Clinical judgment

Chidera Henry madueke

Gastric cancer 

EPIDEMIOLOGY
Worldwide, gastric carcinoma represents the third or fourth most common
malignancy. The frequency of gastric carcinoma occurrence at different sites within
the stomach has changed in the United States over recent decades. The incidence of
cancer of the distal half of the stomach has been decreasing in the United States
since the 1930s.

RISK FACTORS
1)Average age at onset is fifth decade
2)Male-to-female ratio is 1.7:1
3)African American-to-white ratio is 1.8:1
4)Precursor conditions include chronic atrophic gastritis and intestinal metaplasia,
pernicious anemia (10% to 20% incidence), partial gastrectomy for benign disease,
Helicobacter pylori infection (especially childhood exposure—three- to fivefold
increase), Ménétrier’s disease, and gastric adenomatous polyps. These precursor
lesions are largely linked to distal (intestinal-type) gastric carcinoma
5) Family history: first degree (two- to threefold); the family of Napoléon Bonaparte is
an example; familial clustering; patients with hereditary nonpolyposis colorectal
cancer (Lynch syndrome II) are at increased risk; germline mutations of E-cadherin
(CDH1 gene) have been linked to familial diffuse gastric cancer and associated
lobular breast cancer
6) Tobacco use results in a 1.5- to 3-fold increased risk for cancer
7)High salt and nitrosamine food content from fermenting and smoking process
8)Deficiencies of vitamins A, C, and E; β-carotene; selenium; and fiber
9) Blood type A 
10)Alcohol
SCREENING

In most countries, screening of the general populations is not practical because of a

low incidence of gastric cancer. However, screening is justified in countries where
the incidence of gastric cancer is high. Japanese screening guidelines include initial
upper endoscopy at age 50, with follow-up endoscopy for abnormalities. Routine
screening is not recommended in the United States.

PATHOPHYSIOLOGY
Most gastric cancers are adenocarcinomas (more than 90%) of two distinct
histologic types: intestinal and diffuse. In general, the term “gastric cancer” is
commonly used to refer to adenocarcinoma of the stomach. Other cancers of the
stomach include non-Hodgkin’s lymphomas (NHL), leiomyosarcomas, carcinoids
and gastrointestinal stromal tumors (GIST).
Differentiating between adenocarcinoma and lymphoma is critical because the
prognosis and treatment for these two entities differ considerably. Although less
common, metastases to the stomach include melanoma, breast, and ovarian
cancers.
intestinal type :
 The epidemic form of cancer is further differentiated by gland formation and is
associated with precancerous lesions, gastric atrophy, and intestinal metaplasia.
The intestinal form accounts for most distal cancers with a stable or declining
incidence. These cancers in particular are associated with H. pylori infection.
Diffuse Type :
 The endemic form of carcinoma is more common in younger patients and exhibits
undifferentiated signet-ring histology. There is a predilection for diffuse submucosal
spread because of lack of cell cohesion, leading to linitis plastica. Contiguous
spread of the carcinoma to the peritoneum is common. Precancerous lesions have
not been identified
STAGING
The American Joint Committee on Cancer (AJCC) has designated staging by TNM
classification. In the 2010 AJCC 7th edition, tumors arising at the GEJ or in the
cardia of the stomach within 5 cm of the GEJ that extend into the GEJ or esophagus
are termed esophageal rather than gastric cancers. Gastric tumors involving
muscolaris propria (T2), subserosa (T3), and serosa (T4a) are considered resectable,
whereas invasion of adjacent structures (T4b) is not involved.

PROGNOSIS
Pathologic staging remains the most important determinant of prognosis Other
prognostic variables that have been proposed to be associated with an unfavorable
outcome include the following:
■■ Older age
■■ Male gender
■■ Weight loss greater than 10%
■■ Location of tumor
■■ Tumor histology: diffuse versus intestinal high-grade or undifferentiated tumors
■■ Four or more lymph nodes involved.
Paraneoplastic Syndromes
■■ Skin syndromes: acanthosis nigricans, dermatomyositis, circinate erythemas,
pemphigoid, and acute onset of seborrheic keratoses (Leser- Trélat sign)
■■ Central nervous system syndromes: dementia and cerebellar ataxia
■■ Miscellaneous: thrombophlebitis, microangiopathic hemolytic
anemia,membranous nephropathy Tumor Markers Carcinoembryonic antigen (CEA)
is elevated in 40% to 50% of cases. It is useful in follow-up and monitoring response
to therapy, but not for screening. α-Fetoprotein and CA 19-9 are elevated in 30% of
patients with gastric cancer, but are of limited clinical use.

MANAGEMENT OF GASTRIC CANCER

Although surgical resection remains the cornerstone of gastric cancer treatment, the
optimal extent of nodal resection remains controversial. In addition to complete
surgical resection, either postoperative adjuvant chemoradiotherapy (chemoRT) or
perioperative polychemotherapy appear to confer survival advantages. The results of
the Intergroup 0116 study show that the combination of 5-fluorouracil (5-FU)-based
chemoRT significantly prolongs disease-free and overall survival when compared to
no adjuvant treatment. Similarly, the use of polychemotherapy pre- and
postoperatively can increase disease-free and overall survival compared to
observation
In case of resectable disease complete surgical resection of the tumor and adjacent
lymph nodes remains the only chance for cure. For patients with locally advanced or
metastatic disease, moderate doses of external-beam radiation can be used to
palliate symptoms of pain, obstruction, and bleeding, but do not routinely improve
survival
TREATMENT OF GASTRIC CANCER ACCORDING TO STAGE
Gastric Cancer Stage 0 more than 90% of patients treated by gastrectomy with
lymphadenectomy will survive beyond 5 years. An American series has confirmed
these findings. No additional perioperative therapy is necessary.
Stage I and II Gastric Cancer One of the following surgical procedures is
recommended for stage I and II gastric cancer: • Distal SG or Proximal SG or TG, with
distal esophagectomy (if the lesion involves the cardia) • TG (if the tumor involves
the stomach diffusely or arises in the body of the stomach and extends to within 6
cm of the cardia or distal antrum) • Regional lymphadenectomy is recommended
with all of the previously noted procedures • Perioperative polychemotherapy could
also be
considered for patients who present with at least a T2 lesion preoperatively. Stage III
Gastric Cancer: Radical surgery: Curative resection procedures are confined to
patients who do not have extensive nodal involvement at the time of surgical
exploration. Postoperative chemoRT or perioperative polychemotherapy is
recommended.
Distant Metastases (M0) Neoadjuvant polychemotherapy can be considered to
improve resectability. Radical surgery is performed, if possible, either followed by
postoperative chemoRT or perioperative polychemotherapy. For many patients,
chemotherapy may provide substantial palliative benefit and occasional durable
remission, although the
disease remains incurable. Patients with HER2 over expression should be treated
with trastuzumab in combination with chemotherapy. Balancing the
risks to benefits of therapy in any individual patient is recommended.

FOLLOW-UP
Follow-up in patients after complete surgical resection should include routine history
and physical examination, with liver function tests and CEA measurements being
performed .Evaluation intervals of every 3 to 6 months for the first 3 years and then
annually thereafter have been suggested.