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== Definition/Description  ==


Definition<br>Stomach cancer (also known as gastric cancer) is a disease in which the cells forming the inner lining of the stomach become abnormal and start to divide uncontrollably, forming a mass called a tumor. (http://medical-dictionary.thefreedictionary.com/stomach+cancer)<br>
== Introduction  ==
[[File:Stomach cancer patient.png|right|frameless|380x380px]]
Gastric [[Oncology|cancer]] (also known as stomach cancer) is characterized by rapid or abnormal cell growth within the lining of the stomach, forming a tumor.<ref>The Free Dictionary. Stomach Cancer. http://medical-dictionary.thefreedictionary.com/stomach+cancer (accessed 2 Feb 2013)</ref>  
Image R - This is a depiction of a woman suffering from stomach cancer. Typically, a person may not experience any symptoms to begin with. However, as the condition progresses, one may exhibit symptoms, such as loss of appetite. A cross-section of the stomach with a tumour has been shown.
* Gastric cancer is the fifth most frequently diagnosed cancer and the third leading cause of cancer deaths worldwide.
* In the United States, the incidence of gastric cancer has decreased during the past few decades although the incidence of gastroesophageal cancer has concomitantly increased.


== Prevalence  ==
* There are two distinct types of gastric adenocarcinoma, intestinal (well-differentiated) and diffuse (undifferentiated), which have a distinct morphologic appearance, pathogenesis, and genetic profiles.
* The only potentially curative treatment approach for patients with gastric cancer is surgical resection with adequate lymphadenectomy.
* Current evidence supports perioperative therapies to improve a patient’s survival.
* Regrettably, patients with an unresectable, locally advanced, or metastatic disease could solely be offered life-prolonging palliative therapy regimens<ref name=":0">Recio-Boiles A, Waheed A, Babiker HM. [https://www.ncbi.nlm.nih.gov/books/NBK459142/ Cancer, Gastric.] InStatPearls [Internet] 2019 May 18. StatPearls Publishing.Available from:https://www.ncbi.nlm.nih.gov/books/NBK459142/ (last accessed 23.5.2020)</ref>.


Estimated new cases and deaths from stomach cancer in the United States in 2012:
=== Types of Gastric Cancer ===
[[File:Stomach cancer illustration Wellcome L0014136.jpg|right|frameless]]
Different types of cells which make up the stomach. Therefore each particular cell has its own type of cancer.
# <u>'''Adenocarcinoma'''</u> This is the most common type of gastric cancer (95% of gastric cancers<ref name="LivestrongCancerTypes">Livestrong. What are different types of gastric cancer. http://www.livestrong.com/article/102412-different-types-gastric-cancer/ (accessed Feb 13 2013)</ref>). This particular type of stomach cancer originates in the lining of the stomach, and effects the glandular cells of the stomach. It is believed that the majority of stomach cancer cases are caused by&nbsp;Heliobacter pylori bacteria.<ref name="LivestrongCancerTypes" />
# <u>'''Carcinoid'''</u> This type of stomach cancer effects the stomach's hormone producing cells. Carcinoid cells reproduce very slowly, and are incredibly rare. After the cancer has progressed a significant amount, a patient may have symptoms such as flushing of the face and chest, trouble breathing, and diarrhea. &nbsp;This is believed to be caused by hormones from the stomach.<ref name="LivestrongCancerTypes" />
# <u>'''Gastrointesinal Stromal Tumor'''</u> This type of stomach cancer originates in the nervous tissue surrounding the stomach, and is very rare.<ref name="LivestrongCancerTypes" />
# <u>'''Lymphoma'''</u> Rarely, cancer will spread from the lymphnodes within and around the stomach, causing gastric cancer.<ref name="LivestrongCancerTypes" />
As common with any type of cancer, gastric (stomach) cancer (see image R) can present in various stages, ranging from mild to severe.&nbsp;


<span style="line-height: 1.5em;">New cases: 21,320</span><br> Deaths: 10,540<br>(http://cancer.gov/cancertopics/types/stomach)
== Etiology ==
Research is still being conducted as to what actually causes stomach cancer. However, its has been shown to correlate with the following demographics and medical histories...<ref>Mayo clinic. Stomach cancer causes. http://www.mayoclinic.com/health/stomach-cancer/DS00301/DSECTION=causes (accessed 2/13/13)</ref><ref>WebMD. Stomach cancer. http://www.webmd.com/cancer/stomach-gastric-cancer (Accessed 2/13/13)</ref>


== Characteristics/Clinical Presentation  ==
*Diets high in sodium
*Men are two times more as risk than women
*African-Americans and Asians are at greater risk
*Blood group A
*Middle age to elderly
*Family history of stomach cancer
*''Helicobacter pylori''
*Any other past medical history of gastrointestinal complications or surgery
*Toxin exposure and smoking[[Image:H. Pylori.gif|right|frameless]]


In the United States, about 25% of stomach cancer patients present with localized disease, 31% present with regional disease, and 32% present with distant metastatic disease; the remainder of cases surveyed were listed as unstaged.
Most gastric cancers are sporadic, but 5% to 10% of cases have a family history of gastric cancer. Hereditary diffuse gastric cancer (HDGC), gastric adenocarcinoma and proximal polyposis of the stomach (GAPPS), and familial intestinal gastric cancer (FIGC) are three major syndromes accounting up to 3% to 5% of hereditary familial gastric cancer. 


Early disease has no associated symptoms; however, some patients with incidental complaints are diagnosed with early gastric cancer. Most symptoms of gastric cancer reflect advanced disease. Patients may complain of indigestion, nausea or vomiting, dysphagia, postprandial fullness, loss of appetite, melena, hematemesis, and weight loss.
Stomach conditions can often times serve as precursors to cancer.eg,  
* ''atrophic gastritis''  - stomach glands have decreased and are inflamed
* ''intenstinal metaplasia -'' cells within the lining of the intestine invade the stomach and take the place of stomach cells),
* ''Helicobacter pylori'' infection -  said to convert food particles into chemicals that cause mutations within the DNA of stomach cells, leading to cancer (consumption of foods high in antioxidants is said decrease the risk of stomach cancer by blocking the action of these chemicals on the stomach). <ref>Cancer. Stomach cancer causes, risk factors, and prevention topics. http://www.cancer.org/cancer/stomachcancer/detailedguide/stomach-cancer-what-causes (Accessed 2/14/14)</ref><ref>http://bioweb.uwlax.edu/bio203/s2008/pluym_evan/pictures/h_pylori%20scott%20smith.gif (accessed Feb 17 2013)</ref>
== Epidemiology  ==
* Gastric cancer rates are significantly declining worldwide.
* In the United States, an estimated 28,000 new cases will be diagnosed with gastric cancer with an expected 10,960 new deaths during 2017<ref name=":0" />


Late complications include pathologic peritoneal and pleural effusions; obstruction of the gastric outlet, gastroesophageal junction, or small bowel; bleeding in the stomach from esophageal varices or at the anastomosis after surgery; intrahepatic jaundice caused by hepatomegaly; extrahepatic jaundice; and inanition resulting from starvation or cachexia of tumor origin.<br>
== Characteristics/Clinical Presentation  ==
In the United States, most patients have symptoms of an advanced stage at the time of presentation. 
[[File:National-cancer-institute-0YBIMOqQzt0-unsplash.jpg|right|frameless]]
Most common presenting symptoms for gastric cancers are:
* Non-specific weight loss
* Persistent abdominal pain
* Dysphagia
* Hematemesis,
* Anorexia, nausea, early satiety, and dyspepsia.
Patients presenting with a locally-advanced or metastatic disease usually present with significant abdominal pain, potential ascites, weight loss, fatigue, and have visceral metastasis on scans and can have a gastric-outlet obstruction.


