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Gastric cancer
Gastric cancer is linked to H. pylori and is usually found late; an early mucosal tumour is treated by endoscopic resection, and a locally advanced tumour by peri-operative chemotherapy and gastrectomy with D2 lymph node dissection.
Why it matters in the exam
The exam asks about risk factors (H. pylori, smoked and salted food, atrophic gastritis, pernicious anaemia, smoking, and CDH1 carriage in the diffuse type), about the difference between the intestinal and diffuse types ("linitis plastica" — a rigid stomach), and about signs of advanced disease: Virchow's node above the left clavicle, a Sister Mary Joseph nodule at the umbilicus, ovarian metastases (Krukenberg) and a Blumer's shelf on rectal examination.
The second part is work-up and treatment: gastroscopy with biopsies, CT, EUS, and staging laparoscopy for a locally advanced tumour to find peritoneal spread that CT misses. A small mucosal tumour is treated by endoscopic resection (ESD); a T2 or deeper or node-positive tumour is treated with peri-operative chemotherapy (FLOT) and gastrectomy with D2 dissection removing at least 16 nodes. In advanced cancer HER2 and PD-L1 are tested to choose treatment. Candidates are also asked about MALT lymphoma, which responds to H. pylori treatment, and about dumping syndrome after gastrectomy.
Key points
- Risk factors: H. pylori, smoked and salted food, atrophy, pernicious anaemia, CDH1.
- Work-up: gastroscopy, CT, EUS and staging laparoscopy.
- T1a — endoscopic resection; T2 or deeper or nodes — FLOT and resection with D2.
- Advanced disease: Virchow, Sister Mary Joseph, Krukenberg, Blumer.
- MALT — treat H. pylori; after gastrectomy — dumping.
Summary table
| Situation | Finding | Treatment |
|---|---|---|
| Early mucosal tumour (T1a) | Small, not ulcerated, no nodes | Endoscopic resection (ESD) |
| Resectable tumour, T2 or deeper or node-positive | CT, EUS and staging laparoscopy without spread | Peri-operative chemotherapy (FLOT) and gastrectomy with D2 (at least 16 nodes) |
| Peritoneal spread or metastases | Laparoscopy, CT; Virchow, Sister Mary Joseph, Krukenberg | Systemic therapy by HER2 and PD-L1; surgery only for palliation |
| CDH1 carriage | Diffuse gastric cancer in the family | Prophylactic gastrectomy |
| MALT lymphoma | Linked to H. pylori | Treat H. pylori and follow up |
| Dumping after gastrectomy | Early: sweating and palpitations after a meal; late: hypoglycaemia | Small meals, few simple sugars |
Example question from the licensing exam (IMLE)
A 65-year-old male is diagnosed with gastric carcinoma on endoscopy performed due to weight loss. Heavy smoker. Which of the following findings on examination will raise the suspicion for metastatic disease?
- A. Enlarged supraclavicular node (Virchow node)
- B. Enlarged umbilical node (Sister Mary Joseph node)
- C. Ovarian mass (Krukenberg tumor)
- D. Enlarged liver, jaundice, and ascites
- E. All of the above
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Sources
- ESMO Clinical Practice Guideline: Gastric cancer, 2022 — Staging, peri-operative chemotherapy and surgery
- NCCN Clinical Practice Guidelines in Oncology: Gastric Cancer, 2025 — Work-up, endoscopic resection and D2 gastrectomy
- Sabiston Textbook of Surgery, 21st edition (2022) — Stomach
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.