ulcerating carcinoma of the stomach on the greater curvature

What is it a specimen of?
What is the probable diagnosis?
What are the known precursors of this condition?
What are the macroscopic types?
How does it spread?
What are the common ways of clinical presentation?
What diagnostic investigations would you do in a suspected case?
What is the treatment of the condition?
What is the prognosis?

This is a open stomach after resection with an attached spleen and omentum. There is an ulcerating carcinoma of the stomach on the greater curvature. (See below for further details)

Click here for answer(See below for further details)

It is an opened specimen of most of the stomach (subtotal gastrectomy) with attached omentum and spleen. The stomach contains a large ulcerated mass at the pylorus.

In view of the size and raised everted edge of the ulcer, and the operation specimen containing spleen and greater omentum, the pathology is a carcinoma of the stomach.

The definite pre-malignant conditions are:

gastric polyp
pernicious anaemia
gastric ulcer
longstanding H. pylori

The macroscopic types are:

cauliflower-like growth which later ulcerates - polypoid
an ulcer with an irregular indurated edge (as in this specimen)
schirrous carcinoma which may be localised or diffuse (leather-bottle stomach)
gastric ulcer turning malignant

Carcinoma of the stomach spreads by:

direct extension to neighbouring organs such as pancreas and transverse colon
lymphatics - both by embolisation and permeation
by blood stream mainly to the liver
transperitoneally

6. Clinically carcinoma of the stomach may present as:

dyspepsia of recent onset especially after the age of 40
the 3 As - anaemia, anorexia and asthenia
symptoms of obstruction - dysphagia in carcinoma of the cardia and vomiting from gastric outlet obstruction in carcinoma of the pyloric antrum
lump in the upper abdomen
persistent pain - a pain that has lost its periodicity and does not respond to medical treatment any longer
silent - symptoms from secondaries eg jaundice from liver secondaries

On suspicion, a gastroscopy is done to confirm the diagnosis by biopsy. The cancer is then staged by:

CT and U/S of abdomen
CXR
Laparoscopy when curative operation is considered

The curative treatment should be subtotal gastrectomy (usually D2 or R2) and omentectomy with removal of the spleen if necessary. Sometimes the tail of the pancreas may need to be taken en bloc to include the entire lymphatic drainage. The gastrectomy should be of the Poly ante-colic, full width type. Growths in the cardia need upper radical or total gastrectomy by the thoraco-abdominal approach with Roux-en-Y gastrojejunal anastomosis. In advanced pyloric growths causing vomiting a palliative anterior gastrojejunostomy is done. In advanced cardio-oesophageal growths, self-expanding metallic stent is passed as a means of palliation.

The prognosis in general is very poor. 5% of the initial cases and 10% of those having resection are alive after 5 years. In selected centres when a curative procedure is done (D2 gastrectomy) a better 5-year survival is obtained.