Common physical examination findings
* Palpable abdominal mass indicating advanced disease
* Signs of metastatic lymphatic spread distribution including Virchow’s node (left supraclavicular adenopathy), Sister Mary Joseph node (peri-umbilical nodule), and Irish node (left axillary node). Direct metastasis to peritoneum can present as Krukenberg’s tumor (ovary mass), Blumer’s shelf (cul-de-sac mass), ascites (peritoneal carcinomatosis), and hepatomegaly (often diffuse disease burden).
Paraneoplastic manifestations may include dermatological (diffuse seborrheic keratosis or acanthosis nigricans), hematological (microangiopathic hemolytic anemia and hypercoagulable state [Trousseau’s syndrome]), renal (membranous nephropathy), and autoimmune (polyarteritis nodosa) are rare clinical findings and none is specific to gastric cancer.<ref name=":0" />


== Associated Co-morbidities  ==


All physical signs are late events. By the time they develop, the disease is almost invariably too far advanced for curative procedures.
*A Study conducted by Heemskerk et al investigated associated co-morbidities upon history intake of 235 patients diagnosed with gastric cancer between 1992-2004.  
 
*138 of the 235 patient had at least one co-morbidity<ref>Vincent H., Fanneke L., Karel H., Anton H. Gastric carcinoma: review of the results of treatment in a community teaching hospital. World Journal of Surgical Oncology 2007; 5:81</ref>
Signs may include a palpable enlarged stomach with succussion splash; hepatomegaly; periumbilical metastasis (Sister Mary Joseph nodule); and enlarged lymph nodes such as Virchow nodes (ie, left supraclavicular) and Irish node (anterior axillary). Blumer shelf (ie, shelflike tumor of the anterior rectal wall) may also be present. Some patients experience weight loss, and others may present with melena or pallor from anemia.
 
Paraneoplastic syndromes such as dermatomyositis, acanthosis nigricans, and circinate erythemas are poor prognostic features.


Other associated abnormalities also include peripheral thrombophlebitis and microangiopathic hemolytic anemia.
{| style="width: 345px; height: 235px;" cellspacing="1" cellpadding="1" border="1"
 
|+
 
|-
 
| '''Co-morbidity'''
[http://emedicine.medscape.com/article/278744-clinical#a0217 http://emedicine.medscape.com/article/278744-clinical#a0217]
| '''No. of Patients'''
 
| '''%'''
== Associated Co-morbidities  ==
|-
 
| Cardiovascular
http://wjso.com/content/pdf/1477-7819-5-81.pdf<br>
| 87
| 37
|-
| Pulmonary
| 24
| 10
|-
| Diabetes
| 19
| 8
|-
| Other carcinoma
| 20
| 9
|-
| Previous GI surgery
| 18
| 8
|-
| BMI <u>&gt;</u> 30
| 12
| 5
|-
| Clotting disorder
| 2
| 1
|-
| Other
| 11
| 5
|}


== Medications  ==
== Medications  ==


Drugs Approved for Stomach (Gastric) Cancer
There are many medications that are used for gastric cancer, each one prescribed by the patient's physician. Before a specific medication is prescribed to the patient, the physician should go through an extensive overview of the history of the patient, looking for history of allergic reactions to certain drugs. The patient should also be warned of adverse side effects that could effect the patient's everyday activities.
 
This page lists cancer drugs approved by the Food and Drug Administration (FDA) for stomach (gastric) cancer. The list includes generic names and brand names. The drug names link to NCI's Cancer Drug Information summaries. There may be drugs used in stomach (gastric) cancer that are not listed here.
 
Adriamycin PFS (Doxorubicin Hydrochloride)<br>Adriamycin RDF (Doxorubicin Hydrochloride)<br>Adrucil (Fluorouracil)<br>Docetaxel<br>Doxorubicin Hydrochloride<br>Efudex (Fluorouracil)<br>Fluoroplex (Fluorouracil)<br>Fluorouracil<br>Herceptin (Trastuzumab)<br>Mitomycin C<br>Mitozytrex (Mitomycin C)<br>Mutamycin (Mitomycin C)<br>Taxotere (Docetaxel)<br>Trastuzumab<br>
 
http://www.cancer.gov/cancertopics/druginfo/stomachcancer<br>
 
<br>
 
Targeted drugs <br>Targeted therapy uses drugs that attack specific abnormalities within cancer cells. Targeted drugs are used to treat a rare form of stomach cancer called gastrointestinal stromal tumor. Targeted drugs used to treat this cancer include imatinib (Gleevec) and sunitinib (Sutent).
 
http://www.mayoclinic.com/health/stomach-cancer/DS00301/DSECTION=treatments-and-drugs  
 
<br>
 
Xeloda
 
[http://www.drugs.com/condition/stomach-cancer.html http://www.drugs.com/condition/stomach-cancer.html]
 
== Diagnostic Tests/Lab Tests/Lab Values  ==
== Diagnostic Tests/Lab Tests/Lab Values  ==
 
[[Image:Gastroscopy.gif|right|frameless]]All of the following tests are done in order to either to diagnose for gastric cancer or to determine what stage the cancer is in, in order to determine the best treatment approach for that patient. Following are a number of diagnostic and special tests.
Tests and procedures used to diagnose stomach cancer include:
* <u></u>Endoscopy<u><ref name="MayoClinicDxTests">Mayo Clinic. Stomach Cancer Tests and Diagnosis. http://www.mayoclinic.com/health/stomach-cancer/DS00301/DSECTION=tests-and-diagnosis (accessed 2 Feb 2013)</ref></u> - This is a diagnostic procedure involving a thin tube with a camera inside of it that is passed through you esophagus into your stomach. Finds any suspicious tissue within stomach that should be tested for cancer. A biopsy can be done to determine if the suspicious tissue is malignant or benign.<u></u><ref>http://www.newcastlesurgery.com.au.php53-22.ord1-1.websitetestlink.com/wp-content/uploads/2012/06/gastroscopy.gif</ref>
 
* Imaging<u><ref name="MayoClinicDxTests" /></u>
A tiny camera to see inside your stomach (upper endoscopy). A thin tube containing a tiny camera is passed down your throat and into your stomach. Your doctor can look for signs of cancer. If any suspicious areas are found, a piece of tissue can be collected for analysis (biopsy).<br>Imaging tests. Imaging tests used to look for stomach cancer include computerized tomography (CT) and a special type of X-ray exam sometimes called a barium swallow.<br>Determining the extent (stage) of stomach cancer <br>The stage of your stomach cancer helps your doctor decide which treatments may be best for you. Tests and procedures used to determine the stage of cancer include:
** CT scan
 
** PET
Imaging tests. Tests may include CT, positron emission tomography (PET) and magnetic resonance imaging (MRI).<br>Exploratory surgery. Your doctor may recommend surgery to look for signs that your cancer has spread beyond your stomach within your abdomen. Exploratory surgery is usually done laparoscopically. This means the surgeon makes several small incisions in your abdomen and inserts a special camera that transmits images to a monitor in the operating room.<br>Other staging tests may be used, depending on your situation.
** MRI
 
* Exploratory Surgery<u><ref name="MayoClinicDxTests" /></u><br>This is performed should the doctor suspect your cancer has spread beyond just the stomach tissue. This procedure is done laparoscopically
Stages of stomach cancer <br>The stages of adenocarcinoma stomach cancer include:
* <u></u>Physical Exam<u><ref name="WebMDDxTests">WebMD. How is Stomach Cancer Diagnosed. http://www.webmd.com/cancer/stomach-gastric-cancer?page=2 (accessed 2 Feb 2013)</ref></u><br>For enlarged lymph nodes, an enlarged liver, increased fluid in the abdomen (ascites), or abdominal lumps felt during a rectal exam.
 
