ANATOMY

Primary Site.

The stomach is the fi rst division of the abdominal portion of the alimentary tract, beginning
at the esophagogastric junction and extending to the pylorus (Figure 11.1 ). The proximal
stomach is located immediately below the diaphragm and is termed the cardia. The remaining
portions are the fundus and body of the stomach, and the distal portion of the stomach is
known as the antrum. The pylorus is a muscular ring that controls the fl ow of food content
from the stomach into the fi rst portion of the duodenum. The medial and lateral curvatures
of the stomach are known as the lesser and greater curvatures, respectively. Histologically, the
wall of the stomach has fi ve layers: mucosal, submucosal, muscular, subserosal, and serosal.

The arbitrary 10-cm segment encompassing the distal 5 cm of the esophagus and proximal 5
cm of the stomach (cardia), with the EGJ in the middle, is an area of contention. Cancers
arising in this segment have been variably staged as esophageal or gastric tumors, depending
on orientation of the treating physician. In this edition, cancers whose midpoint is in the lower
thoracic esophagus, EGJ, or within the proximal 5 cm of the stomach (cardia) that extend into
the EGJ or esophagus (Siewert III) are staged as adenocarcinoma of the esophagus (see Chap.
10). All other cancers with a midpoint in the stomach lying more than 5 cm distal to the EGJ, or
those within 5 cm of the EGJ but not extending into the EGJ or esophagus, are staged using the
gastric (non-EGJ) cancer staging system (Figure 11.2 ).

Staging of primary gastric adenocarcinoma is dependent on the depth of penetration of the

primary tumor. The T1 designation has been subdivided into T1a (invasion of the lamina
propria or muscularis mucosae) and T1b (invasion of the submucosa). T2 designation has been
changed to invasion of the muscularis propria, and T3 to invasion of the subserosal connective
tissue without invasion of adjacent structures or the serosa (visceral peritoneum). T4 tumors
penetrate the serosa (T4a) or invade adjacent structures (T4b). These T categories have been
changed to harmonize with those of other gastrointestinal sites.

Regional Lymph Nodes. Several groups of regional lymph nodes drain the wall of the stomach.
These perigastric nodes are found along the lesser and greater curvatures. Other major nodal
groups follow the main arterial and venous vessels from the aorta and the portal circulation.
Adequate nodal dissection of these regional nodal areas is important to ensure appropriate
designation of the pN determination. Although it is suggested that at least 16 regional nodes
be assessed pathologically, a pN0 determination may be assigned on the basis of the actual
number of nodes evaluated microscopically.

Involvement of other intra-abdominal lymph nodes, such as the hepatoduodenal,

retropancreatic, mesenteric, and para-aortic, is classi fi ed as distant metastasis. The speci fi c
nodal areas are as follows (Figure 11.3A, B ):

G reater Curvature of Stomach. Greater curvature, greater omental, gastroduodenal,

gastroepiploic, pyloric, and pancreaticoduodenal Pancreatic and Splenic Area.
Pancreaticolienal, peripancreatic, splenic Lesser Curvature of Stomach. Lesser curvature,
lesser omental, left gastric, cardioesophageal, common hepatic, celiac, and hepatoduodenal
Distant Nodal Groups. Retropancreatic, para-aortic, portal, retroperitoneal, mesenteric

Metastatic Sites. The most common metastatic distribution is to the liver, peritoneal
surfaces, and nonregional or distant lymph nodes. Central nervous system and pulmonary
metastases occur but are less frequent. With large, bulky lesions, direct extension may occur
to the liver, transverse colon, pancreas, or undersurface of the diaphragm. Positive peritoneal
cytology is classi fi ed as metastatic disease.