle or linitis plastica). In this type
there is involvement of a broad region of gastric wall or the entire stomach is
diffusely infiltrated by malignancy. The infiltration is deep, the mucosa appears
flattened, and the wall is thickened, rigid and contracted
• d. Localized infiltrating carcinoma: It is present in the pyloric region. It causes
stenosis of the pylorus.
Leather bottle appearance( linitis plastica)
C. According to microscopic appearance:
• a. Intestinal type
❖ Is composed of malignant cells forming neoplastic intestinal glands
resembling those of colonic adenocarcinoma (the well differentiated
variant).
❖This type of carcinoma arises from gastric mucosal cells that have
undergone intestinal metaplasia in chronic gastritis A or B.
❖ Such type is more common in high risk population and occurs
primarily after 50 years, with a male to female ratio of 2:1. Its
incidence has decreased in the last 60 years.
 Intestinal type cancers
► tend to be bulky
► form either an exophytic mass or an ulcerated tumor.
► composed of glandular structures similar to colonic
adenocarcinoma.
► The neoplastic cells often contain apical mucin vacuoles,
and abundant mucin may be present in gland lumina
b. Diffuse type:
• This type is not associated with chronic gastritis.
• It occurs at an earlier age than intestinal type with male to female ratio
1:1.
• It is composed of gastric-type mucus cells that generally do not form
glands but rather permeate the mucosa and the wall as scattered
individual "signet-ring" cells or small clusters in an infiltrative growth
pattern.
• These infiltrative tumours often evoke a dense fibrotic stromal
(desmoplastic) reaction that stiffens the gastric wall and may provide a
valuable diagnostic clue.
• When there are large areas of infiltration, diffuse rugal flattening and a
rigid thickened wall may impart a leather bottle appearance termed
linitis plastica.
 Diffuse gastric cancers

► display an infiltrative growth pattern

► composed of discohesive cells with large mucin
vacuoles
► creating a signet ring cell morphology
 Modes of spread:
Gastric carcinoma may spread by:
• 1. Direct Spread: To the submucosa, the muscle wall and the omental fat.
• 2. Transcelomic spread: Involvement of the serosa leads to spread of tumour cells in the
peritoneal fluid. Such metastases involve the ovaries in females leading to bilateral
ovarian deposits known as "Krukenberg tumour".
• 3. Submucosal lymphatics: It results in satellite nodules present some distance from the
main mass.
• 4. Metastases to lymph nodes: Reaching the lymph nodes around the stomach. Later, the
tumour extends up the thoracic duct to the left supraclavicular lymph node (Virchow's
node).
• 5. Blood spread: Reaching the liver, the lungs and bones. It occurs early in the disease
Clinical features:
• I- Early carcinoma may be asymptomatic. It can be discovered by
repeated endoscopic biopsy examinations in persons at high risk e.g.
in Japan. Few cases of early carcinoma give symptoms resembling
chronic gastric peptic ulcer.
• II- Carcinoma of the cardia presents with dysphagia.
• III- Carcinoma of the pylorus presents with gastric outlet obstruction.
• IV- Advanced carcinoma leads to anemia, anorexia, weight loss and
abdominal discomfort. Hematemesis and melena may occur in
association with gastric carcinoma.
Prognosis:

• Depends on the depth of invasion.

• 5-year survival rate is 90%-95% for resected early gastric carcinoma

(even with positive lymph nodes), and 10% survival for advanced
carcinoma.
 Neuroendocrine (Carcinoid) Tumor

► arise from neuroendocrine- differentiated gastrointestinal epithelial (e.g., G cells).

► A majority of these tumors are found in the gastrointestinal tract, and more than
40% occur in the small intestine.

► called “carcinoid” because they are slowely growing than carcinomas.

► The most current WHO classification describes these as

1. Low- or intermediate-grade neuroendocrine tumors.
2. High-grade neuroendocrine tumors, termed neuroendocrine carcinoma,
resemble small cell carcinoma of the lung and, in the gastrointestinal tract, are
most common in the jejunum.
 MORPHOLOGY

► Neuroendocrine tumors are

intramural or submucosal masses
that create small polypoid lesions
► The tumors are yellow or tan in
appearance and elicit an intense
desmoplastic reaction that may
cause kinking of the bowel and
obstruction.
 MORPHOLOGY

► On histologic examination, neuroendocrine tumors

are composed of islands, trabeculae, strands, glands,
or sheets of uniform cells with scant, pink granular
cytoplasm and a round-to-oval stippled nucleus
► Symptoms are determined by the hormones produced.