* Upper GI Series<u><ref name="WebMDDxTests" /></u><br>X-rays of the esophagus, stomach, and first part of the intestine taken after drink a barium solution. The barium outlines the stomach on the X-ray, which helps the doctor, using special imaging equipment, to find tumors or other abnormal areas
Stage I. At this stage, the tumor is limited to the layer of tissue that lines the inside of the stomach. Cancer cells may also have spread to a limited number of nearby lymph nodes.<br>Stage II. The cancer at this stage has spread deeper, growing into the muscle layer of the stomach wall. Cancer may also have spread to more of the lymph nodes.<br>Stage III. At this stage, the cancer may have grown through all the layers of the stomach. Or it may be a smaller cancer that has spread more extensively to the lymph nodes.<br>Stage IV. This stage of cancer extends beyond the stomach, growing into nearby structures. Or it is a smaller cancer that has spread to distant areas of the body.<br>
 
http://www.mayoclinic.com/health/stomach-cancer/DS00301/DSECTION=tests-and-diagnosis
 
 
 
How Is Stomach Cancer Diagnosed?
 
Your health care provider can often detect advanced stomach cancer by performing a physical exam. He or she may find enlarged lymph nodes, an enlarged liver, increased fluid in the abdomen (ascites), or abdominal lumps felt during a rectal exam.
 
However, if you are having vague symptoms, such as indigestion, weight loss, nausea, and loss of appetite, screening tests may be recommended. These tests may include:
 
Upper GI series . These are X-rays of the esophagus, stomach, and first part of the intestine taken after you drink a barium solution. The barium outlines the stomach on the X-ray, which helps the doctor, using special imaging equipment, to find tumors or other abnormal areas.<br>Gastroscopy and biopsy. This test examines the esophagus and stomach using a thin, lighted tube called a gastroscope, which is passed through the mouth to the stomach. Through the gastroscope, the doctor can look directly at the inside of the stomach. If an abnormal area is found, the doctor will remove some tissue (biopsy) to be examined under a microscope. A biopsy is the only sure way to diagnose cancer. Gastroscopy and biopsy are the best methods of identifying stomach cancer.<br>Once stomach cancer is diagnosed, more tests may be done to determine if the cancer has spread. These tests may include CT scans, PET scans, bone scans, laparoscopy and endoscopic ultrasound.
 
How Is Stomach Cancer Treated?
 
Stomach cancer may be treated with the following, in combination, or alone:
 
Surgery, called gastrectomy, to remove all or part of the stomach, as well as some of the tissue surrounding the stomach.<br>Chemotherapy.<br>Radiation therapy.
 
http://www.webmd.com/cancer/stomach-gastric-cancer?page=2
 
== Etiology/Causes  ==
 
Doctors aren't sure what causes stomach cancer. There is a strong correlation between a diet high in smoked, salted and pickled foods and stomach cancer. As the use of refrigeration for preserving foods has increased around the world, the rates of stomach cancer have declined.
 
In general, cancer begins when an error (mutation) occurs in a cell's DNA. The mutation causes the cell to grow and divide at a rapid rate and to continue living when normal cells would die. The accumulating cancerous cells form a tumor that can invade nearby structures. And cancer cells can break off from the tumor to spread throughout the body.
 
Types of stomach cancer <br>The cells that form the tumor determine the type of stomach cancer. The type of cells in your stomach cancer helps determine your treatment options. Types of stomach cancer include:
 
Cancer that begins in the glandular cells (adenocarcinoma). The glandular cells that line the inside of the stomach secrete a protective layer of mucus to shield the lining of the stomach from the acidic digestive juices. Adenocarcinoma accounts for the great majority of all stomach cancers.<br>Cancer that begins in immune system cells (lymphoma). The walls of the stomach contain a small number of immune system cells that can develop cancer. Lymphoma in the stomach is rare.<br>Cancer that begins in hormone-producing cells (carcinoid cancer). Hormone-producing cells can develop carcinoid cancer. Carcinoid cancer in the stomach is rare.<br>Cancer that begins in nervous system tissues. A gastrointestinal stromal tumor (GIST) begins in specific nervous system cells found in your stomach. GIST is a rare form of stomach cancer.<br>Because the other types of stomach cancer are rare, when people use the term "stomach cancer" they generally are referring to adenocarcinoma.<br>http://www.mayoclinic.com/health/stomach-cancer/DS00301/DSECTION=causes<br>


== Systemic Involvement  ==
== Systemic Involvement  ==


add text here
=== Surgery Side Effects ===
 
The major surgery that patients with gastric cancer recieve is called a gastrectomy, which is where part or all of the patient's stomach is removed. When this happens, many changes will occur in the patient's diet because their body starts to process food differently. For instance, when the entire stomach is removed, the patient will not be able to absorb the vitamin B12<ref name="SideEffects">Cancer Compass. Stomach Cancer. http://www.cancercompass.com/stomach-cancer-information/side-effects.htm (accessed Feb 14 2013)</ref> If this happens, the patient will become anemic<ref name="VitB12">WebMD. Vitamin B12 Deficiency Anemia. http://www.webmd.com/a-to-z-guides/vitamin-b12-deficiency-anemia-topic-overview (accessed Feb 14 2013)</ref>, and therefore must recieve injections of B12. The patient must also slowly resume a normal solid diet, starting with intravenous feeding and progressing to solids. Often times these patients also have cramps, nausea, diarrhea, and dizziness shortly after eating because food and liquid enter the small intestine too quickly<ref name="SideEffects" /> Finally, bile may back up from the small intestine to the esophagus or the part of the stomach that wasn't removed, and can cause stomach pain<ref name="SideEffects" />.
== Medical Management (current best evidence)  ==
 
http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=847a47b5-19ea-4271-87dc-4237732cbddf%40sessionmgr113&amp;vid=5&amp;hid=108
 
<br>
 
Surgical management of gastric cancer<br>Simon Msika, Grégoire Deroide, and Reza Kianmanesh.
 
Louis Mourier University Hospital - Colombes (University Paris 7), Assistance Publique-Hôpitaux de Paris, Colombes Cedex, France<br>Surgical resection remains the primary treatment for gastric cancer (GC). Although declining in incidence in western countries during the last twenty years, it remains an important cancer problem (1). In France, it still occurs with an incidence rate of 13.8 per 100,000 inhabitants per year (Côte d'Or, Burgundy, France, Digestive Tract Cancer Registry 1983–1987) (2). In 1990, GC was the second most frequent cancer in the world (1), the 6th cancer among men in France and the third of all digestive cancers, after colorectal and oesophagal cancer. In France, the number of estimated new cases is about 8700 per year.
 
Prognosis of GC is poor. The 5 year survival rate does not rise over 20%, especially in population-based series (3), far closer to reality than those coming from hospital series. Surgery with curative intent remains the only way to improve survival. However, results in the treatment of GC are globally disappointing and results of population-based series (4–7) concerning improvement of 5 year and 10 year relative survival rate in overall patients and after curative surgery are controversial. The major component of the overall improvement was a decreasing of operative mortality (3, 8). Poor results in survival may be explained by the fact that when symptoms occur, the cancer has often already spread and so far only a few percentage of patients are eligible for curative surgery.
 
