Gastric cancer is one of those Step topics that feels “vague” until you can see the pattern: where it occurs, who it hits, how it spreads, and which histology matches the story. Here’s a quick, draw-it-out way to lock it in—perfect for rapid review and shareable notes.
The Draw-it-out Method (30 seconds)
Grab a scrap paper and draw a stomach shaped like a “J”. Then add these 4 features:
- A target/bullseye in the antrum → intestinal-type adenocarcinoma (classically distal)
- A “leather jacket” outline around the whole stomach → diffuse-type adenocarcinoma (linitis plastica)
- A left supraclavicular node labeled “V” → Virchow node metastasis
- A belly button dot → Sister Mary Joseph nodule (periumbilical metastasis)
One-liner mnemonic
“Bullseye distal = intestinal; leather jacket = diffuse; V-node + belly button = metastasis.”
What You Just Drew (and why it matters)
1) Intestinal-type gastric adenocarcinoma (the “bullseye”)
High-yield vibe: environment-driven, gland-forming, older patient, distal stomach.
Associations to remember (USMLE favorites):
- Chronic H. pylori gastritis → intestinal metaplasia → dysplasia → carcinoma
- Nitrosamines (smoked/salted foods), low fruits/vegetables
- Chronic atrophic gastritis (including autoimmune gastritis via metaplasia pathway)
- More common in older patients, historically more distal (antrum/lesser curvature)
Histology buzzwords:
- Gland formation
- “Intestinal metaplasia” with goblet cells is often in the stem
2) Diffuse-type gastric adenocarcinoma (the “leather jacket”)
High-yield vibe: infiltrative, signet rings, younger, worse prognosis, genetic.
Key mechanism:
- Loss of E-cadherin (CDH1) → decreased cell adhesion → infiltrative growth
Pathology clue:
- Signet ring cells (mucin pushes nucleus to the periphery)
Classic gross description:
- Linitis plastica = rigid, thickened stomach with loss of rugal folds (“leather bottle/jacket stomach”)
Step-relevant association:
- Hereditary diffuse gastric cancer (CDH1 mutations)
- Often co-associated with lobular breast carcinoma risk
Spread Patterns You Must Know (aka why we drew the “V” and the belly button)
Lymphatic spread
- Virchow node: left supraclavicular lymph node enlargement
- Think: abdominal malignancy draining via thoracic duct
Hematogenous spread
- Liver metastases are common (portal circulation logic)
Transcoelomic/peritoneal spread
- Sister Mary Joseph nodule: periumbilical metastatic implant
- Can also seed ovaries → Krukenberg tumor
- Bilateral ovarian metastases with signet ring cells (often from diffuse gastric cancer)
Symptoms & Clinical Clues (what shows up in stems)
Alarm symptoms (don’t ignore):
- Unintentional weight loss
- Early satiety (especially with linitis plastica)
- Anemia (often iron deficiency from occult bleeding)
- Persistent vomiting, dysphagia (more proximal involvement)
Common presentations:
- Vague epigastric pain, anorexia, nausea
- Occult GI bleeding → fatigue, pallor
H. pylori: the nuance Step questions love
H. pylori is most strongly linked to:
- Intestinal-type gastric adenocarcinoma
- MALT lymphoma (can regress with eradication therapy)
Board-style linkage:
- Chronic inflammation → intestinal metaplasia → dysplasia → carcinoma
- Distal stomach involvement is classic, but modern epidemiology varies—Step stems still often test the traditional patterns.
Rapid Compare Table (copy/paste-friendly)
| Feature | Intestinal-type | Diffuse-type |
|---|---|---|
| Core idea | Environmental/inflammatory pathway | Cell-adhesion defect |
| Key association | H. pylori, nitrosamines, chronic gastritis | CDH1 (E-cadherin) loss |
| Histology | Gland-forming | Signet ring cells |
| Gross | Often ulcerating mass | Linitis plastica, thick rigid wall |
| Typical patient | Older | Younger (can be) |
| Spread clue | Virchow, SMJ nodule possible in both | Krukenberg classically tied to signet rings |
Micro–Pearls (1–2 liners you can recall under pressure)
- Virchow node (left supraclavicular) = “abdominal cancer reached the thoracic duct.”
- Sister Mary Joseph nodule = periumbilical metastasis via peritoneal spread.
- Krukenberg tumor = bilateral ovarian metastases with signet ring cells, often gastric.
- Diffuse gastric cancer = E-cadherin loss → infiltrative growth → early satiety.
Mini Self-Check (3 quick prompts)
- A rigid stomach with loss of rugae and early satiety → Diffuse adenocarcinoma (linitis plastica)
- Left supraclavicular node enlargement in GI malignancy → Virchow node
- Bilateral ovarian masses with signet ring cells → Krukenberg tumor (gastric source)