Stomach Cancer

Facts about stomach cancer  

Q1 What is stomach cancer? 

Stomach cancer, also called gastric cancer, starts in the stomach.

After food is chewed and swallowed, it enters the esophagus, a tube that carries food through the throat and chest to the stomach. The esophagus joins the stomach at the gastroesophageal (GE) junction, which is just beneath the diaphragm (the thin sheet of breathing muscle under the lungs). The stomach is a sac-like organ that holds food and starts to digest it by secreting gastric juice. The food and gastric juice are mixed and then emptied into the first part of the small intestine called the duodenum.

Stomach cancer is a malignant tumor that starts in cells of the stomach

Q2 What causes the stomach (gastric) cancer? 

Helicobacter pylori infection

Helicobacter pylori (H. pylori) infection is the strongest and most important risk factor for developing stomach cancer.

Smoking

Family history of stomach cancer

If you have a first-degree relative who has had stomach cancer, you have a higher risk of developing stomach cancer.

Inherited genetic conditions

Hereditary diffuse gastric cancer (HDGC) Familial adenomatous polyposis (FAP) Lynch syndrome (also called hereditary non-polyposis colorectal cancer, or HNPCC) Peutz-Jeghers syndrome

Certain stomach conditions

Chronic atrophic gastritis Adenomas, or adenomatous polyps Ménétrier disease I Pernicious anemia

Previous stomach surgery

Epstein-Barr virus

Exposure to ionizing radiation

Working in the rubber industry

Type A blood

Smoked, cured and processed meats

Q 3 What are the types of stomach cancer?

Adenocarcinoma

Most (about 90% to 95%) cancers of the stomach are adenocarcinomas. Stomach cancer or gastric cancer almost always is an adenocarcinoma. These cancers develop from the cells that form the innermost lining of the stomach (the mucosa).

Lymphoma

A gastrointestinal stromal tumor (GIST)

Carcinoid tumor

Q 4 What are the symptoms of stomach cancer? 

The signs or symptoms of stomach cancer include:

abdominal pain or discomfort (maybe vague or mild)

weight loss

fatigue

changes indigestion, including loss of appetite, feeling full after a small meal (early satiety), heartburn (indigestion) or nausea

difficulty swallowing or pain when swallowing

vomiting, with or without blood

anemia

abdominal bloating, especially after eating

blood in the stool

jaundice (the skin and whites of the eyes become yellow and urine is dark yellow)

the buildup of fluid in the abdomen (called ascites)

a lump in the abdomen that can be felt during a physical exam

a lump on the ovary (Krukenberg tumor)

a lump in the pelvis (Blumer shelf), which may be felt during a rectal exam

a lump in the area of the belly button, or navel (a swollen lymph node, sometimes called Sister Mary Joseph node)

a lump above the left collar bone (1 or more swollen lymph nodes, sometimes called Virchow node)

a lump in the left armpit (a swollen lymph node)

darkening of the skin on body folds and creases (acanthosis nigricans)

wart-like growths on the skin (seborrheic keratoses)

A word of caution

It’s important to remember that these symptoms can be caused by many different conditions and are not usually the result of cancer.

These symptoms are very common and can be caused by many different conditions. Having them does not definitely mean you have stomach cancer.

But it’s important to get them checked by a GP. This is because if they’re caused by cancer, finding it early makes it more treatable.

Q 5 How is stomach cancer diagnosed? 

Health history and physical exam

Upper endoscopy (also called esophagogastroduodenoscopy or EGD) is the main test used to find stomach cancer. It may be used when someone has certain risk factors or when signs and symptoms suggest this disease may be present.

During this test, the doctor passes an endoscope, which is a thin, flexible, lighted tube with a small video camera on the end, down your throat. This lets the doctor see the lining of your esophagus, stomach, and the first part of the small intestine. If abnormal areas are seen, biopsies (tissue samples) can be taken using instruments passed through the endoscope.

A word of caution

  • There is a common myth that taking biopsy leads to the spread of cancer cells in the body. This is not true. Taking a biopsy does not lead to the spread of cancer cells in the body.
  • Biopsy confirms that it is cancer and not infection and also helps in knowing the type of cancer so that further treatment can be planned accordingly.
  • Ultrasound: It is the 1st investigation to be done for any abdominal problem.
  • When ultrasound suspects pancreatic cancer, you’ll usually be referred for further investigation.
  • Contrast-enhanced CT/MRI scan of the abdomen
  • PET-CT scan
  • Blood tests– To assess the state of liver, kidneys and bone marrow
  • Chest X-ray– To check if cancer has spread to the lungs or not

Q 6 What is stomach cancer staging?

Staging is a measurement of how far cancer has spread.

After all the tests have been completed and the results are known, it should be possible to predict what stage the cancer is. The higher the stage, further cancer has spread.

Stage 0 (carcinoma in situ)

The tumor is only within the epithelium of the inner lining (mucosa) of the stomach. Doctors may describe it as high-grade dysplasia, which is a precancerous condition.

Stage 1A

The tumor has grown into the layer of connective tissue in the mucosa, the layer of muscle in the mucosa, or the layer of connective tissue that surrounds the mucosa (submucosa).

Stage 1B

One of the following applies:

The tumor has grown into the layer of connective tissue or muscle in the mucosa or into the submucosa. Cancer has also spread to 1 or 2 lymph nodes near the stomach.