As in the literature, many published studies about surgical treatment of gastric cancer are found, this paper has the main objective to make a synthesis on the evidence based in the treatment of gastric cancer and point out the guidelines and pathways of research in the future.
 
Special points will be discussed:
 
a.<br>the limits of gastric resection,  
 
b.<br>the extension of the lymph node dissection, and
 
c.<br>the value of adjuvant therapy to surgery.
 
Go to:<br>Surgical treatment
 
Actually, surgery is the only reliable possibility of a curative treatment. The aim of surgery is to remove as completely as possible all grossly visible tumor tissue and to obtain histologically free surgical margins. This goal (R0 resection (9)) is usually reached in 45% of cases of diagnosed GC in population-based series (3) and up to 55–60% of cases in specialized centers (10).
 
During the operative procedure, gastric resection depends on cancer spread, i.e. tumoral infiltration through the gastric wall, tumoral extension to adjacent organs, and lymph node involvement.
 
Limits of gastric resection
 
The extension of gastric resection depends on the location of the tumor (according to ICD-O classification (9)).
 
Cancer located to the body or the corpus of the stomach (C-16.2) requires total gastrectomy. Reconstruction of digestive continuity is then realized by a Roux-en-Y oesojejunostomy. Pouch and Roux-en-Y reconstruction seem to improve postoperative quality of life after total gastrectomy (11).
 
Cancer of the antrum (distal third and pylorus: C-16.3 and 16.4), may be managed by sub-total distal gastrectomy. Reconstruction is realized by a method similar to Bilroth I or II procedures. Roux-en-Y gastrojejunostomy has been proposed to avoid bile-reflux in the gastric remnant (12), but vagotomy is mandatory to prevent anastomotic peptic ulcer, depending on the size of the gastric remnant. This type of reconstruction called total duodenal diversion has been proposed in patients with severe gastrooesophageal reflux disease (12); however, it can be indicated for GC after distal gastrectomy, in cases of patients with a hope of long term survival as early gastric cancer (EGC) for example. For a long time, routine radical total gastrectomy was proposed for distal lesions by general authors (13, 14), particularly from Japan (15); it rationale was based on the effect that survival was better after an extensive lymphadenectomy, including pancreatic tail resection; in these conditions, total gastric resection was necessary. Actually, routine total gastrectomy is no more the only recommended treatment for distal lesions as it was demonstrated in a French prospective multicentric controlled study (16). In this study (16), there was no significant difference on the 5-year survival rate between total or subtotal distal gastrectomy for distal lesions. However, one important point was the fact that after subtotal distal gastrectomy, free margins of resection should not be less than 5–6 cm on the stomach and no less than 2 cm on the proximal duodenum.  
 
Cancer of the cardia needs a particular approach. In fact, they are consider as a different clinical entity (17), while others (18) assimilate them to a lower oesophageal cancer whatever histological differences. As a matter of fact, the limits of the resection depends on the oesophageal extension itself. Despite a lack of controlled study, there is a tendency to achieve total gastrectomy for lesions limited to the cardia and proximal oesophago-gastrectomy by abdominal and right thoracic combined approach (Lewis-Santy procedure) for lesions extended to the lower oesophagus (19).  
 
Borrmann type 4 infiltrative GC, whatever their topography (partial or total), are usually treated by total gastrectomy because of a frequent wide extension through the gastric wall (20). The relative incidence of this type of cancer is increasing with time (21, 22, 23), and wider resection to surrounding organs including extended lymphadenectomy, as proposed by Japanese authors (24), does not seem to improve prognosis for all of the TNM stages, except probably in stage III (25), but no controlled trials has been performed in Borrmann type 4 GC.  
 
At last, EGC, whatever its location, requires similar treatment as for other types because of the possibility of wide submucosal extension and lymph-node involvement. Some Japanese authors suggested limited resections (26) for EGC, but these procedures are not currently diffused in Europe.
 
Lymph-node dissection
 
Lymph node extension is the most prognostic feature in GC. Therefore the crucial question of the last twenty years was related to the prognostic impact of lymph node dissection. Many studies have been realized successively: retrospective, prospective and finally controlled prospective studies. During the last ten years, four prospective controlled studies (27–30) compared the type of lymph-node dissection limited (D1) versus extended (D2), in the surgical treatment of GC. The two last controlled studies gave firstly only results about mortality and morbidity of the D1 and D2 procedures (29, 30), then secondly results about long term survival (31, 32).
 
Actually, until now, none of these randomized trials has demonstrated the superiority of D2 versus D1 specially in term of 5-year survival (no superiority after D2 dissection); furthermore, they showed an increased incidence of postoperative complications rate after D2 vs. D1 dissection. Highest rates of morbidity and mortality are partly due to anastomotic leakage and consequences of the pancreatic tail resection during D2 dissection. These findings led some authors (32) to conclude that D2 resection without pancreatico-splenectomy, excluding the negative effect on operative mortality, may be a good approach for the lymph-node dissection of GC rather than standard D1.
 
The debate seemed to be definitively closed, but a recent multicentric prospective non controlled study (10) pointed out a significant improvement of 10-year survival rate in TNM stage II cancer after D2 dissection (defined in this study as an extended lymph-node dissection with more than 25 removed nodes). Although this study was multicentric, involving many surgeons, standardization of lymph-node dissection was set and routinely realized after several meetings, as well as the last controlled trials (31, 32). In addition to these results, extended lymph-node dissection did not increase mortality and morbidity rates.
 
In France, standardized extended lymphadenectomy for gastric cancer is not routinely performed by all the surgical teams, and systematic count of lymph-nodes in the specimen, as proposed in most of actual trials specially by Japanese authors, but also by western ones, is not standardized for all western pathologists. In the near future, the standardized techniques of lymph-node dissection and pathological analysis might be needed for oncological accreditation.
 
As morbidity and mortality are correlated to resection of the spleen and pancreatic tail in controlled studies, the German study (10) suggests that D2 resection should be associated to subtotal distal gastrectomy in stage II and IIIA to prevent the necessity of a resection of the spleen and pancreatic tail.
 
When a total gastrectomy is performed in curative intent, intermediate “1.5” lymph-node dissection between D1 and D2 could be realized, including splenic lymph-node dissection without splenectomy as it was suggested by a Japanese author (33).
 
Despite the effect of lymph-node dissection on survival has not been proved, it is worth to standardize and familiarize European teams, to precise staging and margin clearance.  
 
Palliative surgical treatment
 
The best palliation in GC whenever possible is still surgical resection. In fact, morbidity and mortality of palliative surgery without resection (laparotomy alone or by-pass procedures) is extremely high and should be avoided. Perhaps a better pre-operative evaluation by CT scan (heliscan) and/or laparoscopic staging indicated in selected patients could decrease the number of explanatory laparotomy in unresectable GC (34).
 
Although, 25% of the patients with diagnosed GC can benefit from palliative procedures (3). There are two different types of the palliative treatment of GC: resection of the tumor and surgical by-pass procedures without resection. Actual pre-operative investigations can not always predict the type of operative procedure as exactly as during operative exploration. Laparoscopic staging could be indicated in these conditions (34).
 
