several countries , such as chile ( 46.1  100,000 inhabitants ) , costa rica ( 41.2  100,000 inhabitants ) , ecuador ( 37.8  100,000 inhabitants ) , and peru ( 37.5  100,000 inhabitants ) have a high rate , while other countries , such as paraguay ( 19.5  100,000 inhabitants ) , argentina ( 14.6  100,000 inhabitants ) , and mexico ( 13.1  100,000 inhabitants ) , have much lower rates.2,3 in mexico , according to the official histopathological registry of neoplasms , gastric cancer is the fifth - most prevalent form of cancer in the general population ( 3.4% ) , with a calculated incidence rate of 10.9 per 100,000 inhabitants . types of cancer that are more common in mexico are cancer of the uterine cervix , skin cancer ( nonmelanoma ) , breast cancer , and prostate cancer ( which is the most common form of cancer in the country ) . gastric cancer is the second - leading cause of death from cancer in mexico , and the most common cause of death from gastrointestinal cancer . in general , mexico is considered a low - risk area , with a mortality rate of 5.0 per 100,000 inhabitants,3 with great geographic variability within the country . the state of chiapas has the highest mortality rate ( 6.4 per 100,000 ) ; the federal district comprising mexico city and surroundings has a rate of 4.5 per 100,000 inhabitants , and the state of mexico , has a rate of 2.5 per 100,000 . men are affected more frequently than women at a ratio of 1.5:12:1.4 in mexico , gastric cancer has been most frequently observed in persons aged between 50 and 70 years ; however , < 10% of cases are detected prior to the age of 45 years.5 the proportion of young patients with gastric adenocarcinoma has varied from 6%8% in studies in which patients were defined as young when aged < 41 years and from 2%6% in studies in which young patients were defined as being < 36 years of age . in these younger population subsets , epidemiological differences exist in localization , with an increase of lesions at the proximal level as well as in those in the antral region . lesions at the proximal level have been most often experienced by those whose race can be characterized as white ( 71% vs 29% ) , while antral lesions were predominant in those who were characterized as black ( 64% vs 36%).6 with respect to clinical and pathological characteristics among people aged < 30 years compared with those 3039 years of age , both groups exhibited similar symptoms , undifferentiated neoplasms , and poor prognosis . a delay in diagnosis existed in both groups and exerted influence on patient management and prognosis.711 in patients with a familial history of gastric cancer , with symptoms of ulcer that do not improve with adequate medical management , or who have received a diagnosis of an ulcer , panendoscopy should be performed , with a biopsy for early diagnosis.12 the majority of young patients come in for an appointment with a long disease history and with advanced disease.13 the instituto nacional de cancerologa de mxico ( incan ) is a cancer center that cares for 3,985 patients with cancer per year . gastric cancer represents 3.7% of neoplasms seen at the institute , with 150 cases of gastric cancer reported annually . our study attempts to retrospectively evaluate the general characteristics and behavior of gastric cancer in patients < 30 years of age seen at this institution . at the incan s surgery department , we carried out a review of cases of patients aged < 30 years who had received a diagnosis of gastric cancer between january 1985 and january 2006 . from this search , we identified a total of 2153 cases , among which only 30 were corroborated in patients aged < 30 years . this group was eligible for this retrospective analysis . for each case , we included age , gender , familial oncological history , signs and symptoms referred , types of preparatory studies performed , and methods utilized for diagnosis ; in addition , we considered follow - up time and time lapse to death or date of last medical appointment . overall survival ( os ) time was considered , as were the date of specific treatment initiation , whether the patient died ( due to any cause ) , and date of last medical appointment . we only employed descriptive statistical methods in statistical analysis with central tendency and dispersion measurements . survival curves were estimated using the kaplan  meier method , and the log - rank test was utilized to compare survival data . in all cases , we employed the spps ( v 19.0 ibm corporation , armonk , ny , usa ) for windows software package for statistical analysis . we reported on 30 patients aged < 30 years , with an age range of 1830 years . the patient cohort included 16 males and 14 females ; 33% of the population had oncological histories , including four cases of cervical uterine cancer , three cases of leukemia , and one case each of breast cancer , gall bladder cancer , and