Stomach cancer
A student seminar
Epidemiology
Gastric cancer is the fifth most frequently diagnosed cancer and the third leading cause of cancer deaths
worldwide , based on the GLOBOCAN 2018 data
In the United States, the incidence of gastric cancer has decreased significantly in the past 50 years, but the
incidence of tumors of the gastric cardia and gastroesophageal junction (GEJ) have increased 4% to 10% per
year among US men since 1976.
There is a 15–20-fold variation in risk between the highest- and the lowest-risk populations. The high-risk
areas are East Asia (China and Japan), Eastern Europe, Central and South America. The low-risk areas are
Southern Asia, North and East Africa, North America, Australia, and New Zealand
Risk factors
Average age of onset is 5th decade
Male to female ratio is 1.7:1
African American-to-white ratio is 1.8:1
Blood type A
In 1994, H. pylori was classified as a class I carcinogen by the International Agency for Research on
Cancer.
Cigarretes : 60% greater risk for males and 20% greater risk for females compared to non smokers
Alcohol
Occupational exposure to dust, nitrogen oxides, N-nitroso compounds, radiation (e.g. Fishermen,
machine operators, launderers, dry cleaners...)
Pathohistology
Most gastric cancers are adenocarcinomas (more than 90%) and have 2 histologic types: intestinal
and diffuse
Intestinal type is associated with H. Pylori infection that produces nitirtes and nitroso comounds,
leads to glandular atrophy and gastritis, increased pH, intestinal metaplasia/dysplasia and cancer at
the end
Also precancerous lesions and interplay with environmental factors
Hereditary diffuse gastric cancer is more rare (1%-3% of all GC) and occurs in younger patients. It
results from inherited syndromes and germline mutations of CDH1 gene that encodes E-cadherin. It
is autosomal dominant mutation, results in diffuse, aggressive, poorly differentiated GC that does
not stay in 1 area.
Other cancers of the stomach include: Li-Fraumeni syndrome (p53 mutation), leiomyosarcoma, non-
Hodgkin lymphoma, gastrointestinal stromal tumor (GIST), carcinoids and have different treatments
Symptoms
The disease becomes symptomatic in advanced stage
Problems in digestion
Trapped wind
Iron-deficiency anemia
Heartburn
Early satiety
Nausea
Abdominal pain
Weight loss
Hematemesis, melena and hematochezia(profuse bleeding)- emergencies!!!
Screening and diagnosing GC
Full blood count, HgB, serum albumin levels, liver function tests
Noninvasive test for H. Pylori : serum IgG, urea breath test, fecal test
(latter 2 have 95% accuracy)
Proximal endoscopy/gastroscopy with biopsy
Endoscopic ultrasound: evaluates depth of tumor infiltration/layers
involved
Multidetector CT, contrast-enhanced CT or PET CT scan for nodal
involvement
MRI
Barium x-ray
Pathology: IHC/ FISH testing for CDH1 mutation, HER2, microsatellite
instability, Ki-67
Tumor markers: Carcinoembryonic antigen (CEA) is elevated in 40-50%-
monitor response, Alpha fetoprotein and CA 19-9
Staging
Early GC or the superficial form is
limited to the mucosa and submucosa and
can appear as a small circumscribed,
sometimes ulcerated thickening of the
gastric wall
Advanced GC involves the muscularis
propria or beyond and can be polypoid,
ulcerating, ulcerating infiltrating and
diffusely infiltrating (linitis plastica).
TNM staging: 5 stages, 0 being in
situ/only confined to epithelium
Management
In stages I to III, resection is indicated and
resectable if the tumor does not go beyond
serosa
Complete surgical resection and
lymphadenectomy is the only chance for cure
Partial or total gastrectomy
Sleeve gastrectomy or Roux-en-Y
Neoadjuvant/adjuvant chemotherapy
Radiotherapy is justified in cases of
unresectable GC with anemia, and/or in the
cases with pyloric or cardiac obstruction
Chemotherapy
A new standard of care was also recently established by the presentation of the
German FLOT4 study. Reportedly it prolonogs overall survival from 35 to 50
months. Docetaxel, oxaliplatin, leucovorin/folic acid, and 5-fluorouracil are the
drugs used, usually 3-4 cycles before the surgery and 3-4 cycles after.
Patients ECOG : 0-1
Take patients blood every time prior to chemo
Order differential blood count, monitor HgB, liver enzymes, serum creatinine and urea; blood pressure
Chemotherapy may sometimes trigger internal bleeding(from the tumor site). In that case give IV fluid first.
Then order blood transfusion, especially if hemoglobin is <9g/dl (90 g/l) with risk for adverse CV outcomes or
8g/dl
Acceptable blood range: Neutrophils >1.5, platelets >100
Side Effects: Myelosuppression, alopecia, mucositis, diarrhoea, neurotoxicity, allergic reactions, coronary artery
spasm, palmar/plantar erythema, nausea, vomiting, stomatitis, loss of appetite, fatigue, renal impairment,
infection, ovarian failure/infertility, auditory impairment
Give supportive therapy:
Granulocyte stimulating factor (subcutaneously)
Treat nausea (antiemetics e.g. Metoclopramide)
Treat mucositis
Treat constipation
Provide analgetics if needed
Targeted therapy/immunotherapy in metastatic
setting
Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the
tissue environment that contributes to cancer growth and survival.
Targeted therapy for stomach cancer includes:
HER2-targeted therapy if GC is HER2 positive
Anti-angiogenesis therapy
Immunotherapy: PD-L1 immune checkpoint inhibitor; FDA approved Keytruda
Post-surgical complications and management
Anastomosis leak
Esophageal reflux disease
Ulcers/inflamamation
Esophageal stenosis
Barret*s esophagus
Vitamin B12 deficiency is an inevitable
complication (lack of intrinsic factor). B12 shots
monthly
Anemia
Malabsorption
Calcium deficiency- add vitamin D
Vitamin C
Follow up
Diet
Thank you for attention!