Mostly, in many cases, the possibility of tumoral resection appears to surgeons as a perioperative finding, and per-operative manual exploration may find hepatic metastasis, wide or localized peritoneal implants. in these conditions, palliative surgery depends on local anatomy and preoperative clinical symptoms. A bleeding tumor is more to be resected than an obstructive one for which a by-pass might be recommended. In a general manner, oncologic rules of resections must respect the followings: little free margin on surrounding organs, inutility of lymph node dissections, unless it is required to obtain a free margin. There is a lower mortality and morbidity in palliative resections rather than in by-pass without resections. However, by-pass procedures can still be indicated when resection risk appears to be too high (morbidity and mortality) and/or in case of biliary and/or digestive obstruction. Then, a gastroenterostomy and/or a biliary diversion may be realized.
 
Non operative treatment
 
Non surgical treatment represents 30% of diagnosed GC (3) and is indicated in case of diffuse hepatic, peritoneal and/or extra-abdominal metastasis without obstructive symptoms, sub-clavicular lymph nodes and/or the presence of severe physiological disorders and/or undernutrition. Treatment in these cases is difficult and varies from abstention to endoscopic desobstruction (endoscopic laser therapy, argon beam, heater probe coagulation therapy, endoscopic stent). Chemotherapy can be indicated only in phase II protocols.
 
Go to:<br>Non surgical treatment
 
Chemotherapy
 
Adjuvant and neo adjuvant


There is a high risk of peritoneal and/or hepatic recurrence in GC. It depends on perioperative staging. This feature has led naturally to a plethora of adjuvant chemotherapy series. Drugs usually employed are 5-fluorouracil (5-FU), mitomycin-C, cisplatin, adriamycin, and methyl-CCNU. Many authors report poor and disappointing results in the survival rates and the oldest trials demonstrating improvement with adjuvant chemotherapy (35, 36) were not confirmed by a recent prospective controlled study from the French Associations for Surgical Research (37). This study (37) did not demonstrate any improvement in survival by the administration after curative surgery of an association of cisplatin and 5-FU versus no treatment. A meta-analysis (38) came to the same conclusions. Improvement may come from new associations of drugs, reduction of toxicity and better observance of treatments. Actually, new protocols of neo-adjuvant chemotherapy have been proposed and are in process.  
=== Chemotherapy Side Effects ===
There are many side effects of chemotherapy that can be detrimental to a person's [[Quality of Life|quality of life]]. The reason being is because the role of chemotherapy is to kill any rapidly dividing cell, not just cancer cells. Therefore, patient's undergoing chemotherapy for gastric cancer can expect to lose there hair<ref name="SideEffects" />. They may also have oral problems such as sores and decreased taste buds<ref name="SideEffects" />. Since the digestive tract is also included in rapidly dividing cells, patients may also have digestive problems including stomach aches, nausea, vomiting and loss of appetite<ref name="SideEffects" />. Probably more importantly than all of this, though, the patient's immune system is often compromised due to the chemo's nature to kill off red and white blood cells<ref name="SideEffects" />.  


Intraperitoneal chemotherapy with or without hyperthermia
=== Radiation Side Effects ===
Radiaton has very similar side effects to chemotherapy. On top of this, it can cause patients to develop skin problems such as rashes and easier cuts<ref name="SideEffects" />. Patients can also expect to be extremely fatigued during their radiation treatment<ref name="SideEffects" />.


Intraperitoneal chemotherapy is a logical alternative to the systemic way, as peritoneal diffusion and seeding is important. It is related to be easier to deliver chemotherapy with a higher intracellular concentration. Until now, there were 5 controlled trials (39–43) about intraperitoneal chemotherapy (IPC), essentially as a preventive therapy. All came from Japanese surgical teams except the last one which was performed in collaboration with the Washington Cancer Institute (43). This trial compared a particular type of chemotherapy, early post operative intraperitoneal chemotherapy (EPIC), developed by Sugarbaker in the treatment of carcinomatosis. There was no hyperthermia in this trial and the treatment started the day after the operative procedure using the drain catheter in place. This study included a great number of patients: 248 were divided into two groups of 125 and 123 respectively: surgery vs. EPIC + surgery all stage together. There was no significant difference in the 5-year survival rate but a little advantage to EPIC was observed (38.7% vs. 29.3%). In the stage III patients, there was a significant superiority of EPIC (49.1% vs. 18.4%; p = 0.011).  
== Medical Management  ==
[[File:Stomach bypass surgery CRUK 108 pl.png|right|frameless]]
Medical management of stomach cancer is dependent on its stage.


Special attention to these techniques is needed because of high morbidity and mortality rates. Complication rate due to EPIC is approximatively 37.7%, including prolonged ileus, leucopenia and pain. High incidence rate of post-operative hemoperitoneum and intra abdominal sepsis without anastomosis fistula was observed. Post operative mortality was higher but not significantly: 6.4% in the EPIC group vs. 1.6% in the control group. Authors concluded that this procedure could be interesting in the prevention of carcinomatosis, but in selected patients.  
Image R:  Diagram showing before and after stomach bypass surgery
* The most common form of intervention is surgery, mainly emphasizing removal or part or all of the stomach.  
* Radiation or chemotherapy may also be indicated should the cancer have metastisized to lymph nodes or other structures.  
Three common surgical interventions include endoscopic mucosal resection, subtotal (partial) gastrectomy, and total gastrectomy.  
# Endoscopic mucosal resection is indicated when the cancer has not spread beyond the inner lining of the stomach. The surgeon removes the cancerous cells via a long tube which travels down the esophagus and into the stomach.
# A subtotal or partial gastrectomy is when only part of the stomach is removed. In this case, the cancer has spread significantly to the point in which it cannot be treated endoscopically. In addition, this procedure may involve the removal of a portion of the esophagus, small intestine, or nearby lymph nodes.
# A total gastrectomy is when the cancer has invaded the entire stomach and it needs to be removed completely. Patients that have underwent a total gastrectomy must eat more often and in very small amounts.  
Palliative treatment is often times indicated for patients in the severe stages of gastric cancer (III and IV). The cancer has invaded the body to the point where a complete cure it is difficult. Palliative treatment aims to subside the effects of cancer as much as possible without actually curing it. For example, a stage III or IV tumor can put pressure against the esophagus, making it difficult to eat. A palliative treatment technique for this may involve the placement of a stent in the esophagus, or lazer beam therapy to vaporize that portion of the tumor.<ref>Cancer. Treatment choices by type and stage of stomach cancer. http://www.cancer.org/cancer/stomachcancer/detailedguide/stomach-cancer-treating-by-stage (Accessed 2/14/13)</ref><ref>Cancer. Surgery for stomach cancer. http://www.cancer.org/cancer/stomachcancer/overviewguide/stomach-cancer-overview-treating-surgery (Accessed 2/14/13)</ref>


The problem of morbidity can be resolved with time as long as the learning curve progresses. It is certainly a new way of research and it might improve prognosis.  
NB.Gastro-jejunostomy - a procedure in which an anastamosis is made with the stomach and the second part of the small intestine or jejunum via a small tube. Normal function of the outlet from the stomach into the first part of the small intestine (duodenum) is compromised due to the cancer. A gastro-jejunostomy is a form of palliative treatment to allow for proper transition of foods or medications from the stomach to the intestine.<ref>"Gastric Cancer; Report Summarizes Gastric Cancer Study Findings from Catholic University." Medical Devices &amp; Surgical Technology Week (2013): 454. ProQuest Nursing &amp; Allied Health Source. Web. 14 Feb. 2013.</ref>


Radiotherapy
== Enhancing Outcomes Team Outcomes  ==
The incidence of gastric cancer correlates with socioeconomic status and is clearly dependent on environmental/geographical factors. The management of gastric cancer patient requires the medical expertise of an interprofessional team in addition to a supportive team (nutritionist, social worker, nurses, geneticists, and palliative care providers). Members and patients should discuss the controversy surrounding the benefit of perioperative chemotherapy or radiotherapy alone or combined with competing standards of care and before choosing the best operation for gastric cancer and extension lymph node dissection<ref name=":0" />.