colon cancer . among the other important patient characteristics , 44% had a report of signet ring cell adenocarcinoma ; 70% indicated that pain was the primary manifestation of a disorder ; 83% were diagnosed by endoscopy ; 56.6% had been submitted to computerized axial tomography ( cat ) as the auxiliary diagnostic method ; and 40% of patients had been managed outside of our institution using a variety of therapeutic regimens ( see table 1 ) ; thus , only 56.6% of patients were candidates for management at our institution . of this group , only 40% ( 12 patients ) were scheduled to undergo surgery ( see table 2 ) . of these , 42% ( five patients ) qualified for tumor resection , an additional five ( 42% ) were submitted to gastrojejunal anastomosis - type derivations , and two ( 16% ) were submitted to exploratory procedures ( one laparoscopy and one laparotomy ) . the predominant histology found was signet ring cell adenocarcinoma , in 13 patients ( 44% ) . twenty - five patients ( 83% ) were diagnosed with clinical stage iv disease , and five ( 17% ) with clinical stage iii disease ( see table 4 ) . with respect to symptoms , 70% ( 21 patients ) presented with pain , and 3 patients each ( 10% ) presented with a clinical profile of gastric obstruction or early gastric fullness ( see table 5 ) ; duration from symptom initiation to disease diagnosis was 612 months in 80% of cases , and 12 years in 10% of cases ( see table 6 ) . average follow - up was 5 months ( range , 1 day to 26 months ) . it is noteworthy that only four ( 13% ) patients had a 1-year follow - up ; 15 ( 50% ) patients had a < 1 month follow - up period and 11 ( 37% ) patients had a follow - up period of between 2 months and < 1 year . the clinical and pathological characteristics of gastric cancer diagnosed in young patients have been described in various recently published reports . in a population that included patients who were over and under the age of 30 years , bedikian et al reported that both groups presented with similar symptoms , predominantly undifferentiated neoplasms , and poor prognosis.8 in 51 patients aged < 45 years , these authors observed that this cancer was more frequent in females ( 57% vs 36.3% ) , with the most common cancer type being diffuse ( according to the lauren classification ) . lymphatic invasion presented with greatest frequency ( 59% vs 38.9% ) and with greatest frequency in stage iv at diagnosis ( 49% vs 35.7% ) ; notwithstanding this , no difference was observed in 5- to 10-year survival rates between young patients and those aged > 45 years.8 in a retrospective analysis of 72 cases of patients aged < 40 years compared with 51 cases of patients above 70 years of age , park et al showed that at the time of diagnosis young patients had a greater frequency of muscular layer invasion ( 65.3% vs 39.2% ) without differences in survival.15 on the other hand alterations have been studied in cell signaling pathways that can induce the genesis of gastric cancer , hereditary or not , and among these we find mutations in cdh1 . it is thought that fewer than 10% of patients who develop gastric cancer with signet ring cells do so prior to the age of 45 years ( in our series , this was 44% ) , and that , if they do so , their genetic information is different from that which leads to sporadic carcinomas at an older age . additionally , the role of environmental carcinogenic factors in carcinogenesis is presumably less prominent in young people than is the genetic one ; thus , hereditary gastric cancer and early - onset gastric cancer can aid in the study of carcinogenesis at this age . in our series , 33% had familial oncological histories without formation of hereditary or familial cancer , suggesting a genetic transmission component because the most frequently found types of cancer were cervical uterine cancer and leukemia.11,12 gastrointestinal adenocarcinomas of the esophagus , stomach , and colon exhibit distinct patterns of genomic instability and oncogenesis . focal amplifications were substantially more prevalent in gastric / esophageal adenocarcinomas than in colorectal tumors . these genomic amplifications act as biomarkers to guide therapy.1416 it is thought that gastric cancer results from a combination of environmental factors and an accumulation of specific genetic alterations , due to the fact that the growing genetic instability mainly affects older patients , as different p53 alterations in different events of gastric carcinogenesis have demonstrated.17 rugge et al related gastric epithelial dysplasia ( ged ) with the development of cancer , concluding that in ged 1 with atrophic gastritis in older patients and in ged 2 strict follow - up must be conducted . surgical management is justified for ged 3.18 there is a tendency of late diagnosis of the disease in young patients . physicians should have a high suspicion of the disease in patients