Stomach Cancer

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  • VIDEO
  • CONTENT
  • QUIZ
  • MATERIALS
  • Quick Facts
  • Risk Factors
  • Familial Risk
  • HNPCC
  • Prevention
  • Initial Diagnostic
  • Staging
  • TNM
  • Endoscopic Therapy
  • Surgery
  • Multimodal Approach
  • Palliative Therapy
  • Nutrition

Stomach cancer, also known as gastric cancer, involves the growth of cancerous cells within the lining of the stomach. Here are some quick facts:

  1. Prevalence: Stomach cancer is more common in older adults, typically over the age of 50.
  2. Risk Factors: Key risk factors include a diet high in salty or smoked foods, smoking, a family history of stomach cancer, stomach surgery for ulcers, and certain bacterial infections such as Helicobacter pylori.
  3. Symptoms: Early symptoms may be non-specific and can include discomfort or pain in the stomach area, persistent nausea, and loss of appetite. As the cancer progresses, symptoms can include vomiting, weight loss, difficulty swallowing, and the presence of blood in the stool.
  4. Diagnosis: It often involves endoscopy, where a camera is used to inspect the stomach, and a biopsy, where tissue samples are taken for analysis. Imaging tests such as CT scans and PET scans can determine the extent of cancer.
  5. Stages: Stomach cancer is classified into stages from I to IV. Stage I is early-stage cancer, while Stage IV indicates advanced cancer that has spread to other parts of the body.
  6. Treatment: Treatment options depend on the stage of the cancer and can include surgery to remove part or all of the stomach, chemotherapy, radiation therapy, targeted drug therapy, or immunotherapy.
  7. Survival Rates: Survival rates vary depending on the cancer stage at diagnosis. Early detection generally leads to a better prognosis.
  8. Prevention: Prevention strategies may include maintaining a healthy diet, avoiding smoking, and managing conditions like Helicobacter pylori infections.
  9. Research: Ongoing research is focused on understanding the molecular and genetic basis of stomach cancer to develop more targeted therapies.
  1. Helicobacter pylori: H. pylori infection is a significant risk factor for stomach cancer. Eradication of H. pylori is recommended for the prevention of gastric cancer, especially in individuals at high risk such as those with a family history of the disease.
  2. Age: The risk of stomach cancer increases with age, particularly after the age of 50.
  3. Socioeconomic Status: Lower socioeconomic status can be linked to factors like poor diet and living conditions that may increase the risk of stomach cancer.
  4. Tobacco Smoking: Smoking damages the lining of the stomach and increases the risk of stomach cancer.
  5. Alcohol Consumption: Excessive alcohol intake can also increase stomach cancer risk, particularly when combined with other risk factors.
  6. Family History: A family history of stomach cancer can increase risk due to genetic predispositions and shared lifestyle factors.
  7. Previous Gastric Surgery: Surgeries on the stomach can increase the likelihood of developing stomach cancer, possibly due to changes in the stomach environment.
  8. Pernicious Anemia: This autoimmune condition damages the stomach lining and impairs vitamin B12 absorption, which may increase the risk of stomach cancer.
  9. Living in a High-risk Population: Stomach cancer is more common in certain parts of the world, such as Japan and Korea, partly due to genetic factors and dietary habits.
  10. Diet and Environmental Factors: A diet high in salted, smoked, or poorly preserved foods and low in fresh fruits and vegetables can increase the risk for stomach cancer.
  11. Gastroesophageal Reflux Disease (GERD): GERD can increase the risk of developing adenocarcinoma at the gastroesophageal junction, which is the area connecting the stomach and the esophagus.

First-degree relatives of patients with gastric cancer have an increased risk of developing the disease compared to the general population. Here are some details on familial risk and management recommendations:

