Gastric cancer gives little warning, and what a patient or clinician sees depends on how far the tumour has grown and where it sits in the stomach.
Symptoms and signs at presentation
Early gastric cancer is asymptomatic in more than 80% of cases, which explains why it is usually found by screening rather than by symptoms. Most patients with gastric cancer are symptomatic at the time of diagnosis. The symptoms are often vague, which is why they are easy to attribute to something harmless:
- vague upper abdominal discomfort
- hematemesis (vomiting of blood) or melena (black, tarry stool from digested blood), and the anemia that follows the blood loss
- anorexia and early satiety
- unexplained weight loss
- dysphagia (difficulty swallowing) and odynophagia (painful swallowing), in patients with cancer of the gastroesophageal junction
What the common symptoms are
The common manifestations of gastric cancer are weight loss, in 60%, and abdominal pain, in 50%. Other less common symptoms are nausea, vomiting, melena, dysphagia, early satiety and anorexia.
The location of the tumour shapes the presentation. Tumours of the distal part of the stomach can lead to pyloric outlet obstruction, while tumours of the proximal part can lead to dysphagia and pseudoachalasia.
A paraneoplastic syndrome, a remote effect of the tumour not caused by its local growth or spread, very rarely occurs with gastric cancer. Anemia and a positive occult fecal test can be seen because of bleeding from an ulcerated mass.
Physical signs and metastatic disease
Physical examination can reveal lymphadenopathy or deposits of tumour at characteristic sites:
- the supraclavicular lymph nodes (Virchow’s node)
- peri-umbilical masses (Sister Mary Joseph nodules)
- a pelvic mass on rectal examination (Blumer’s shelf)
- an ovarian mass (Krukenberg tumour)
These signs reflect spread, and gastric cancer is metastatic in more than 33% of cases. The most common sites of metastasis are the liver, in 40%, the peritoneum, the peri-umbilical lymph node (Sister Joseph nodule), the left supraclavicular lymph node (Virchow node), the pouch of Douglas, and the ovaries (Krukenberg tumour). Liver enzymes can be altered secondary to liver metastasis.