2. INTRODUCTION
• Esophageal and gastric cancers have a high global incidence and mortality
• Major risk factors: tobacco, alcohol, H. pylori, dietary habits, GERD.
• Histologies: SCC & adenocarcinoma (esophagus); intestinal & diffuse types
(stomach).
11. STOMACH
• Regions:
◦ Cardia: just distal to GE junction
◦ Fundus: dome-shaped part superior to GE
junction
◦ Body (Corpus): main central portion
◦ Antrum: distal funnel-shaped region
◦ Pylorus: sphincter leading into the duodenum
• Curvatures:
◦ Lesser curvature: right/medial border
◦ Greater curvature: left/lateral border
• Wall Layers: Mucosa Submucosa Muscularis
→ →
externa (3 layers: oblique, circular, longitudinal) →
Serosa
12. BLOOD SUPPLY AND LYMPHATICS OF THE STOMACH
🔴 Arterial Supply:
• Left gastric artery (from celiac trunk)
• Right gastric artery (from hepatic artery)
• Right & left gastroepiploic arteries
• Short gastric arteries (from splenic artery)
🟢 Lymphatic Drainage:
• Follow arterial supply:
◦ Left/right gastric perigastric celiac nodes
→ →
◦ Greater curvature gastroepiploic nodes
→
• Japanese Gastric Cancer Association (JGCA) nodal
levels:
◦ N1: perigastric nodes (stations 1–6)
◦ N2: along major vessels (stations 7–11)
◦ N3/N4: para-aortic, distant
23. VIRCHOW’S NODE
ANATOMY AND RELEVANCE
• Virchow’s node is the left supraclavicular lymph node, located at the junction of
the thoracic duct and left subclavian vein.
• It receives lymph from the thoracic duct, which drains the abdomen, pelvis,
and lower limbs.
• Acts as a sentinel node for abdominal malignancies, especially gastric cancer.
• Troisier’s sign: a firm, enlarged Virchow’s node suggesting advanced intra-
abdominal malignancy.
• Lymphatic pathway: Tumor perigastric nodes celiac nodes cisterna chyli
→ → →
thoracic duct Virchow’s node
→ → .
• Commonly involved in gastric, pancreatic, testicular, and pelvic cancers.
25. Global and Regional Burden
• Esophageal Cancer:
◦ 7th most common cancer worldwide; ~600,000 new cases/year
◦ High incidence in “esophageal cancer belt”: Eastern Asia, Central Asia, parts
of Eastern Africa
◦ Two main histologies: Squamous Cell Carcinoma (SCC) prevalent in
Asia/Africa; Adenocarcinoma (AC) rising in Western countries
• Gastric Cancer:
◦ 5th most common cancer worldwide; ~1 million new cases/year
◦ High burden in East Asia (Japan, Korea, China), Eastern Europe, South
America
27. PREVENTION AND EARLY DETECTION
1. Risk Reduction: Avoid tobacco, alcohol, manage obesity and GERD to lower esophageal
adenocarcinoma (ACA) risk; H. pylori eradication may reduce gastric cancer incidence.
2. Barrett’s Esophagus: High-grade dysplasia requires EMR (Endoscopic Mucosal
Resection), RFA, or surgery; endoscopic surveillance every 3–5 years for non-dysplastic
cases.
3. Chemoprevention: NSAIDs (e.g., aspirin) may reduce SCC and ACA risk; ongoing trials
like AspECT evaluate long-term benefit.
4. Early Detection: Japan’s mass screening increased early gastric cancer diagnosis (5-
year OS ~90%); not cost-effective in Western populations due to low incidence.
5. Genetic Syndromes: CDH1 mutation carriers (hereditary diffuse gastric cancer) advised
prophylactic gastrectomy due to 70% lifetime cancer risk.
