Article: Stomach cancer

Stomach cancer (also called gastric cancer) can develop in any part of the stomach and may spread throughout the stomach and to other organs, particularly the esophagus, small intestine. It also may extend through the stomach wall and spread to nearby lymph nodes and to organs such as the liver, pancreas, and colon. Stomach cancer also may spread to distant organs, such as the lungs, the lymph nodes above the collar bone, and the ovaries. Metastasis to the ovary is called a Krukenberg tumor.

Diagram of the stomach

Epidemiology

Stomach cancer represents roughly 2% (21,500) cases of all new cancer cases yearly in the United States, but it is much more common in Japan, Great Britain, South America, and Iceland, possibly due to increased dietary consumption of nitrates. It is also associated with high salt in the diet, smoking, and low intake of fruits and vegetables. Infection with H. pylori is the main risk factor in about 80% or more of gastric cancers. It is more common in men.

A very small percentage of diffuse-type gastric cancers (see Histopathology below) are thought be genetic. Hereditary Diffuse Gastric Cancer (HDGC) has only recently been identified and research is ongoing, but genetic testing and treatment options are available for families at risk (Brooks-Wilson et al., 2004).

Metastasis occurs in 80-90% of individuals with stomach cancer, with a five year survival rate of 75% in those diagnosed in early stages and less than 30% of those diagnosed in late stages. The death rate is 12,400 a year in the United States.

Symptoms

Endoscopic image of linitis plastica, a type of stomach cancer where the entire stomach is invaded, leading to a leather bottle like appearance.

Stomach cancer is often asymptomatic or causes only nonspecific symptoms in its early stages. By the time symptoms occur, the cancer has generally metastasized to other parts of the body, one of the main reasons for its poor prognosis. Stomach cancer can cause the following signs and symptoms:

Early

• Indigestion or a burning sensation (heartburn)
• Loss of appetite, especially for meat

Late

• Abdominal pain or discomfort in the upper abdomen
• Nausea and vomiting
• Diarrhea or constipation
• Bloating of the stomach after meals
• Weight loss
• Weakness and fatigue
• Bleeding (vomiting blood or having blood in the stool), which can lead to anemia

These can be symptoms of other health problems, such as a stomach virus or gastric ulcer, and diagnosis should be done by a gastroenterologist or an oncologist.

Diagnosis

To find the cause of symptoms, the doctor asks about the patient's medical history, does a physical exam, and may order laboratory studies. The patient may also have one or all of the following exams:

• Gastroscopic exam is the diagnostic method of choice
• Upper GI series (may be called barium roentgenogram)
• Fecal occult blood test is obsolete except possibly as a screening test; a negative test proves nothing and a positive result may result from a large number of other conditions beside gastric carcinoma.

Abnormal tissue seen in a gastroscope examination will be biopsied by the surgeon or gastroenterologist. This tissue is then sent to a pathologist for histological examination under a microscope to check for the presence of cancerous cells. A biopsy, with subsequent histological analysis, is the only sure way to confirm the presence of cancer cells.

Histopathology

Low differentiated Adenocarcinoma of the stomach.

• Gastric adenocarcinoma is a malignant epithelial tumor, originating from glandular epithelium of the gastric mucosa. It invades the gastric wall, infiltrating the muscularis mucosae, the submucosa and thence the muscularis propria. Histologically, there are two major types of gastric cancer (Lauren classification): intestinal type and diffuse type.
• Intestinal type adenocarcinoma: tumor cells describe irregular tubular structures, harboring pluristratification, multiple lumens, reduced stroma ("back to back" aspect). Often, it associates intestinal metaplasia in neighboring mucosa. Depending on glandular architecture, cellular pleomorphism and mucosecretion, adenocarcinoma may present 3 degrees of differentiation: well, moderate and poorly differentiate.
• Diffuse type adenocarcinoma (mucinous, colloid): Tumor cells are discohesive and secrete mucus which is delivered in the interstitium producing large pools of mucus/colloid (optically "empty" spaces). It is poorly differentiated. If the mucus remains inside the tumor cell, it pushes the nucleus at the periphery - "signet-ring cell". [1]

