carcinoma at early tumor stage typically produces mild or no
symptoms.  This explains why at the time of disease detection
in the West the tumor is often locally advanced or metastatic.
As the tumor becomes more extensive, an insidious upper abdominal
discomfort may develop, ranging in intensity from a vague sense
of postprandial fullness to a severe, steady pain. Anorexia,
nausea, vomiting and weight loss are also frequently reported
at the time of presentation, whereas dysphagia may be the main
symptom associated with a lesion of the cardia. Hematemesis
or melena is reported by 20 percent of patients but it is more
likely to be associated with leiomyoma and leiomyosarcoma. There
are no physical findings associated with early gastric cancer,
and the presence of a palpable abdominal mass generally indicates
long-standing growth and regional extension. [47, 48] Laboratory
tests may demonstrate anemia, hypoproteinemia, abnormal liver
function, and fecal occult blood. 
Patients with gastric carcinoma infrequently present with various
paraneoplastic conditions such as microangiopathic hemolytic
anemia, membranous nephropathy,  the sudden appearance
of seborrhcic Keratoses (the Leser-Trelat sign),  filiform
and papular pigmented lesions in skin folds and mucous membranes
(acanthosis nigricans)  , chronic intravascular coagulation
leading to arterial and venous thrombi (Trousseau's syndrome)
 , and in rare cases, dermatomyositis. 
upper gastrointestinal series and double-contrast techniques
are performed to evaluate symptoms related to the upper gastrointestinal
tract but their diagnostic accuracy to differentiate a benign
tumor from a malignant ulcer is not high. Fiberoptic endoscopy
and biopsy had a diagnostic accuracy of 95 percent in previous
studies. [57, 58] Since the accuracy increases with the number
of biopsies, multiple biopsies are recommended.  Gastric
carcinomas may be difficult to distinguish from gastric lymphomas,
and because of the submucosal location of lymphoid neoplasms,
it is important to obtain biopsy specimens at an adequate depth.
Computed tomography (CT) scans of the abdomen can delineate
the extent of the primary tumor, as well as the presence of
nodal or distant metastases. [60, 61] Endoscopic ultrasound
(EUS) significantly increases the preoperative accuracy particularly
of tumor depth (T-category) and nodal status (N-category 
and despite some previous debate for routine use  is currently
considered essential in the preoperative staging for an appropriate
treatment option 
the initial enthusiasm about serologic tumor markers, they have
not been useful in diagnosing gastric carcinoma in an early
stage. Carcinoembryonic (CEA), alpha-fetoprotein and CA 19-9
levels , as well as recently CA 72-4 levels have no clinical
value for early detection and even in the follow-up period after
a curative surgery their contribution to the improvement of
outcome is of little efficacy.
pathological tumor stage (pTNM) and the completeness of surgical
resection (R-classification) remain the most important determinant
of the prognosis of gastric cancer. Both have been identified
as independent predictor of survival in multiple reports with
multivariate analyses. The tumor depth into the stomach wall
(T-category) and the presence or absence of metastases to regional
lymph nodes (pN-category) or distant organs (M-category) are
important predictors of disease-free and overall survival. [47,
In the past there were major differences between Japan and Western
world regarding the classification of the local spread of gastric
cancer. Currently, classification according to tumor depth (T-stage)
and distant metastasis (M-stage) is identical in Western countries
(International Union Against Cancer/American Joint Committee
on Cancer (UICC/AJCC) [66,67] and in Japan (Japanese Research
Society for Gastric Cancer [JRSGC ). However, the nodal
staging system remains different. The Japanese nodal system
is based on the anatomical location of lymph nodes. According
to the guidelines, of the JRSGC, the upper abdominal lymph nodes
are grouped into 16 stations, which are subsequently divided
into four levels (N1-N4) according to the location of the primary
tumour. N1 level includes the perigastric lymph nodes directly
attached to the stomach (stations 1 to 6), N2 level the extraperigastric
lymph nodes along the left gastric artery (no. 7), common hepatic
artery (no. 8), coeliac artery (no. 9), and splenic artery (no.
11) and at the splenic hilus (no. 10) [N2 level], and N3, N4
levels include hepatoduodenal, retro-pancreatic, mesenteric
and para-aortic lymph nodes (stations 12 to16). Although the
prognostic significance of this, based on the anatomical location
of lymph-nodes nodal system, may be clear, it is very complicated
for routine practice. A number of observational studies have
shown the prognostic significance of the number of positive
nodes and thus a classification based on the number of positive
nodes has been proposed with a variety of cut-off points ranging
from 2 to 16 involved lymph nodes. [69-72] The new UICC/AJCC
classification is based on the number of positive nodes; pN1:
metastasis in 1 to 6 lymph nodes, pN2: 7 to 15 nodes, pN3: 16
or more nodes.  Several studies have confirmed the superiority
of this new nodal system in estimation of the prognosis. [74-77]
In addition, these studies have shown that the new pN classification
can be applied without methodological problems and appears more
reproducible than the old pN-system or the Japanese nodal system.
However, the value of the D classification for the description
of the extent of a surgical procedure and the analysis of the
treatment results remains unchanged. Nevertheless, for clinical
trials that evaluate the therapeutic benefit of extended node
dissection the classification of nodal status should include
both anatomical location and number of positive nodes per N
Table 2 demonstrates the grouping of TNM-system according to
the latest 5th-edition of UICC/AJCC (1997).
STAGE GROUPING (UICC/AJCC 1997)
Tis N0 M0
T1 N0 M0
T1 N1 M0
T2 N0 M0
T1 N2 M0
T2 N1 M0
T3 N0 M0
T2 N2 M0
T3 N1 M0
T4 N0 M0
T3 N2 M0
T4 N1,N2,N3 M0
T1,T2,T3 N3 M0
Any T Any N M1
Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ (intraepithelial tumor without invasion
of the lamina propria)
T1 Lamina propria, submucosa
T2 Muscularitis propria, submucosa
T3 Penetrates serosa (visceral peritoneum) without invasion
of adjacent structures
T4 Invades adjacent structures
1. A tumor may penetrate muscularitis propria with extension
into the gastrocolic or gastrohepatic ligaments or the greater
lesser omentum without perforation of the visceral peritoneum
covering these structures. In this case, the tumor is classified
as T2. If there is perforation of the visceral peritoneum covering
the gastric ligaments or omenta, the tumor is classified as
2. The adjacent structures of the stomach are the spleen,
transverse colon, liver, diaphragm, pancreas, abdominal wall,
adrenal gland, kidney, small intestine, and retroperitoneum.
3. Intramural extension to the duodenum or esophagus
is classified by the depth of greatest invasion in any of these
sites including stomach.
Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in 1 to 6 regional lymph nodes
N2 Metastasis in 7 to 15 regional lymph nodes
N3 Metastasis in more than 15 regional lymph nodes
Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
absence or presence of residual tumor after treatment may be
described by the symbol R. The definitions of the R classification
apply to all digestive system tumors. These are:
Presence of residual tumor cannot be assessed
R0 No residual tumor
R1 Microscopic residual tumor
R2 Macroscopic residual tumor
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