Background-According to a recent report published by the Ministry of Health and

Medical Education of the I. R. of Iran, gastric cancer (GC) is the most common fatal cancer in

this country and its prevalence is highest in Ardabil province, Northwest of Iran. This

descriptive endoscopic survey was designed to determine the type of upper gastrointestinal

(GI) malignancy in this high prevalence area.

Method-This study was conducted in the first established subspeciality outpatient GI

clinic in the city of Ardabil. From 11,518 patients who attended this clinic in a one-year

period, 1,152 (10%) with persistent upper GI symptoms underwent upper GI fiberoptic

endoscopy and 162 (14.1%) had a tumor with malignant appearance. At least six endoscopic

punch biopsies were obtained from all the tumors and sent for histopathologic examination.

Demographic data was obtained from all 162 patients. Statistical analysis was performed

using the SPSS statistical software.

Results-The mean age of the patients with cancer was 63.5 ± 10.8 years and the male to

female ratio was 2.14:1. Villagers constituted 111 (70.7%) and urban dwellers constituted 46

(29.3%) patients. Upper GI cancer was diagnosed by histopathology in 157 patients (13.4%).

Stomach cancer constituted 107 cases (68.2%), 53 (49.5%) of which were cancers of the

gastric cardia and 50(31.8%) were esophageal cancer. The most common site of upper GI

malignancy was the gastric cardia 53 (33.8%) followed by the antrum 32(20.4%), esophageal

body 27 (17.2%), distal esophagus 23 (14.6%), and gastric body 22 (14.0%).

Conclusion-Cancer of the gastric cardia is now the most common upper GI malignancy

in Ardabil and constitutes almost half of all gastric cancers. It is recommended that subsitespecific

gastric cancer risk factors, including H. pylori and dietary nitrates, be studied in the

future in this region.

Keywords • Gastri

درخشان, محمدحسین

سجادی, علیرضا

عرشی, شهنام

ملک زاده, رضا

یزدانبد, عباس

English

ArUMS Digital Repository (سامانه اطلاعات زیست پزشکی و سلامت)