Staging

If cancer cells are found in the tissue sample, the next step is to stage, or find out the extent of the disease. Various tests determine whether the cancer has spread and, if so, what parts of the body are affected. Because stomach cancer can spread to the liver, the pancreas, and other organs near the stomach as well as to the lungs, the doctor may order a CT scan, an ultrasound exam, or other tests to check these areas. Blood tests for tumor markers, such as carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) may be ordered, as their levels correlate to extent of metastasis, especially to the liver, and the cure rate.

Staging may not be complete until after surgery. The surgeon removes nearby lymph nodes and possibly samples of tissue from other areas in the abdomen for examination by a pathologist.

Treatment

Like any cancer, treatment is adapted to fit each person's individual needs and depends on the size, location, and extent of the tumor, the stage of the disease, and general health. Cancer of the stomach is difficult to cure unless it is found in an early stage (before it has begun to spread). Unfortunately, because early stomach cancer causes few symptoms, the disease is usually advanced when the diagnosis is made. Treatment for stomach cancer may include surgery, chemotherapy, and/or radiation therapy. New treatment approaches such as biological therapy and improved ways of using current methods are being studied in clinical trials.

Surgery

Surgery is the most common treatment for stomach cancer. The surgeon removes part (subtotal or partial gastrectomy) or all (total gastrectomy) of the stomach, as well as some of the tissue around the stomach, with the basic goal of removing all cancer and a margin of normal tissue. Depending on the extent of invasion and the location of the tumor, surgery may also include removal of part of the esophagus, spleen, ovaries, or intestines. Tumors in the lower parts of the stomach may call for a Billroth I or Billroth II procedure. Endoscopic mucosal resection is a treatment for early gastric cancer that has been pioneered in Japan, but is available in the United States at some centers. In this procedure, the tumor is removed from the wall of the stomach using an endoscope, with the advantage in that it is a smaller operation than removing the stomach. Surgical interventions are currently curative in less than 40% of cases, and, in cases of metastasis, may only be palliative.

Chemotherapy

Chemotherapy is the use of systemic drugs to fight the stomach cancer. Unfortunately, gastric cancer has not been especially sensitive to these drugs until recently, and, even now, primarily serve to palliatively reduce the size of the tumor and increase survival time. Some drugs used in stomach cancer treatment include: 5-FU(fluorouracil), BCNU (carmustine), methyl-CCNU (Semustine), and doxorubicin (Adriamycin), as well as Mitomycin C,and more recently cisplatin and taxotere in various combinations. Scientists are exploring the benefits of giving chemotherapy before surgery to shrink the tumor, or as adjuvant therapy after surgery to destroy remaining cancer cells. Combination treatment with chemotherapy and radiation therapy is also under study. Doctors are testing a treatment in which anticancer drugs are put directly into the abdomen (intraperitoneal hyperthermic chemoperfusion). Chemotherapy also is being studied as a treatment for cancer that has spread, and as a way to relieve symptoms of the disease. The side effects of chemotherapy depend mainly on the drugs the patient receives.

Radiation therapy

Radiation therapy (also called radiotherapy) is the use of high-energy rays to damage cancer cells and stop them from growing. Stomach cancer tumors have low radiosensitivity and have a very limited response to this therapy. When used, it is generally in combination with surgery and chemotherapy, or used only with chemotherapy in cases where the individual is unable to undergo surgery. Radiation therapy may be used to relieve pain or blockage by shrinking the tumor in cases of terminal disease.

Biological therapy

Biologic therapy is still in the testing stages for stomach cancer. The side effects of biological therapy vary with the type of treatment. Some cause flu-like symptoms, such as chills, fever, weakness, nausea, vomiting, and diarrhea. Patients sometimes get a rash, and they may bruise or bleed easily. These problems may be severe, and patients may need to stay in the hospital during treatment.