Gastric Adenocarcinoma: Part Two DIAGNOSIS AND STAGING Clinical Manifestations

Early gastric cancer is detected commonly in Japanwhere there is an aggressive screening program.Unfortunately, in the United States, most gastric cancers present at an advanced stage. This is because screening programs are not employed in the United States, and patients are usually diagnosed once symp-toms are investigated. Symptoms generally do not occur until the cancer has invaded the muscularis propria or metastasized to distant organs. Weight loss and persis-tent abdominal pain are the most common symptoms, occurring in greater than 60 % and 50 % of patients, respectively (1). Location may determine symptom pre-sentation, with antral cancers commonly presenting with gastric outlet obstruction and cardia cancers pre-senting with dysphagia. Pseudoachalasia can occur with tumor involvement of Auerbach’s plexus. Feculent emesis or passage of recently ingested food per rectum can be seen with a gastrocolic fistula. Physical examination is usually unremarkable and nonspecific. Rarely an epigastric mass, hepatomegaly, ascites, or lower extremity edema is present. When there are physical findings, the most common are cachexia and evidence of bowel obstruction. Metasta-tic disease may manifest as a palpable lymph node at the umbilicus (Sister Mary Joseph node) or supraclav-icular region (Virchow’s node). Metastasis to the ovaries (Krukenberg’s tumor) or rectal shelf can occur, occasionally translating into a palpable mass. Paraneo-plastic phenomena are unusual and include throm-bophlebitis or Trousseau’s syndrome, acanthosis nigri-cans, and seborrheic keratoses or Leser-Trelat sign, although none are specific for gastric cancer. DIAGNOSI