Ar
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Arch Irn Med 2001; 4 (2): 76-79
Archives of Iranian Medicine, Vol 4, No 2, April 200176
GASTRIC CARDIA CANCER; THE MOST COMMON
TYPE OF UPPER GASTROINTESTINAL
CANCER IN ARDABIL, IRAN:
AN ENDOSCOPY CLINIC EXPERIENCE
Abbas Yazdanbod MD*, Shahnam Arshi MD*, Mohammad-Hossein Derakhshan MD**,
Ali-Reza Sadjadi MD**, Reza Malekzadeh MD**•
*Department of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
**Digestive Disease Research Center, Shariati Hospital, Tehran University of Medical Sciences,
Tehran, Iran
Abstract
Background-According to a recent report published by the Ministry of Health and
Medical Education of the I. R. of Iran, gastric cancer (GC) is the most common fatal cancer in
this country and its prevalence is highest in Ardabil province, Northwest of Iran. This
descriptive endoscopic survey was designed to determine the type of upper gastrointestinal
(GI) malignancy in this high prevalence area.
Method-This study was conducted in the first established subspeciality outpatient GI
clinic in the city of Ardabil. From 11,518 patients who attended this clinic in a one-year
period, 1,152 (10%) with persistent upper GI symptoms underwent upper GI fiberoptic
endoscopy and 162 (14.1%) had a tumor with malignant appearance. At least six endoscopic
punch biopsies were obtained from all the tumors and sent for histopathologic examination.
Demographic data was obtained from all 162 patients. Statistical analysis was performed
using the SPSS statistical software.
Results-The mean age of the patients with cancer was 63.5 ± 10.8 years and the male to
female ratio was 2.14:1. Villagers constituted 111 (70.7%) and urban dwellers constituted 46
(29.3%) patients. Upper GI cancer was diagnosed by histopathology in 157 patients (13.4%).
Stomach cancer constituted 107 cases (68.2%), 53 (49.5%) of which were cancers of the
gastric cardia and 50(31.8%) were esophageal cancer. The most common site of upper GI
malignancy was the gastric cardia 53 (33.8%) followed by the antrum 32(20.4%), esophageal
body 27 (17.2%), distal esophagus 23 (14.6%), and gastric body 22 (14.0%).
Conclusion-Cancer of the gastric cardia is now the most common upper GI malignancy
in Ardabil and constitutes almost half of all gastric cancers. It is recommended that subsite-
specific gastric cancer risk factors, including H. pylori and dietary nitrates, be studied in the
future in this region.
Keywords • Gastric cancer  •GI cancer  •cardia  •Ardabil  •adenocarcinoma
Introduction
recent cancer surveillance study
performed by the Ministry of Health of
the I.R. of Iran1 revealed that gastric
adenocarcinoma is the most common fatal cancer
in   Iran   with   a   wide   variation of  death rate in
•Correspondence: R. Malekzadeh MD, Digestive Disease Research
Center, Shariati Hospital, Tehran, Iran. E-mail: malek@ ams.ac.ir.
different provinces. The mortality rate in Bushehr,
southern Iran  (Persian Gulf Coast), is 3.6 per
100,000 per year as compared to a rate of 8.4 per
100,000 in East Azarbaijan, northern Iran.
According to a study in 19712, antral
adenocarcinoma was considered to be the
predominant type of gastric cancer in Iran.  Some
unpublished data from Ardabil in Easthern
Azarbaijan on the west coast of the Caspian Sea,
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Gastric Cardia Cancer; The most Common Type of Upper GI Cancer in Ardabil
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Table 1. Esophageal cancer: location of tumor and age.
    Site of lesion N (%) Mean age ± SD Median  age Minimum  age Maximum age
Upper third 6 (12.0) 54.7 ± 17.2 54 27 75
Middle third 21 (42.0) 62.6 ± 11.8 62 40 85
Lower third 23 (46.0) 61.7 ± 14.1 65 24 88
Total 50 (100) 61.3 ± 13.5 63 24 88
however, reported a higher frequency of gastric
cardia cancer. This descriptive, endoscopic study
was designed to further explore the anatomic
subsite of different GI cancers in this high
prevalence gastric cancer area. To the best of our
knowledge, this is the first descriptive study
performed to evaluate the anatomic subsite of
gastric cancer in Iran.
Materials and Methods
This study was conducted in the first
established subspeciality outpatient GI clinic in
Ardabil city. Out of the 11,518 patients who
attended this clinic during a one-year period  (Dec.
1999-Dec. 2000), 1,152 patients (10%) presented
with persistent or alarming GI symptoms and/or
signs (dysphagia, abdominal pain, weight loss,
anemia, abdominal mass, anorexia, nausea and
vomiting). Using 10% lidocaine spray in the
pharynx, standard upper GI endoscopy was
performed with the Olympus-E model
gastrofibroscope (Olympus-Keymed, UK) for the
patients with persistent or alarming manifestations
of disease. The first author, who is a certified and
experienced gastroenterologist, performed all
endoscopies. The esophagus was carefully
scrutinized for location of the Z-line (level of
transition of pale squamous epithelium of the
esophagus to the velvety-red gastric epithelium).
The distal esophagus was defined as the area 5 cm
above the Z-line, and the gastric cardia was
defined as the most proximal 3cm of the stomach.
All cancers originating from this segment were
recorded as cancer of the cardia. Location of
tumors was registered accurately and at least 6
punch biopsies were obtained from all tumors.
Biopsy specimens were oriented, fixed in 10%
buffered formalin, sectioned and stained by the
hematoxylin and eosin technique. Experienced
pathologists then examined the specimens for
evidence of cancer.
Results
During the one-year period of the study, 1,152
upper endoscopies were performed. From 162
cases endoscopically suspected to have
malignancy, gastroesophageal cancer was proved
by histopathologic studies of the endoscopic
biopsies in 151 cases and by histopathologic
studies of the surgically resected lesions in another
6 patients; thus making a total of 157 (13.4%)
upper GI cancers. The mean age of all patients was
63.5 ± 10.8 years and the male to female ratio was
2.14: 1.
Of these 157 gastroesophageal cancer cases, 50
(31.8%) had esophageal cancer and 107 (68.2%)
suffered gastric cancer. Also, 111 (70.7%) and
46(29.3%) patients were from rural and urban
areas respectively.
Considering the site of esophageal tumors, 6