Its efficacy has not been demonstrated; there are few trials on the subject and most associate radiotherapy and chemotherapy. Per operative radiotherapy still constitute an interesting way of research as a non significant tendency was observed.  
== Physical Therapy Management  ==
 
[[File:Strengthing exercise for old people .jpg|right|frameless]]
Immunotherapy
Physical therapy should be utilized during cancer treatment to help a patient maintain function and to prevent the effects of bed rest. However, some people may choose not to go through PT because of fatigue or pain. After cancer treatment, though, patients can go to physical therapy to try and reverse some of the side effects of treatment, and to try and regain function that may have been lost after cancer treatment.
 
* Lymphatic Therapy - Since [[Lymphoedema|lymphoedema]] can occur in conjunction with gastric cancer treatment, [[Lymphoedema|lymphatic]] drainage may be indicated. Since physical therapists are certified to perform lymphatic drainage, it is their responsibility to try and minimize the effects of lymphoedema<ref>Cancer Support Therapies. Manual Lymphatic Drainage Lymphoedema Cancer Related. http://cancersupporttherapies.com/therapies-available/lymphatic-drainage/ (accessed Feb 15 2013)</ref>.
Several Japanese reviews have studied the effect of immune stimulators as adjuvant therapy to curative gastric cancer surgery. There was a small number of randomized trials and all compared standard chemotherapy program with and without the immune stimulator protein-bound polysaccharide (PSK). In one report (44), the PSK group had both an improved 5-year disease free survival and overall 5-year survival. However, no Western trials have confirmed these results.
* Exercise - It is important for patients undergoing cancer treatment to stay active. Exercise during cancer treatment can help to minimize fatigue, improve a patient's immune system, reduce the effects of bed rest (such as contractures and muscle atrophy) and increase general quality of life.
 
Some facilities may offer [[Cancer Rehabilitation and the Importance of Balance Training|Cancer Rehabilitation]] courses.
http://www.ncbi.nlm.nih.gov/books/NBK6969/
 
 
 
Pain medications &amp; modalities
 
Your pain management clinician may recommend anti-inflammatory medications, opioid medications or non-opioid medications to help control your pain. These pain medications may be taken orally or delivered using the following administration methods:<br>Intravenous<br>Implanted pain pumps<br>Peripheral<br>Epidural<br>Rectal<br>Topically<br>Medicated patches<br>Nerve blocks for stomach cancer pain
 
There are two nerve block therapies commonly used for stomach cancer pain management:<br>Celiac Plexus Block – This procedure aims to reduce chronic pain in the upper abdomen. It blocks the sensation of pain in the bundle of nerves in and around the stomach, liver, pancreas, gallbladder, kidneys and bowel.<br>Hypogastric Plexus Block – This block affects nerves in the lower abdomen, near the upper front of the pelvis. It can prevent pain in the bladder and lower bowel. For men, it also reduces pain in the testicles, penis and prostate; for women, it minimizes pain in the uterus, ovaries and vagina.<br>For either of these procedures, an anesthesiologist first must inject a temporary, local anesthetic into the area where the affected nerves are to determine if you experience pain relief. If the temporary block works, the anesthesiologist will administer a neurolytic solution (i.e., pain killing medication) to the same area 24 hours later. This long-term nerve block will destroy the nerves, thereby preventing you from feeling pain in that region of the abdomen.<br>Stomach cancer patients may experience pain relief from a celiac plexus block or hypogastric plexus block for an extended period, which may last days, weeks or months (depending on your response to the nerve block).
 
 
 
http://www.cancercenter.com/stomach-cancer/pain-management.cfm
 
== Physical Therapy Management (current best evidence) ==
 
add text here
 
== Alternative/Holistic Management (current best evidence) ==
 
add text here
 
== Differential Diagnosis  ==
 
add text here


See also [[Physical Activity in Cancer]] and [[Breast Cancer]]
== Case Reports/ Case Studies  ==
== Case Reports/ Case Studies  ==
[[Gastric Cancer Case Studies|1) The Management Of Double Neoplasms: A Case Of A Patient With Small Cell Lung And Gastric Cancer Successfully Treated With Chemotherapy. By: Rossi, David, Alessandroni, Paolo, Fedeli, Stefano Luzi, Fedeli, Anna, Giordani, Paolo, Catalano, Vincenzo, Balzelli, Anna Maria, Casadei, V., Catalano, Giuseppina, Internet Journal of Oncology, 15288331, 2005, Vol. 3, Issue 1]]<br>


add links to case studies here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>
== Resources <br>  ==
add appropriate resources here
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]
<div class="researchbox">
<rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1NGmwZeh8JwVIzrKgHG1LrDm0izTr7ViJiDkSYAY2BW5hiXsx0|charset=UTF-8|short|max=10</rss>
</div>
== References  ==
== References  ==


see [[Adding References|adding references tutorial]].
<references />  
 
<references />&nbsp;


[[Category:Management]][[Category:Cancer]][[Category:Medical]][[Category:Bellarmine_Student_Project]]
[[Category:Oncology]]  
[[Category:Medical]]  
[[Category:Bellarmine_Student_Project]]
[[Category:Conditions]]

Latest revision as of 11:46, 8 August 2023

Original Editors -Nick Goulooze & Corey Malone from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Corey Malone, Nicholas Goulooze, Lucinda hampton, Admin, Kim Jackson, Elaine Lonnemann, Evan Thomas, WikiSysop, 127.0.0.1, Wendy Walker and Vidya Acharya

Introduction[edit | edit source]

Stomach cancer patient.png

Gastric cancer (also known as stomach cancer) is characterized by rapid or abnormal cell growth within the lining of the stomach, forming a tumor.[1] Image R - This is a depiction of a woman suffering from stomach cancer. Typically, a person may not experience any symptoms to begin with. However, as the condition progresses, one may exhibit symptoms, such as loss of appetite. A cross-section of the stomach with a tumour has been shown.

  • Gastric cancer is the fifth most frequently diagnosed cancer and the third leading cause of cancer deaths worldwide.
  • In the United States, the incidence of gastric cancer has decreased during the past few decades although the incidence of gastroesophageal cancer has concomitantly increased.
  • There are two distinct types of gastric adenocarcinoma, intestinal (well-differentiated) and diffuse (undifferentiated), which have a distinct morphologic appearance, pathogenesis, and genetic profiles.
  • The only potentially curative treatment approach for patients with gastric cancer is surgical resection with adequate lymphadenectomy.
  • Current evidence supports perioperative therapies to improve a patient’s survival.
  • Regrettably, patients with an unresectable, locally advanced, or metastatic disease could solely be offered life-prolonging palliative therapy regimens[2].

Types of Gastric Cancer[edit | edit source]

Stomach cancer illustration Wellcome L0014136.jpg

Different types of cells which make up the stomach. Therefore each particular cell has its own type of cancer.