with a familial history of gastric cancer , with ulcer symptoms that do not improve with adequate medical management , or when an ulcer is diagnosed . in addition , panendoscopy should be inevitably carried out with a biopsy for early diagnosis , which can increase the survival of young patients ; the latter can increase with knowledge of the patient s familial history , such as the existence of carriers of pernicious anemia , and of their first - degree relatives , in whom progression of atrophic gastritis is 20 times more rapid than in general population.19,20 tumor staging directly affects treatment options and survival ; in many cases , we encountered unstaged disease , although not in all patients . also , there are differential staging levels for age , gender , race , marital status , disease incidence , and lethality.20 two general rules are clear now that helicobacter pylori is accepted as the cause of atrophic gastritis and as a determining factor in the severity of the disease ; that the severity of atrophic gastritis is related to cancer risk ; and that atrophic gastritis is associated with other diseases such as duodenal ulcer , gastric ulcer , gastric carcinoma , and mucosa - associated lymphatic tissues ( [ malt]-type gastric lymphoma ) . first , the pattern of gastritis is the greatest determinant of the disease ; second , countries with a high prevalence of gastric cancer , such as japan and peru , have a low prevalence of duodenal ulcer.18,21,22 isik et al concluded that young patients ( < 40 years of age ) with gastric cancer present with poorly differentiated adenocarcinoma and with more advanced and metastatic disease ; the patient s health status , tumor localization , metastatic sites , and smoking status did not confer significant difference in disease state , which coincides with our series that reported a histology of poorly differentiated signet ring cell adenocarcinoma in 44% of our patient population.23 smith and stabile , in a report on 350 patients , and with 30 patients ( 9% ) aged < 35 years compared with those aged > 35 years , found a greater incidence of invasion of adjacent organs ( 74% vs 29% ) and distant metastasis ( 81% vs 50% ) in patients younger than 35 years , as well as a reduced possibility of curative surgery ( 58% vs 17% ) and greater postsurgical mortality ( 22% vs 2%).24 age as an adverse prognostic factor appears to be related to a greater degree with delay in diagnosis . lai et al , in a series of 6954 patients divided into three groups by age ( with 12.7% of patients aged < 40 years , 66.7% aged 4165 years , and 20.6% > 65 years of age ) , concluded that patients < 40 years of age exhibited significantly better survival than those in group two ; multivariate analysis indicated that age was an independent prognostic factor.25 to date , the reason for the occurrence of gastric cancer in young people remains inexplicable . in our series , we did not find that women predominantly have gastric cancer in this age group , as has been reported in other series in the literature.26 conversely , in our study , 54% of the patients with gastric cancer were men . additionally , we found that despite aggressive surgical resection or neoadjuvancy , the outcomes from having gastric cancer continue to be invariably devastating . however , an attempt should be made to identify the subgroup of patients who can benefit from screening , and in whom early detection can be recommended . attempting to identify the environmental factors that favor the progression or development of gastric cancer would also be ideal . we also recommend searching for a tumor marker to detect this disease in its earliest stages , given that therapies used for standard management of gastric cancer to date have not substantially improved the disease s prognosis . prevention of the disease is optimal , as gastric cancer is truly difficult to control once it has been established . to date , there has been a trend toward late diagnosis of gastric cancer in younger patients who present with symptoms . physicians should account for the possibility of gastric cancer in patients with a familial history , or with symptoms of ulcer that do not improve under adequate medical management . with the diagnosis of an ulcer , panendoscopy should without exception be conducted to obtain a biopsy for early diagnosis , which can increase survival in young patients . the clinical and pathological characteristics of gastric cancer in a series of patients included the following : similar proportion in both genders . delay in diagnosis of young patients leads to presentation at advanced disease stages and to young patients being candidates for palliative care . despite the lack of demonstrating a statistically significant p the patients studied were found to have progressed to advanced disease stages , when treatment was oriented toward palliative care of the disease .