(12.0%), 21 (42.0%) and 23 (46.0%) cases were
located at the upper, middle and lower thirds of the
esophagus, respectively. Table 1 shows the site and
age of patients with esophageal tumors. Only
5(10.0%) esophageal cancer cases were
adenocarcinomas and the remaining were
Table 2. Gastric cancer: location of tumor and age.
Site of
tumor
N(%) M/F ratio Mean age ± SD
Male
Median age
Male
Mean age ±SD
Female
Median age
Female
Cardia 53(49.5) 2.5 : 1 65.2 ± 10.3 66 59.8 ± 9.7 60
Body 22(20.6) 3.4 : 1 65.4 ± 8.6 65 66.0 ± 8.9 66
Antrum 32(29.9) 6.8 : 1 66.0 ± 7.5 66 59.3 ± 5.0 61
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A. Yazdanbod, Sh. Arshi, M. H. Derakhshan, et al.
Archives of Iranian Medicine, Vol 4, No 2, April 200178
Table 3. Gastric Cancer: location of tumor and type of residence
Site of
tumor
n(%) Rural/Urban
ratio
Mean age ± SD
Rural
MedianAge
Rural
Mean age ± SD
Urban
Median Age
Urban
Cardia 53(49.5) 1.7 : 1 65.2 ± 9.2 65 61.2 ± 11.9 62
Body 22(20.6) 2.1 : 1 66.5 ± 8.6 66 63.4 ± 8.4 61
Antrum 32(29.9) 2.4 : 1 66.0 ± 8.7 66 63.8 ± 4.1 62
squamous cell carcinomas. The mean age of the
patients with esophageal cancer was 61.3 ± 13.5
years with a female to male ratio of 1: 0.92. Other
findings related to esophageal cancer are presented
in Table 1.
With the exception of a 60-year-old man who
had large-cell lymphoma of the distal stomach the
remaining gastric cancer patients had
adenocarcinoma. Gastric cardia, with 53 cases
(49.5%), was the most common site of cancer. The
antrum and body of the stomach were the second
and third most common sites of cancer with
32(29.9%) and 22(20.6%) cases, respectively. The
mean age of cardia cancer patients at time of
diagnosis was 63.5 ± 10.2 years; males being older
than females. Urban patients were affected 6 years
earlier than rural subjects but the differences were
not found to be statistically significant (Tables 2,
3).
Discussion
During the past 50 years, the incidence of
adenocarcinoma of the stomach has decreased in
western industrialized countries.3-5 A striking
feature  of  this  decline is a concomitant rise in the
Tumor sub site
Antrum
Body
Cardia
Lower esophagus
Mid esophagus
Upper esophagus
Pe
rc
en
t
40
30
20
10
0
Figure 1. Topographic distribution of upper GI
cancers in Ardabil
incidence of gastric cardia cancer 5-8, which is now
becoming more common than adenocarcinoma of
the distal esophagus.9 In developing countries the
overall incidence of gastric cancer is increasing
and projections indicate that the annual number of
new cases will increase significantly during the
next few decades as a result of adult population
growth.10
There is now some evidence that there may be a
different etiology for tumors located in gastric
cardia and antrum. Demographic differences and a
diverging incidence trend point to the fact that the
two tumors may be epidemiologically distinct and
therefore the anatomic subsite of gastric tumor
should be taken into account in studies of etiology
and carcinogenesis of this fatal cancer.8, 11 Gastric
cardia cancer has also been shown to have a
different clinical and biological behavior from that
of distal gastric cancer and patients with proximal
gastric cancer have worse outcomes and shorter
survival times as compared to patients with antral
gastric cancer.12
Recent studies have clearly shown that
environmental factors13 are the overwhelming
contributors to the pathogenesis of gastric cancer,
among which H. pylori gastritis, dietary habit and
occupational exposure are well established risk
factors.
H. pylori infection is very common in most
parts of Iran. Seroepidemiologic studies reveal that
up to 90% of the Iranian population are infected14
and about 80% are infected with the more virulent
cog-positive strain (Massarrat personal
communication, 2000). Infection tends to occur
early in life in most parts of the country. Previous
investigations performed on elementary school
children of Ardabil, revealed a 34% and 48%
seropositive rate in the 5-10 and 10-15 year age
groups respectively. This was significantly higher
than children of the same age groups from Yazd in
central Iran (20% and 31% respectively).
    Few recently published studies14 have shown
that contrary to the previous belief that H. pylori is
a risk factor only for noncardia gastric cancer, both
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Gastric Cardia Cancer; The most Common Type of Upper GI Cancer in Ardabil
Archives of Iranian Medicine, Vol 4, No 2, April 2001 79
cardia and antral cancer could be the consequence
of H. pylori infection.15 Dietary fiber and
antioxidants are both abundant in the diet of people
of Ardabil, and do not seem to protect against
cancer of the cardia in Ardabil as reported
elswhere.16 Since H. pylori infection has been
endemic for many decades, other dietary or
environmental factors may be responsible for this
rise of gastric cancer in Iran.
     According to recent cancer statistics, death due
to gastric cancer constitutes about 30% of all
deaths due to cancer each year in Ardabil.17 Most
gastric cancers are diagnosed at an advanced stage
with very poor survival, usually not more than
15% at 5 years. This cancer alone is the cause of
more than 750,000 annual deaths in the world.10
Both traditional and genetic epidemiological
research should be undertaken with especial focus
on etiological factors and pathogenesis in order to
develop effective preventive strategies against this
disease.
      Further epidemiologic studies need to be
performed to evaluate the role of dietary nitrates
and other carcinogens, which may be secreted in
saliva and accumulated in the cardia, in the
pathogenesis of gastric cardia cancer.
    Epidemiolgic studies should be performed in
different ethnic subgroups of north, central and
southern Iran with different prevalence rates for all
four major types of upper GI cancers including
cancers of the distal stomach and gastric cardia as
well as adenocarcinoma and squamous cell
carcinoma of the esophagus.
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Gastric Cardia Cancer; The Most Common Type of Upper Gastrointestinal Cancer in Ardabil, Iran: An Endoscopy Clinic experience

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