  1. Adenocarcinoma This is the most common type of gastric cancer (95% of gastric cancers[3]). This particular type of stomach cancer originates in the lining of the stomach, and effects the glandular cells of the stomach. It is believed that the majority of stomach cancer cases are caused by Heliobacter pylori bacteria.[3]
  2. Carcinoid This type of stomach cancer effects the stomach's hormone producing cells. Carcinoid cells reproduce very slowly, and are incredibly rare. After the cancer has progressed a significant amount, a patient may have symptoms such as flushing of the face and chest, trouble breathing, and diarrhea.  This is believed to be caused by hormones from the stomach.[3]
  3. Gastrointesinal Stromal Tumor This type of stomach cancer originates in the nervous tissue surrounding the stomach, and is very rare.[3]
  4. Lymphoma Rarely, cancer will spread from the lymphnodes within and around the stomach, causing gastric cancer.[3]

As common with any type of cancer, gastric (stomach) cancer (see image R) can present in various stages, ranging from mild to severe. 

Etiology[edit | edit source]

Research is still being conducted as to what actually causes stomach cancer. However, its has been shown to correlate with the following demographics and medical histories...[4][5]

  • Diets high in sodium
  • Men are two times more as risk than women
  • African-Americans and Asians are at greater risk
  • Blood group A
  • Middle age to elderly
  • Family history of stomach cancer
  • Helicobacter pylori
  • Any other past medical history of gastrointestinal complications or surgery
  • Toxin exposure and smoking
    H. Pylori.gif

Most gastric cancers are sporadic, but 5% to 10% of cases have a family history of gastric cancer. Hereditary diffuse gastric cancer (HDGC), gastric adenocarcinoma and proximal polyposis of the stomach (GAPPS), and familial intestinal gastric cancer (FIGC) are three major syndromes accounting up to 3% to 5% of hereditary familial gastric cancer. 

Stomach conditions can often times serve as precursors to cancer.eg,

  • atrophic gastritis - stomach glands have decreased and are inflamed
  • intenstinal metaplasia - cells within the lining of the intestine invade the stomach and take the place of stomach cells),
  • Helicobacter pylori infection - said to convert food particles into chemicals that cause mutations within the DNA of stomach cells, leading to cancer (consumption of foods high in antioxidants is said decrease the risk of stomach cancer by blocking the action of these chemicals on the stomach). [6][7]

Epidemiology[edit | edit source]

  • Gastric cancer rates are significantly declining worldwide.
  • In the United States, an estimated 28,000 new cases will be diagnosed with gastric cancer with an expected 10,960 new deaths during 2017[2]

Characteristics/Clinical Presentation[edit | edit source]

In the United States, most patients have symptoms of an advanced stage at the time of presentation. 

National-cancer-institute-0YBIMOqQzt0-unsplash.jpg

Most common presenting symptoms for gastric cancers are:

  • Non-specific weight loss
  • Persistent abdominal pain
  • Dysphagia
  • Hematemesis,
  • Anorexia, nausea, early satiety, and dyspepsia.

Patients presenting with a locally-advanced or metastatic disease usually present with significant abdominal pain, potential ascites, weight loss, fatigue, and have visceral metastasis on scans and can have a gastric-outlet obstruction.

Common physical examination findings

  • Palpable abdominal mass indicating advanced disease
  • Signs of metastatic lymphatic spread distribution including Virchow’s node (left supraclavicular adenopathy), Sister Mary Joseph node (peri-umbilical nodule), and Irish node (left axillary node). Direct metastasis to peritoneum can present as Krukenberg’s tumor (ovary mass), Blumer’s shelf (cul-de-sac mass), ascites (peritoneal carcinomatosis), and hepatomegaly (often diffuse disease burden).

Paraneoplastic manifestations may include dermatological (diffuse seborrheic keratosis or acanthosis nigricans), hematological (microangiopathic hemolytic anemia and hypercoagulable state [Trousseau’s syndrome]), renal (membranous nephropathy), and autoimmune (polyarteritis nodosa) are rare clinical findings and none is specific to gastric cancer.[2]

Associated Co-morbidities[edit | edit source]

  • A Study conducted by Heemskerk et al investigated associated co-morbidities upon history intake of 235 patients diagnosed with gastric cancer between 1992-2004.
  • 138 of the 235 patient had at least one co-morbidity[8]
Co-morbidity No. of Patients %
Cardiovascular 87 37
Pulmonary 24 10
Diabetes 19 8
Other carcinoma 20 9
Previous GI surgery 18 8
BMI > 30 12 5
Clotting disorder 2 1
Other 11 5

Medications[edit | edit source]

There are many medications that are used for gastric cancer, each one prescribed by the patient's physician. Before a specific medication is prescribed to the patient, the physician should go through an extensive overview of the history of the patient, looking for history of allergic reactions to certain drugs. The patient should also be warned of adverse side effects that could effect the patient's everyday activities.

Diagnostic Tests/Lab Tests/Lab Values[edit | edit source]

Gastroscopy.gif

All of the following tests are done in order to either to diagnose for gastric cancer or to determine what stage the cancer is in, in order to determine the best treatment approach for that patient. Following are a number of diagnostic and special tests.

  • Endoscopy[9] - This is a diagnostic procedure involving a thin tube with a camera inside of it that is passed through you esophagus into your stomach. Finds any suspicious tissue within stomach that should be tested for cancer. A biopsy can be done to determine if the suspicious tissue is malignant or benign.[10]
  • Imaging[9]
    • CT scan
    • PET
    • MRI
  • Exploratory Surgery[9]
    This is performed should the doctor suspect your cancer has spread beyond just the stomach tissue. This procedure is done laparoscopically
  • Physical Exam[11]
    For enlarged lymph nodes, an enlarged liver, increased fluid in the abdomen (ascites), or abdominal lumps felt during a rectal exam.
  • Upper GI Series[11]
    X-rays of the esophagus, stomach, and first part of the intestine taken after drink a barium solution. The barium outlines the stomach on the X-ray, which helps the doctor, using special imaging equipment, to find tumors or other abnormal areas

Systemic Involvement[edit | edit source]

Surgery Side Effects[edit | edit source]

The major surgery that patients with gastric cancer recieve is called a gastrectomy, which is where part or all of the patient's stomach is removed. When this happens, many changes will occur in the patient's diet because their body starts to process food differently. For instance, when the entire stomach is removed, the patient will not be able to absorb the vitamin B12[12] If this happens, the patient will become anemic[13], and therefore must recieve injections of B12. The patient must also slowly resume a normal solid diet, starting with intravenous feeding and progressing to solids. Often times these patients also have cramps, nausea, diarrhea, and dizziness shortly after eating because food and liquid enter the small intestine too quickly[12] Finally, bile may back up from the small intestine to the esophagus or the part of the stomach that wasn't removed, and can cause stomach pain[12].

Chemotherapy Side Effects[edit | edit source]

There are many side effects of chemotherapy that can be detrimental to a person's quality of life. The reason being is because the role of chemotherapy is to kill any rapidly dividing cell, not just cancer cells. Therefore, patient's undergoing chemotherapy for gastric cancer can expect to lose there hair[12]. They may also have oral problems such as sores and decreased taste buds[12]. Since the digestive tract is also included in rapidly dividing cells, patients may also have digestive problems including stomach aches, nausea, vomiting and loss of appetite[12]. Probably more importantly than all of this, though, the patient's immune system is often compromised due to the chemo's nature to kill off red and white blood cells[12].

Radiation Side Effects[edit | edit source]

Radiaton has very similar side effects to chemotherapy. On top of this, it can cause patients to develop skin problems such as rashes and easier cuts[12]. Patients can also expect to be extremely fatigued during their radiation treatment[12].