► For example, the carcinoid syndrome is caused by

vasoactive substances secreted by the tumor that
cause
1. cutaneous flushing,
2. sweating,
3. Broncho-spasm,
4. colicky abdominal pain,
5. diarrhea,
6. right-sided cardiac valvular fibrosis.
Malignant lymphoma

• It Accounts for 4%-5% of malignant tumours of the stomach.

• There are two types:

• 1. Low grade B cell lymphoma. (also referred to as Lymphomas of

mucosa-associated lymphoid tissue, MALT)

• 2. High grade aggressive large B-cell lymphoma.

Pathogenesis
• Low Grade lymphomas (MALT omas) usually arise at sites of chronic
inflammation.

• In the stomach, it is associated with chronic H pylori infection.

• Irradication of the infection using antibiotics induces durable

remissions in most patients.

• Three translocations are associated with gastric Maltomas; t(11;18),

t(1;14) t(14;18).
• Morphology
• Grossly, the lymphoma appears as polypoid mass, an ulcer, diffuse
thickened mucosal folds.

• Prognosis: lymphoma localized to the stomach shows a 5 years

survival rate of 60% It responds to chemotherapy.
 Gastrointestinal stromal tumor
(GIST)
► They arise from the interstitial cells of Cajal (cells responsible
for control of peristalsis).

► characterized by c-KIT immunoreactivity.

► Both benign and malignant behaving types of GIST may occur

at any age and in either sex.
 GIST
► arise
from the interstitial cells of Cajal, or
pacemaker cells, of the gastrointestinal
muscularis propria.
 MORPHOLOGY

GROSS
► Primary gastric GISTs usually
form a solitary, well-
circumscribed, fleshy,
submucosal mass.
► Metastases may form multiple
small serosal nodules or fewer
large nodules in the liver; spread
outside of the abdomen is
uncommon.
 MICROSCOPY

► GISTs can be composed of

thin, elongated spindle cells
or plumper epithelioid cells.
► The most useful diagnostic
marker is KIT, which is
immunohistochemically
detectable in 95% of these
tumors
 Interstitial cells of Cajal

Positive for C kit = CD117

Sarcoma
• It constitutes 2% of malignant tumours of stomach.
• Morphology:
• Grossly, It may present as a large mass involving the wall or may protrude
into the mucosa, associated with mucosal ulceration, or it may protrude as
an extragastric mass.it has less tendency to metastasize or infiltrate than
gastric carcinoma, so its resection is more successful.
• Microscopically, may be in the form of undifferentiated sarcoma or
leiomyosarcoma.
• Clinically, it may present in the form of a mass, bleeding or anemia.
HAEMATEMESIS (Vomiting of Blood)
• Morphology:
• The blood is dark brown, mixed with food, its pH is acidig. The brown colouration is due to acid hematin.

• Causes: may be in the oesophagus, stomach, duodenum or generalized disease.

• 1. Oesophageal causes:

• a.Oesophageal varices in portal hypertension. It is the most frequent cause in the oesophagus.

• b.Carcinoma of the oesophagus.

• c.Reflux oesophagitis with ulceration. d.

• d.Oesophageal perforation (traumatic or post endoscopic).

• E.Leiomyosarcoma & lymphoma.

• 2. Gastric causes:

• a. Chronic gastric peptic ulcer. It is the most frequent cause in the

stomach.

• b. Postgastrectomy marginal ulcer.

• C. Acute erosive gastropathy.

• d. Tumours of the stomach especially gastric carcinoma.

• 3. Duodenal Causes:

• i Chronic duodenal peptic ulcer.

• ii Stress ulcers

• iii. Duodenal neoplasms,

• 4. Generalized Diseases:
a) Hereditary hemorrhagic telangiectasia.
b) Scurvy,
c) Henoch Schoenlein purpura. disorder that causes the small blood vessels in your skin, joints, intestines and kidneys to become inflamed and
bleed

d) Polyarteritis nodosa.
e) Amyloidosis.
f) Kaposi's-Sarcoma.