Updated: 3/10/2017

Stomach Cancer

Topic
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Questions
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Snapshot
  • A 78-year-old Japanese man, who moved to New York last year to live with his daughter, presents to the emergency room with fatigue, loss of appetite, and signs of anemia. His stool is guaiac positive.
Introduction
  • Major types of gastric tumors include
    • gastric adenocarcinoma 
      • accounts for 95% of malignant tumors of the stomach
      • most located in lesser curvature of pylorus and antrum
      • subtypes includes diffuse type of gastric adenocarcinoma/Linitis plastica
        • infiltration and diffuse spread
          • causes inability of stomach peristalsis
          • presence of signet ring cells 
        • most lethal form of gastric adenocarcinoma
          • produces Krukenberg tumors
          • mucinous, signet-ring cells with metastasis to the ovaries
          • not associated with H.pylori
    • lymphomas/MALToma
      • less common
      • associated with H. pylori
    • leiomyomas
      • less common
      • benign
  • Risk factors include
    • male
    • >50 years old
    • Japanese population
      • due to consumption of smoked foods
    • nitrosamines (beer, pickled foods)
    • chronic gastritis
      • H. pylori, achlorhydria, EtOH
Presentation
  • Early-stage stomach cancer produces no specific symptoms
  • Symptoms
    • heartburn or indigestion
    • epigastric pain
    • anorexia
    • nausea
    • sensation of pressure in the stomach
    • weight loss
  • Physical Exam
    • acanthosis nigricans 
    • seborrheic keratosis
    • painless, hard supraclavicular node
      • Virchow's nodule
        • left supraclavicular node
    • palpable ovarian masses 
      • with Krukenberg tumor
    • hard nodes at umbilicus 
      • Sister Mary Joseph sign
Prognosis, Prevention, and Complications
  • Poor prognosis
  • Linitis plastica
    • invariably fatal within months
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.ON.83) A 70-year-old female presents to your office with nausea, vomiting, and 3 months of weight loss. On physical exam, you observe a finding seen in Figure A. You suspect adenocarcinoma, and you immediately order a biopsy to ascertain the extent of metastatic disease. In which of the following organs would you observe the primary tumor with abundant mucus and signet ring cells on biopsy if metastatic disease were present? Review Topic

QID: 101140
FIGURES:
1

Stomach

68%

(91/134)

2

Lung

5%

(7/134)

3

Colon

6%

(8/134)

4

Ovary

19%

(25/134)

5

Kidney

1%

(1/134)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(M1.ON.9) A 60-year-old Japanese male presents to your office with epigastric pain following 1 month of unintentional weight loss. He reports that he has followed a strict diet of low-fat smoked fish all his life. On physical exam, you note a skin finding similar to Figure A. If this patient undergoes aggressive surgical treatment, which of the following may result? Review Topic

QID: 101066
FIGURES:
1

Cobalamin deficiency

74%

(98/133)

2

Increased prothrombin time

3%

(4/133)

3

Acute cellular rejection

2%

(2/133)

4

Diabetes

11%

(15/133)

5

Esophageal squamous cell carcinoma

10%

(13/133)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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