29. CLINICAL PRESENTATION
Dysphagia (difficulty swallowing):
• Most common presenting symptom ( 80%)
≥
• Progresses from solids to liquids
Weight loss:
• Present in 60–80% of patients
Odynophagia (painful swallowing):
• 20–40%
Chest/back pain:
• 15–30%
Hoarseness:
• 5–10% (due to recurrent laryngeal nerve
involvement)
Cough/aspiration:
• If fistula develops
ESOPHAGEAL CANCER GASTRIC CANCER
Epigastric pain or discomfort: 60–70%
Weight loss: 50–70%
Anorexia: 40–60%
Nausea/vomiting: 20–30%
Early satiety: 20–30%
Occult bleeding/anemia: 30–50%
Dysphagia:
• If tumor involves cardia/GEJ (10–
20%)
30. PHYSICAL EXAMINATION FINDINGS
Cachexia and weight loss (common in advanced cases)
Palpable abdominal mass:
• Rare, but can be found in large tumors or nodal
masses
Virchow’s node (left supraclavicular):
• Present in 10–30% (sign of metastatic disease)
Sister Mary Joseph’s nodule (periumbilical):
• Rare (1–3%) but specific for peritoneal spread
Ascites:
• Indicates peritoneal carcinomatosis
Hepatomegaly:
• May suggest liver metastases
Clubbing:
• Occasionally reported in esophageal cancer
31. RED FLAG SIGNS
• Progressive dysphagia (solids to liquids)
• Significant unintentional weight loss (>10% body weight)
• Persistent anemia (iron deficiency)
• Palpable Virchow’s node or Sister Mary Joseph’s nodule
• New-onset hoarseness or cough (possible recurrent laryngeal nerve or fistula)
• Signs of obstruction (vomiting, severe early satiety)
SUGGESTIVE OF ADVANCED DISEASE
33. ESOPHAGOGASTRODUODENOSCOPY (EGD)
• Gold standard for visualizing mucosal lesions
in esophagus and stomach
• Allows direct visualization of tumor location,
size, extent
• Essential for targeted biopsies to confirm
diagnosis
• Assess for synchronous lesions or multifocal
disease
34. BIOPSY AND HISTOPATHOLOGY
• Multiple biopsies taken from tumor and
suspicious areas
• Techniques: forceps biopsy, brush
cytology (less common)
• Histopathology confirms cancer type
(SCC, adenocarcinoma, others)
• Immunohistochemistry may assist in
difficult cases or molecular profiling
35. IMAGING: CONTRAST ENHANCED CT
• Contrast-enhanced CT scan of thorax
and abdomen is routine for staging
• Evaluates tumor extent, nodal
involvement, and distant metastases
(liver, lung, adrenal)
• Helps assess resectability and treatment
planning
• Limitations: less sensitive for early T-
stage or small nodes
A dumb-bell configuration mass in the cervicothoracic
esophagus with mediastinal extension. Aorto-pulmonary
window extension is responsible for recurrent laryngeal
nerve palsy. Probable achalasia cardia-pre-existing.
36. IMAGING: ENDOSCOPIC ULTRASOUND
• Gold standard for T (tumor) and N (nodal)
staging of esophageal and gastric cancers
• Provides detailed images of tumor depth
and regional lymph nodes
• Guides fine needle aspiration (FNA) of
suspicious nodes
• Improves accuracy of staging, impacts
treatment decisions (neoadjuvant vs.
surgery)
37. IMAGING: MRI
• Limited role, but useful in selected cases for assessing local invasion into adjacent
structures
• Preferred for evaluating invasion of the aorta, vertebrae, or other mediastinal
structures
• Can complement CT and EUS findings in complex cases
38. IMAGING: PET-CT
• Used to detect occult metastases and distant
disease
• High sensitivity for metabolically active nodes
and distant lesions
• Particularly useful in esophageal cancer
staging
• Helps avoid unnecessary surgery by
identifying advanced disease
39. MOLECULAR PROFILING
• HER2 Testing (especially in gastric & GEJ adenocarcinoma)
• Overexpressed in ~15–20% Targeted therapy with trastuzumab
→
• PD-L1 Expression
• Evaluated by Combined Positive Score (CPS)
• High expression Potential benefit from immunotherapy (e.g., pembrolizumab)
→
• MSI-H / dMMR Status
• Found in ~5–10% of gastric cancers
• Predicts response to immune checkpoint inhibitors
• EBV-associated Gastric Cancer
• ~10% of cases
• Associated with better prognosis, high PD-L1, and immune infiltration
• NTRK Fusions (rare)
• If present eligible for TRK inhibitors (e.g., larotrectinib)
→
40. OTHER INVESTIGATIONS
• CBC and comprehensive chemistry profile (LFT/KFT)
• Screen for family history
• Assess H. pylori status and conduct genetic testing as needed
• Gene profiling with PCR and NGS
51. PATTERNS OF SPREAD
• Direct Extension: Invades adjacent structures like omentum, pancreas,
diaphragm, colon, duodenum.
• Peritoneal Spread: Serosal breach leads to carcinomatosis; common with
transmural invasion.
• Lymphatic Spread: Via rich submucosal/subserosal plexus early
→
microscopic spread; nodes involved include gastric, gastroepiploic, celiac,
splenic, suprapancreatic, para-aortic.
• Venous Spread: Predominantly via portal circulation liver metastases in
→
~30% at diagnosis.
• Skip Metastasis: Occurs due to complex lymphatic drainage and rich
plexus connections.
