Stomach cancer (or Gastric cancer, GC)

Notes
  • GC is the 5th most common cancer globally. It the 2nd most common cause of cancer mortality globally and also the 3rd most common cancer of GIT, after esophageal and colorectal cancers.
  • GC can be classified as cardiac and non- cardiac.
  • Causes and risk factors of GC include: Helicobacter pylori (especially non-cardiac) and to a lesser extent Epstein-Barr virus, tobacco, weight gain, probably salted food and processed meat, atrophic gastritis, gastric ulcer disease, male gender, family history among others.
  • Gastric polyps are the precursors of cancer.
  • Statistics: Proportion of gastric adenocarcinoma among malignant tumors of
  • the stomach - 95% (gastric lymphomas and leiomyosarcomas constitute the remaining 5%); new cases of GC diagnosed in 2012 - 952,000; gender prevalence – 2 times more common in men than in women
  1. Staging of GC

 

STAGE

STAGE GROUPING

COMMENTS

0

Tis

N0

M0

♦Tis- Carcinoma in situ: intraepithelial tumor without invasion of the lamina propria

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

1A

T1

N0

M0

♦T1-Tumor invades lamina propria, muscularis mucosae, or submucosa ♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

1B

T2

N0

M0

 

 

 

 

 

T1

N1

M0

♦Tumor invades muscularis propria

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

 

♦T1-Tumor invades lamina propria, muscularis mucosae, or submucosa ♦N1-Metastasis in 1-2 regional lymph nodes

♦M0 - The tumor has not metastasized

IIA

T3

N0

M0

 

 

 

 

 

 

♦T3-Tumor penetrates subserosal connective tissue without invasion of visceral peritoneum or adjacent structures

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

T2

N1

M0

 

 

 

♦T2-Tumor invades muscularis propria

♦N1-Metastasis in 1-2 regional lymph nodes

♦M0 - The tumor has not metastasized

T1

N2

M0

♦T1-Tumor invades lamina propria, muscularis mucosae, or submucosa

♦N2-Metastasis in 3-6 regional lymph nodes

♦M0 - The tumor has not metastasized

IIB

T4a

N0

M0

 

♦T4a-Tumor invades serosa (visceral peritoneum) or adjacent structure

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

T3

N1

M0

♦T3-Tumor penetrates subserosal connective tissue without invasion of visceral peritoneum or adjacent structures

♦N1-Metastasis in 1-2 regional lymph nodes

♦M0 - The tumor has not metastasized

T2

N2

M0

♦T2-Tumor invades muscularis propria

♦N2-Metastasis in 3-6 regional lymph nodes

♦M0 - The tumor has not metastasized

T1

N3

M0

♦T1-Tumor invades lamina propria, muscularis mucosae, or submucosa

♦ N3-Metastasis in seven or more regional lymph nodes

♦M0 - The tumor has not metastasized

IIIA

T4a

N1

M0

♦T4a-Tumor invades serosa (visceral peritoneum) or adjacent structure

♦N1-Metastasis in 1-2 regional lymph nodes

♦M0 - The tumor has not metastasized

T3

N2

M0

♦T3-Tumor penetrates subserosal connective tissue without invasion of visceral peritoneum or adjacent structures

♦N2-Metastasis in 3-6 regional lymph nodes

♦M0 - The tumor has not metastasized

T2

N3

M0

♦T2-Tumor invades muscularis propria

♦ N3-Metastasis in seven or more regional lymph nodes

♦M0 - The tumor has not metastasized

IIIB

T4b

N0

M0

♦T4b -Tumor invades adjacent structures

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

T4a

N2

M0

♦T4a-Tumor invades serosa (visceral peritoneum) or adjacent structure

♦N2-Metastasis in 3-6 regional lymph nodes

♦M0 - The tumor has not metastasized

T3

N3

M0

♦T3-Tumor penetrates subserosal connective tissue without invasion of visceral peritoneum or adjacent structures

♦ N3-Metastasis in seven or more regional lymph nodes

♦M0 - The tumor has not metastasized

IIIC

T4b

N2

M0

♦T4b -Tumor invades adjacent structures

♦N2-Metastasis in 3-6 regional lymph nodes

♦M0 - The tumor has not metastasized

T4b

N3

M0

♦T4b -Tumor invades adjacent structures

 

♦N3-Metastasis in seven or more regional lymph nodes

♦M0 - The tumor has not metastasized

 

T4a

N3

M0

♦T4a-Tumor invades serosa (visceral peritoneum) or adjacent structure

♦N3-Metastasis in seven or more regional lymph nodes

♦M0 - The tumor has not metastasized

IV

Any T

Any N

M1

♦Any T

♦Any N

♦Distant metastasis

Symptoms
  • Early GC is often asymptomatic
  • Symptoms of peptic ulcer such as dyspepsia and epigastric pain
  • Early satiety
  • Hematemesis or melena (though not common)
  • Obstruction
  • Occult blood loss
  • Secondary anemia
  • Weight loss
  • Symptoms of metastasis that include jaundice, ascites, fractures, epigastric mass, mass in the axillary lymph nodes, hepatomegaly, an ovarian or rectal mass among others.
Diagnosis
  • Endoscopy
  • CT and endoscopic ultrasonography
  • Double-contrast barium x-ray (but endoscopy has to be done)
  • CT of the chest and abdomen to determine the status of metastasis.
  • Complete Blood Test (CBC)
  • Electrolytes analysis
  • Liver function tests (LFTs)
  • Carcinoembryonic antigen (CEA) measurement pre- and post surgery (rise of CEA levels implies recurrence)
Differential
  • Peptic ulcer (this is very critical)
Management
  • The 5 - year survival is 5 to 15% due to the fact that most patients present with advanced disease.
  • Surgery that is mostly combined with adjuvant chemotherapy and radiation therapy.
  • Commonly used drugs (in combination) are: 5-fluorouracil, doxorubicin, mitomycin, cisplatin, or leucovorin, capecitabine, epirubicin, oxaliplatin, paclitaxel, docetaxel, trastuzumab, irinotecan, bevacizumab and cetuximab.
  • In resource limited setting the most commonly used combinations are doxorubicin or epirubicin, cisplatin and 5FU.
  • Trastuzumab may be included in Her 2 overexpressing tumours
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