Early Gastric Carcinoma

The following play important role in the diagnosis of early gastric carcinoma:
-screening 'at risk' population
-advanced endoscopic techniques,
-recognition of subtle endoscopic abnormalities,
-careful histopathological examination to identify the depth of invasion.
Following surgical resection, the average five year survival rate is almost 95%.

- Early gastric carcinoma is defined as carcinoma confined to the mucosa or submucosa irrespective of lymphnode involvement (corresponds to T1 gastric carcinoma).

- Macroscopic subypes (see diagram). Often a combination of these three types are present.
- Depressed Type (IIC) is the commonest form of early gastric carcinoma.

- Histological features are similar to those of advanced carcinoma. Classified according to Lauren's Classification into : intestinal, diffuse (signet ring cell) or mixed types.

- Type I and IIa : usually multiple lesions and are likely to be well-differentiated (intestinal type)
- Type IIc & III: Poorly differentiated or signet-ring cell type.
- Tumour behaviour can be predicted by the shape of advancing edge of tumour through the muscularis mucosae into the submucosa.
Early gastric carcinoma with a broad pushing edge (PEN A -subtype) has a poor prognosis.
Tumour with a sharp infiltrating edge (PEN B - subtype) has a better prognosis.
- Histopathologists should be aware of the prognostic implications of the histological features.
- The biopsy must include the full thickness of the tumour and hence must be fully excised to determine whether the tumour fits into the definition of early gastric carcinoma.
- Prognosis is related to depth of invasion. Deeper the penetration (into submucosa) greater the chance of metastases.
- Comment should be made on completeness of excision,lymphatic invasion and presence of ulceration (predictive of lymph node metastasis).
- Endoscopic mucosal resection is performed (mainly in Japan) in case of intramucosal early gastric carcinoma.
- Radical surgery is necessary in case of lymphnode metastasis.
- High grade dysplasia can be indistinguishable from early gastric carcinoma in biopsies.The two often co-exist in more than 80% cases.
- Differences exist in the criteria used to separate high grade dysplasia from intramucosal carcinoma between Japanese (rely on cytological and architectural features only) and Western pathologists (invasion of lamina propria must be present).

Further reading:

Early gastric carcinoma diagnosed on endobiopsic and surgical specimens.Rom J Morphol Embryol. 2006;47(3):235-8.

Tumor growth patterns and biological characteristics of early gastric carcinoma.Oncology. 2001;61(2):102-12.

Natural history of early gastric cancer: a non-concurrent, long term follow up study. Gut 2000;47:618-621

Early gastric cancer: diagnosis, surgical treatment and follow-up of 45 cases.Tumori. 1998 Sep-Oct;84(5):547-51.

Problems arising from eastern and western classification systems for gastrointestinal dysplasia and carcinoma: are they resolvable?Histopathology. 1998 Sep;33(3):197-202.

Differences in diagnostic criteria for gastric carcinoma between Japanese and Western pathologists. Lancet 1997;349:1725-1729.

Risk factors for lymph node metastasis from intramucosal gastric carcinoma. Cancer 1996;77: 602-606

Long-term follow-up in early gastric cancer: evaluation of prognostic factors.J Pathol. 1995 Dec;177(4):343-51.

Early gastric cancer. Ann Surg. 1984 May;199(5):604-9.

Pathomorphological diagnosis. Definition and classification of early gastric cancer, in Early Gastric Cancer, (Ed T Mukarami), Gann Monograph on Cancer research 11, University of Tokyo Press. 1971:53-55

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