Medical Management[edit | edit source]

Stomach bypass surgery CRUK 108 pl.png

Medical management of stomach cancer is dependent on its stage.

Image R:  Diagram showing before and after stomach bypass surgery

  • The most common form of intervention is surgery, mainly emphasizing removal or part or all of the stomach.
  • Radiation or chemotherapy may also be indicated should the cancer have metastisized to lymph nodes or other structures.

Three common surgical interventions include endoscopic mucosal resection, subtotal (partial) gastrectomy, and total gastrectomy.

  1. Endoscopic mucosal resection is indicated when the cancer has not spread beyond the inner lining of the stomach. The surgeon removes the cancerous cells via a long tube which travels down the esophagus and into the stomach.
  2. A subtotal or partial gastrectomy is when only part of the stomach is removed. In this case, the cancer has spread significantly to the point in which it cannot be treated endoscopically. In addition, this procedure may involve the removal of a portion of the esophagus, small intestine, or nearby lymph nodes.
  3. A total gastrectomy is when the cancer has invaded the entire stomach and it needs to be removed completely. Patients that have underwent a total gastrectomy must eat more often and in very small amounts.

Palliative treatment is often times indicated for patients in the severe stages of gastric cancer (III and IV). The cancer has invaded the body to the point where a complete cure it is difficult. Palliative treatment aims to subside the effects of cancer as much as possible without actually curing it. For example, a stage III or IV tumor can put pressure against the esophagus, making it difficult to eat. A palliative treatment technique for this may involve the placement of a stent in the esophagus, or lazer beam therapy to vaporize that portion of the tumor.[14][15]

NB.Gastro-jejunostomy - a procedure in which an anastamosis is made with the stomach and the second part of the small intestine or jejunum via a small tube. Normal function of the outlet from the stomach into the first part of the small intestine (duodenum) is compromised due to the cancer. A gastro-jejunostomy is a form of palliative treatment to allow for proper transition of foods or medications from the stomach to the intestine.[16]

Enhancing Outcomes Team Outcomes[edit | edit source]

The incidence of gastric cancer correlates with socioeconomic status and is clearly dependent on environmental/geographical factors. The management of gastric cancer patient requires the medical expertise of an interprofessional team in addition to a supportive team (nutritionist, social worker, nurses, geneticists, and palliative care providers). Members and patients should discuss the controversy surrounding the benefit of perioperative chemotherapy or radiotherapy alone or combined with competing standards of care and before choosing the best operation for gastric cancer and extension lymph node dissection[2].

Physical Therapy Management[edit | edit source]

Strengthing exercise for old people .jpg

Physical therapy should be utilized during cancer treatment to help a patient maintain function and to prevent the effects of bed rest. However, some people may choose not to go through PT because of fatigue or pain. After cancer treatment, though, patients can go to physical therapy to try and reverse some of the side effects of treatment, and to try and regain function that may have been lost after cancer treatment.

  • Lymphatic Therapy - Since lymphoedema can occur in conjunction with gastric cancer treatment, lymphatic drainage may be indicated. Since physical therapists are certified to perform lymphatic drainage, it is their responsibility to try and minimize the effects of lymphoedema[17].
  • Exercise - It is important for patients undergoing cancer treatment to stay active. Exercise during cancer treatment can help to minimize fatigue, improve a patient's immune system, reduce the effects of bed rest (such as contractures and muscle atrophy) and increase general quality of life.

Some facilities may offer Cancer Rehabilitation courses.

See also Physical Activity in Cancer and Breast Cancer

Case Reports/ Case Studies[edit | edit source]

1) The Management Of Double Neoplasms: A Case Of A Patient With Small Cell Lung And Gastric Cancer Successfully Treated With Chemotherapy. By: Rossi, David, Alessandroni, Paolo, Fedeli, Stefano Luzi, Fedeli, Anna, Giordani, Paolo, Catalano, Vincenzo, Balzelli, Anna Maria, Casadei, V., Catalano, Giuseppina, Internet Journal of Oncology, 15288331, 2005, Vol. 3, Issue 1

References[edit | edit source]

  1. ↑ The Free Dictionary. Stomach Cancer. http://medical-dictionary.thefreedictionary.com/stomach+cancer (accessed 2 Feb 2013)
  2. ↑ 2.0 2.1 2.2 2.3 Recio-Boiles A, Waheed A, Babiker HM. Cancer, Gastric. InStatPearls [Internet] 2019 May 18. StatPearls Publishing.Available from:https://www.ncbi.nlm.nih.gov/books/NBK459142/ (last accessed 23.5.2020)
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Livestrong. What are different types of gastric cancer. http://www.livestrong.com/article/102412-different-types-gastric-cancer/ (accessed Feb 13 2013)
  4. ↑ Mayo clinic. Stomach cancer causes. http://www.mayoclinic.com/health/stomach-cancer/DS00301/DSECTION=causes (accessed 2/13/13)
  5. ↑ WebMD. Stomach cancer. http://www.webmd.com/cancer/stomach-gastric-cancer (Accessed 2/13/13)
  6. ↑ Cancer. Stomach cancer causes, risk factors, and prevention topics. http://www.cancer.org/cancer/stomachcancer/detailedguide/stomach-cancer-what-causes (Accessed 2/14/14)
  7. ↑ http://bioweb.uwlax.edu/bio203/s2008/pluym_evan/pictures/h_pylori%20scott%20smith.gif (accessed Feb 17 2013)
  8. ↑ Vincent H., Fanneke L., Karel H., Anton H. Gastric carcinoma: review of the results of treatment in a community teaching hospital. World Journal of Surgical Oncology 2007; 5:81
  9. ↑ 9.0 9.1 9.2 Mayo Clinic. Stomach Cancer Tests and Diagnosis. http://www.mayoclinic.com/health/stomach-cancer/DS00301/DSECTION=tests-and-diagnosis (accessed 2 Feb 2013)
  10. ↑ http://www.newcastlesurgery.com.au.php53-22.ord1-1.websitetestlink.com/wp-content/uploads/2012/06/gastroscopy.gif
  11. ↑ 11.0 11.1 WebMD. How is Stomach Cancer Diagnosed. http://www.webmd.com/cancer/stomach-gastric-cancer?page=2 (accessed 2 Feb 2013)
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 12.8 Cancer Compass. Stomach Cancer. http://www.cancercompass.com/stomach-cancer-information/side-effects.htm (accessed Feb 14 2013)
  13. ↑ WebMD. Vitamin B12 Deficiency Anemia. http://www.webmd.com/a-to-z-guides/vitamin-b12-deficiency-anemia-topic-overview (accessed Feb 14 2013)
  14. ↑ Cancer. Treatment choices by type and stage of stomach cancer. http://www.cancer.org/cancer/stomachcancer/detailedguide/stomach-cancer-treating-by-stage (Accessed 2/14/13)
  15. ↑ Cancer. Surgery for stomach cancer. http://www.cancer.org/cancer/stomachcancer/overviewguide/stomach-cancer-overview-treating-surgery (Accessed 2/14/13)
  16. ↑ "Gastric Cancer; Report Summarizes Gastric Cancer Study Findings from Catholic University." Medical Devices & Surgical Technology Week (2013): 454. ProQuest Nursing & Allied Health Source. Web. 14 Feb. 2013.
  17. ↑ Cancer Support Therapies. Manual Lymphatic Drainage Lymphoedema Cancer Related. http://cancersupporttherapies.com/therapies-available/lymphatic-drainage/ (accessed Feb 15 2013)
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