Stomach cancer

What is it?

It is a malignant neoplasm that predominantly affects the distal (antrum) and proximal (fundus) parts of the stomach. 10% of people with chronic atrophic gastritis develop gastric cancer 9-26 years after the diagnosis. In 95% of cases it is adenocarcinoma.

Stomach cancer is characterized by degeneration of the cells of the stomach wall, which in the locally advanced stage can spread to the perigastric lymph nodes. The most common form of gastric cancer is glandular (adenocarcinoma), which is divided into a diffuse form, more common in young people with A blood type, and an intestinal form, more common in older patients and usually located in the distal part of the stomach.

It is a common neoplasm, ranking sixth in morbidity and fourth in mortality. The annual incidence in Europe is 12-15 new cases per 100,000 people. Disease and mortality rates have decreased in recent years, particularly in more developed countries, due to improved living conditions and increased consumption of fresh fruits, vegetables and vitamins in the diet, as well as more adequate medical and surgical treatment. Currently, there is an increase in the incidence of proximal (cardiac) stomach cancer and a decrease in the incidence of distal (bodily-antral) stomach cancer.

A number of risk factors for gastric cancer have been identified. These include:
- Helicobacter pylori infection: this microorganism causes chronic inflammation of the gastric mucosa and subsequent decrease in gastric juice secretion. As a result, chronic atrophic gastritis develops and, subsequently, intestinal metaplasia, which can be considered precancerous. HP infection also reduces the absorption of vitamin C, the value of which in the blood plasma tends to decrease, resulting in a predisposing factor for the development of stomach cancer. Therefore, for primary prevention of gastric cancer it is important that HP, when diagnosed, be eliminated. However, only a small percentage of patients with chronic atrophic gastritis and Helicobacter pylori infection develop cancer. Thus, Helicobacter pylori should be considered only one of the risk factors, since this type of neoplasm is the result of the combined action of many different factors, not all of which are known.

  • dietary factors: eating food cooked in such a way that it is partially charred and eating too much red meat all contribute to stomach cancer;
  • smoking and alcohol abuse;
  • previous stomach resection surgery;
  • pernicious anemia (due to vitamin B12 deficiency);
  • Menetrier’s disease (insufficient gastric juice secretion);
  • stomach polyps.

Which are the symptoms?

Symptoms of stomach cancer are not specific and depend on the stage of the disease. This is one of the reasons why diagnosis in Western countries is often delayed. In early cases, symptoms may be absent or there may be dyspepsia or dysphagia. In neglected cases with epigastric pain (usually as postprandial burning), fatigue, anorexia, sarcophobia (refusal to eat meat), poor digestion, weight loss, repeated vomiting medical attention is strongly recommended. A late symptom, usually a manifestation of a complication, is bleeding, which may show through bloody vomiting (bright red or coffee-colored blood) or the discharge of stools the color of tar or more or less digested blood (melena).

  • epigastric pain
  • fatigue
  • anorexia
  • sarcophobia
  • maldigestion
  • weight loss
  • repeated vomiting
  • hemorrhage
  • hematemic vomiting
  • melena
  • fecal occult blood

How is it diagnosed?

Studies that are necessary to determine the level of spread of the disease and, therefore, to choose the most appropriate therapy, are:

  • esophageal gastroduodenoscopy (EGDS): this is an essential study for diagnosis since it makes it possible to visualize the lesion, take a biopsy, determine the presence of risk factors such as precancerous condition (intestinal metaplasia, dysplasia), follow the course of time (the study is actually easy to repeat) and perform endoscopic resection surgery when tumors are at an early stage. The completion of staging includes computed axial tomography (CT) of the chest and entire abdomen and, in some cases, ecoendoscopy and diagnostic laparoscopy with peritoneal lavage with STM detection to rule out peritoneal carcinosis. Metastases are detected by abdominal ultrasound, chest and whole abdominal CT or abdominal MRI, as well as skeletal scintigraphy or brain MRI if there are neurologic symptoms suspicious of brain metastases;
  • endoscopic ultrasound: contact ultrasound of the gastric wall during EGDS, a necessary examination to better determine the degree of tumor infiltration in the gastric wall (stage T), the presence of abnormal perigastric lymph nodes (stage N) and to determine any infiltration of neighboring organs (such as the pancreas);
  • computed tomography: for diagnosis of distant lymphatic or parenchymal metastases (liver, lungs);
  • laparoscopy: introduction of a video camera into the abdominal cavity to assess the presence of secondary localizations in the peritoneum.
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How is it treated?

Several methods of treatment are possible. Their combination and order of application are determined by the stage of the disease.

Endoscopic treatment: this option is possible only in some cases of early stomach cancer, in which the risk of metastasis to lymph nodes is zero or close to zero.

Surgical treatment: surgery remains the main method of stomach cancer treatment and is mandatory for non-locally advanced forms and in the absence of distant metastases. In locally advanced forms, surgery is performed after neoadjuvant (preoperative) chemotherapy. The choice of the type of surgery (subtotal gastrectomy or total gastrectomy) depends on the location and extent of the disease. Ablation of the stomach or its part should always be combined with careful removal of locoregional lymph nodes. In recent years, the laparoscopic gastrectomy technique has been improved, which does not require large surgical incisions and therefore allows for shorter hospital stays, less postoperative pain, and a faster return to nutrition and social life.

Palliative surgery: in some cases of pyloric stenosis a laparoscopic operation of gastro-entero-anastomosis is performed.

Endoscopic palliation: is performed as an alternative to surgery by endoscopic installation of self-expanding endoprostheses or laser treatment, in cases of pyloric obstruction, to allow the patient to eat.

Chemotherapy: the evolution of surgery has been progressing hand in hand with the evolution of chemotherapy. The advent of new anti-cancer drugs that are more effective and have fewer side effects has led to their use in the treatment of stomach cancer. Three different methods of treatment can be distinguished:

  • neoadjuvant chemotherapy: is a treatment with anticancer drugs before surgery. It is used in cases of locally advanced tumors, and its goal is to reduce the volume of the neoplasm and therefore provide better oncologic radicality of surgery, as well as reduce the risk of recurrence and increase the survival rate;
  • adjuvant chemotherapy: is a postoperative treatment with antitumor drugs, which aims at reducing the risk of recurrence of the disease and thus improving long-term survival. In the case of metastatic disease, only chemotherapy, more or less combined with an anti-HER2 monoclonal antibody (Trastuzumab) if HER2 positive, aimed at increasing overall survival, survival free of progression and disease-associated symptoms, and improving the quality of life is performed;
  • intraperitoneal chemotherapy: administration of anticancer drugs into the peritoneal cavity to reduce the risk of peritoneal recurrence of stomach cancer;

Radiotherapy: in the pT3-4, N + stages and / or in the case of positive resection margins, post-operative radiation treatment, associated with chemotherapy, is indicated. In inoperable patients, exclusive chemo-radiotherapy treatment can be considered.

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