Gastric cancer (GC) metastasizes through three primary pathways: hematogenous (bloodborne)
spread, peritoneal spread, and lymphatic spread, each contributing to disease progression and
prognosis.
Hematogenous (Bloodborne) Spread
Through the bloodstream, tumor cells disseminate to distant organs. The liver is the most
frequent site of hematogenous metastasis due to its connection to the gastric venous system via
the portal circulation. Intestinal-type GC primarily spreads to the liver through this route, while
diffuse-type GC exhibits liver metastases in only half of hematogenous cases. As the disease
advances, metastases may also develop in the lungs, leading to lymphangitic carcinomatosis or
multiple lung lesions, and in bones, causing skeletal complications such as pain and fractures.
Peritoneal Spread
Peritoneal carcinomatosis occurs when cancer cells shed from the primary tumor and implant
onto peritoneal surfaces. This spread is commonly associated with Krukenberg tumors (KT),
where GC metastasizes to the ovaries, a frequent cause of treatment failure in female patients.
Peritoneal metastases are the most common pattern of recurrence after curative surgery,
affecting 10-20% of patients intraoperatively. These metastases often result in ascites,
abdominal pain, and bloating, significantly impacting patient quality of life.
Lymphatic Spread
Gastric cancer frequently metastasizes via the lymphatic system, using lymph nodes as a
conduit for tumor cell dissemination. Initially, cancer spreads to regional lymph nodes, including
N1 (perigastric) and N2 (intermediate) nodes. As the disease progresses, distant lymph node
involvement signals widespread metastasis. Key distant metastatic sites include Virchow’s Node
(left supraclavicular lymph node), a hallmark of advanced GC; Sister Mary Joseph’s
Nodule(periumbilical lymph node), presenting as a palpable nodule near the navel; and Irish
Node (left axillary lymph node), indicating extensive dissemination. Other distant lymphatic
metastases involve para-aortic, mesenteric, mediastinal, and cervical lymph nodes.
Common Sites of Metastases and Recurrence Patterns
GC frequently metastasizes to the liver (5-14%), lungs (16%), ovaries (Krukenberg tumors, 21%
of malignant ovarian tumors), peritoneum, and lymph nodes. Rare sites include the central
nervous system and bones, typically seen in late-stage disease. Recurrence studies show that
40.1% of GC patients experience disease recurrence, with peritoneal dissemination (53%) being
the most common distant recurrence, followed by hematogenous metastases (43.3%), primarily
affecting the liver, lungs, and bones, and distant lymphatic recurrence (28.6%).
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