  1. Early Onset and Family History: An early age of onset, the presence of gastric cancer, and a family clustering of the disease, even in healthy individuals, may indicate an inherited form of gastric cancer. In such cases, the index patient should be referred to a multidisciplinary team including a geneticist and access to psychosocial counseling.
  2. Multidisciplinary Approach: Those affected by or at risk for hereditary gastric cancers should be informed about the availability and benefits of psychosocial counseling and support.
  3. Risk Individuals: Persons from families meeting the criteria of the International Gastric Cancer Linkage Consortium (IGCLC) for hereditary diffuse gastric cancer (HDGC) are considered at risk.
  4. Assessment by Physicians: It is recommended that physicians take a thorough family history to determine if a patient meets the IGCLC criteria for HDGC.
  5. Regular Endoscopy: For individuals with a confirmed pathogenic CDH1 germline mutation who do not undergo prophylactic gastrectomy, regular endoscopic surveillance should be offered.
  6. Genetic Counseling: Risk individuals for HDGC should be offered genetic counseling upon reaching the age of consent (18 years or older). Once the disease-causing mutation in the family is identified, at-risk individuals should be informed about the possibility of predictive testing.
  7. Prophylactic Gastrectomy: For carriers of a pathogenic CDH1 mutation, prophylactic gastrectomy should be offered from the age of 20.

Hereditary nonpolyposis colorectal cancer (HNPCC), also known as Lynch syndrome, is an inherited disorder that increases the risk of many types of cancer, particularly colorectal cancer and often cancer of the stomach and other organs. Here are the key points about HNPCC/Lynch syndrome:

  1. Screening Recommendations: For patients with HNPCC and individuals at risk for HNPCC, in addition to colonoscopy, it is recommended to perform a regular upper gastrointestinal endoscopy (esophagogastroduodenoscopy or EGD) starting at the age of 35.
  2. Genetic Basis: Lynch syndrome is caused by hereditary mutations in one of the mismatch repair (MMR) genes. These mutations are inherited in an autosomal dominant pattern, meaning that a mutation in just one of the two copies of the gene a person has is sufficient to increase the risk of cancer.
  3. Cancer Risks: HNPCC is characterized by an increased risk of synchronous (multiple cancers that develop at the same time) and metachronous (cancers that develop at different times) colorectal carcinomas. Individuals with Lynch syndrome also have a higher risk of developing other cancers, including stomach (gastric) cancer, endometrial cancer, ovarian cancer, and cancers of the small intestine, liver, gallbladder ducts, upper urinary tract, brain, and skin.
  4. Management: The management of individuals with HNPCC involves regular and more frequent screening for the cancers for which they are at risk, use of specific surgical techniques to minimize cancer risk, and sometimes prophylactic surgeries. Genetic counseling is also a critical part of managing HNPCC, as it can guide family members in understanding their own risks and the potential need for genetic testing.

PPIs and Gastric Cancer Risk:

  • Current evidence (Level of Evidence 2a) does not support an increased risk for gastric cancer with the use of proton pump inhibitors (PPIs).
  • PPI therapy leads to an increase in gastrin secretion due to reduced stomach acidity, which could potentially increase the risk of gastric and colorectal cancers.
  • Long-term PPI use is associated with increased gastrin levels and enterochromaffin-like cell hyperplasia.
  • Studies have shown mixed results. Some suggest a possible increased risk of gastric cancer with PPI use, particularly in patients with H. pylori infection and atrophic gastritis, while others do not find a significant increase in incidence rate ratios (IRRs) for gastric cancer between PPI users and H2-blocker users.
  • One study from Hong Kong indicated an increased risk of cancer with PPI use post H. pylori eradication therapy, but this may be influenced by factors like age and unconfirmed eradication success.

NSAIDs and Cancer Prevention:

  • Acetylsalicylic acid (ASA or aspirin) and nonsteroidal anti-inflammatory drugs (NSAIDs) have shown a protective effect against the development of gastric cancer, attributed to their anti-inflammatory properties.
  • Long-term aspirin use has been associated with a nearly 50% risk reduction for gastric adenocarcinomas.
  • COX-2 inhibitors may regress mucosal alterations like intestinal metaplasia and atrophy, but evidence is inconsistent.
  • Meta-analyses suggest risk reduction for both gastric and distal esophageal adenocarcinomas with the use of ASA, with a greater effect noted for regular intake.
  • However, the studies have heterogeneity, and many are retrospective and questionnaire-based.

Recommendations:

  • Evidence does not support using ASA or NSAIDs solely for the prevention of gastric cancer due to limited definitive studies.
  • More conclusive data may come from ongoing studies like the AspECT trial, focusing on the impact of ASA/NSAIDs in combination with esomeprazole on esophageal cancers.

