Main histological types and development
In pathological anatomy, two fundamentally different variants of the tumor are distinguished:
- Intestinal-type carcinoma: develops in stages via precancerous conditions. The classic Pelayo Correa cascade includes H. pylori colonization, chronic inflammation, atrophy, intestinal metaplasia, dysplasia (adenoma), and progression to invasive cancer. At these stages, mutations in APC, p53, K-ras genes, as well as DNA methylation changes, are detected.
- Diffuse-type carcinoma: arises de novo, bypassing the stage of metaplasia and adenoma. It is characterized by genetic instability, p53 mutations, loss or mutation of the E-cadherin gene, and the formation of signet-ring cell structures with high mucin content.
The extreme manifestation of diffuse endophytic growth is scirrhous carcinoma, causing marked wall thickening and the picture of linitis plastica (linitis plastica).
Bormann macroscopic classification
To describe advanced forms of the tumor, a macroscopic classification is used, dividing the process into four types:
- Type 1 (Polypoid / Fungating) — an exophytic solitary lesion in the form of a node or cauliflower-like mass with a clear boundary from healthy tissue.
- Type 2 (Ulcerated with distinct margins) — a crateriform "ulcer-cancer" with raised roller-like margins and a clear demarcation from the mucosa.
- Type 3 (Ulcerative-infiltrative) — ulceration without distinct borders, smoothed edges, and invasion into deep layers of the wall.
- Type 4 (Diffusely infiltrative / Scirrhous) — endophytic growth with diffuse wall thickening and rigidity of folds.
Early cancer and precancerous lesions
The concept of early cancer refers to a tumor that does not spread beyond the mucosa or submucosa, crucially without invading the muscularis propria of the organ wall. Despite this, due to the location of lymphatic vessels in the lamina propria, the risk of lymph node metastasis remains.
The central concept of precancerous GI lesions is intraepithelial neoplasia, equivalent to epithelial dysplasia:
- Adenoma is considered an obligate precancerous condition with a high risk of malignant transformation.
- Atrophic gastritis increases the risk of malignant transformation by 5–6 times.
- Reactive foveolar hyperplasia (a response to H. pylori or NSAIDs) is not a premalignant lesion.
Briefly: answers to topical questions
What are the main pathways of metastasis in gastric cancer?
The main pathways of metastasis in gastric cancer include lymphogenous, hematogenous, and implantation.
- Lymphogenous pathway — can be orthograde (to regional lymph nodes along the greater and lesser curvature) and retrograde. Distant retrograde metastases include:
- Virchow's node metastasis — to the left supraclavicular lymph node.
- Krukenberg tumor — to the ovaries.
- Schnitzler's metastasis — to the perirectal tissue.
- Irish's node metastasis — to the axillary lymph nodes.
- Hematogenous and implantation pathways — lead to involvement of the liver, ovaries, and other organs.
What clinical symptoms are characteristic of early and late stages of gastric cancer?
Clinical symptoms of gastric cancer depend on localization, growth pattern, and the presence of metastases.
- Early stages — usually asymptomatic or accompanied by non-specific complaints: dyspepsia, decreased appetite, aversion to meat.
- In advanced disease, general symptoms of tumor intoxication join in: weakness, weight loss, anemia.
Symptoms depending on localization and form:
- Cardioesophageal junction involvement — dysphagia.
- Antral involvement with pyloric stenosis — nausea and vomiting of ingested food.
- Ulcerated cancer — bleeding and perforation.
- Diffusely infiltrative cancer — wall rigidity, reduced gastric volume, and a feeling of early satiety after small amounts of food.
What diagnostic methods are used to confirm the diagnosis of gastric cancer?
To confirm the diagnosis of gastric cancer, endoscopic, radiological, and surgical methods are used.
- EGD with targeted biopsy — the "gold standard" of diagnostics with mandatory subsequent morphological examination of the biopsy specimen.
- Barium swallow / Upper GI radiography (with double contrast) — reveals a "filling defect". Multiposition radiocontrast examination is especially effective in diffuse-infiltrative cancer (linitis plastica), where biopsy may yield false-negative results.
- Diagnostic laparoscopy — used to detect peritoneal dissemination, includes peritoneal washing for cytologic examination and biopsy.
- Neck lymph node ultrasound — used to assess the extent of the process and rule out Virchow's metastases.
The Correa cascade is remembered through the chain: "Bacteria strike the mucosa -> inflammation -> intestinal cell metaplasia -> adenoma with dysplasia -> invasive cancer".
Class and exam questions
What is the main difference between intestinal and diffuse types of cancer?
The intestinal type develops in stages via precancerous conditions and metaplasia, whereas the diffuse type arises de novo, bypassing the adenoma stage, and is characterized by the presence of signet-ring cells.
What is early gastric cancer in terms of depth of invasion?
This is a tumor confined to the mucosa or submucosa and crucially not invading the muscularis propria of the gastric wall.
Is reactive foveolar hyperplasia a precancerous condition?
No, reactive foveolar hyperplasia reflects a response to injury or mitogenic stimuli and has no basis to be classified as a premalignant lesion.
What else to study on this topic
- Molecular and genetic markers (p53, TERT, C-erbB2, CD44)
- Gastric MALT lymphoma and its association with Helicobacter pylori
- Hereditary forms of cancer and familial adenomatous polyposis
- Features of histological variants of adenocarcinoma
- The role of loss of heterozygosity (LOH) and DNA methylation
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