Conclusion: While there is some evidence of PPIs affecting gastrin levels, which could potentially impact cancer risk, there is no strong evidence supporting a direct increase in gastric cancer risk. NSAIDs and ASA have some protective effects, but they should not be used with the sole indication of gastric cancer prevention. Further research is necessary to clarify these associations.

Endoscopic Examination:

  • Alarm Symptoms for Referral:
    • Dysphagia (difficulty swallowing)
    • Recurrent vomiting
    • Loss of appetite (inappetenz)
    • Unexplained weight loss
    • Gastrointestinal bleeding
    • Unclear iron deficiency anemia
  • Procedure in Case of Neoplasia Suspicion:
    • Perform a complete esophagogastroduodenoscopy (EGD) to examine the esophagus, stomach, and duodenum.
  • Primary Diagnosis for Adenocarcinoma:
    • Use high-resolution video endoscopy.
  • Enhanced Detection Techniques:
    • Employ magnification.
    • Use computer-assisted chromoendoscopy for better detection and treatment planning.
  • Biopsy Protocol:
    • Obtain biopsies from all suspicious lesions to confirm malignant changes in the esophagus and stomach.

Staging:

  • Classification of Intraepithelial Neoplasia:
    • The World Health Organization (WHO) categorizes gastric and gastroesophageal junction intraepithelial neoplasia into low-grade and high-grade.
  • Second Opinion for Histological Diagnosis:
    • A second, competent pathological opinion is required for each diagnosis of intraepithelial neoplasia/dysplasia, following the four-eyes principle.
  • Histology Protocol:
    • If the initial histology is negative despite a macroscopically suspicious tumor lesion or suspicion of linitis plastica, multiple biopsies should be repeated shortly from the margin and center of the lesion, or a diagnostic endoscopic resection should be performed.
    • When extensive biopsies do not confirm the diagnosis despite high clinical and endoscopic suspicion of gastric or gastroesophageal neoplasia, endoscopic ultrasound (EUS) can be used for primary diagnostic confirmation.

Staging

  • Ultrasound Imaging:
    • Metastasis should be ruled out with sonography, CT scans of the chest, and CT scans of the abdomen including the pelvis.
    • Ultrasound is recommended as the initial imaging method to detect liver metastases.
    • Neck sonography should be used in staging to detect lymph node metastases for cancers of the gastroesophageal junction. In cases of gastric cancer, it should be performed if there is clinical suspicion of lymph node metastasis.
  • Endoscopic Ultrasound (EUS):
    • EUS is an integral part of staging for primary tumors when the treatment intent is curative.
    • EUS is highly accurate in assessing the local invasion depth of adenocarcinomas of the stomach and gastroesophageal junction.
    • A Cochrane Review in 2015 highlighted EUS’s high sensitivity (86%) and specificity (90%) in differentiating early (T1 and T2) from locally advanced (T3 and T4) stages.
  • Radiographic Imaging:
    • For curative treatment plans, CT scans of the chest, abdomen, and pelvis with intravenous contrast and gastric distension with oral contrast or water should be done.
    • MRI is reserved for patients who cannot undergo a CT scan.
    • Bone scintigraphy should not be conducted in staging without suspicion of bone metastasis.
    • PET-CT is not recommended for routine staging of gastric cancer.
    • Staging laparoscopy is beneficial for treatment decisions in locally advanced gastric cancer (especially cT3, cT4) and should be performed before starting neoadjuvant therapy.
  • Laboratory Testing:
    • There is no evidence to support the utility of tumor marker determination.
    • Molecular markers should not be used outside of clinical trials for primary diagnostic purposes to estimate prognosis.
TNM Classification Table
Staging TNM Classification Explanation
T-Category T1 Superficially infiltrating tumor
T1a Tumor infiltrates lamina propria or muscularis mucosae
T1b Tumor infiltrates submucosa
T2 Tumor infiltrates muscularis propria
T3 Tumor infiltrates subserosa
T4 Tumor perforates serosa (visceral peritoneum) or infiltrates adjacent structures
N-Category N0 No regional lymph node metastases
N1 Metastases in 1-2 regional lymph nodes
N2 Metastases in 3-6 regional lymph nodes
N3 Metastases in 7 or more regional lymph nodes
N3a 7-15 lymph nodes
N3b More than 16 lymph nodes
M-Category M0 No metastases
M1 Distant metastases

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