The tumor has grown into the thick muscle layer of the stomach (muscularis propria).

Stage 2A

One of the following applies:

The tumor has grown into the layer of connective tissue or muscle in the mucosa or into the submucosa. Cancer has also spread to 3 to 6 lymph nodes near the stomach.

The tumor has grown into the muscularis propria. Cancer has also spread to 1 or 2 lymph nodes near the stomach.

The tumor has grown into the area between the muscular propria and the outer covering of the stomach (serosa). This area is called the subserosa.

Stage 2B

One of the following applies:

The tumor has grown into the layer of connective tissue or muscle in the mucosa or into the submucosa. Cancer has also spread to 7 to 15 lymph nodes near the stomach.

The tumor has grown into the muscularis propria. Cancer has also spread to 3 to 6 lymph nodes near the stomach.

The tumor has grown into the subserosa. Cancer has also spread to 1 or 2 lymph nodes near the stomach.

The tumor goes through the serosa.

Stage 3A

One of the following applies:

The tumor has grown into the muscularis propria. Cancer has also spread to 7 to 15 lymph nodes near the stomach.

The tumor has grown into the subserosa. Cancer has also spread to 3 to 6 lymph nodes near the stomach.

The tumor goes through the serosa. Cancer has also spread to 1 to 6 lymph nodes near the stomach.

The tumor has grown into nearby organs or areas, such as the spleen, colon, small intestine, liver, diaphragm, or abdominal wall.

Stage 3B

One of the following applies:

The tumor has grown into the layer of connective tissue or muscle in the mucosa, the submucosa or the muscular propria. Cancer has also spread to 16 or more lymph nodes near the stomach.

The tumor has grown into the subserosa or it goes through the serosa. Cancer has also spread to 7 to 15 lymph nodes near the stomach.

The tumor has grown into nearby organs or areas. Cancer has also spread to 1 to 6 lymph nodes near the stomach.

Stage 3C

One of the following applies:

The tumor has grown into the subserosa or it goes through the serosa. Cancer has also spread to 16 or more lymph nodes near the stomach.

The tumor has grown into nearby organs or areas. Cancer has also spread to 7 or more lymph nodes near the stomach.

Stage 4

Cancer has spread to other parts of the body (called distant metastasis), such as to the lungs, bone, peritoneum or omentum. This is also called metastatic stomach cancer.

A word of caution 

The above staging is a simplified version for your basic understanding. The reader is advised to follow the TNM staging system developed by the American Joint Committee on Cancer (AJCC) in which 

  • T stands for the size and location of the primary tumor
  • N stands for nodes. It tells whether cancer has spread to the nearby lymph nodes
  • M stands for metastasis. It tells whether cancer has spread to distant parts of the body

Q 7 How is stomach cancer treated? 

Stomach cancer is often curable if it’s diagnosed at an early stage.

When deciding treatment options for a particular patient, the doctor will consider the following factors and will decide individual treatment plan:

  • The size of the cancer
  • The stage of the cancer
  • The location of the cancer
  • Your overall health and ability to recover from surgery, radiation therapy or chemotherapy
  • Your personal preferences

Following are the general guidelines but treatment may vary from patient to patient:

Surgery

Surgery is often used to treat stomach cancer. The type of surgery you have depends mainly on the size and location of the tumor.

Endoscopic mucosal resection may be done to treat early stomach cancer.

Laparoscopic staging and exams are done to see if cancer has spread from the stomach to other parts of the abdomen, such as the liver or pancreas.

Limited surgical resection removes a section of the stomach wall containing the tumor along with a healthy margin around the tumor to treat early stomach cancer.

Subtotal (partial) gastrectomy

This operation is often recommended if the cancer is only in the lower part of the stomach. It is also sometimes used for cancers that are only in the upper part of the stomach.

Only part of the stomach is removed, sometimes along with part of the esophagus or the first part of the small intestine (the duodenum). The remaining section of the stomach is then reattached.

Total gastrectomy

This operation is done if cancer has spread throughout the stomach. It is also often advised if the cancer is in the upper part of the stomach, near the esophagus.

The surgeon removes the entire stomach, nearby lymph nodes, and omentum, and may remove the spleen and parts of the esophagus, intestines, pancreas, or other nearby organs. The end of the esophagus is then attached to part of the small intestine. This allows food to move down the intestinal tract.

Gastrectomy is the most common surgery to treat stomach cancer. A gastrectomy is the surgical removal of all or part of the stomach through an incision in the abdomen.

Lymph node dissection is often done along with a gastrectomy to remove lymph nodes around the stomach.

Palliative surgery may be done to relieve the symptoms of advanced stomach cancer such as bleeding, pain or not being able to eat. Palliative surgery may include stomach bypass surgery (to change the flow of food or fluids around a stomach tumour that is blocking the stomach or esophagus), a stent or feeding tube placement, or an endoscopic tumor ablation (laser surgery given with the aid of an endoscope).

Palliative surgery for unresectable cancer

For people with unresectable stomach cancer, surgery can often still be used to help control cancer or to help prevent or relieve symptoms or complications.

Subtotal gastrectomy: For some people who are healthy enough for surgery, removing the part of the stomach with the tumor can help treat problems such as bleeding, pain, or blockage in the stomach, even if it does not cure cancer. Because the goal of this surgery is not to cure cancer, nearby lymph nodes and parts of other organs usually do not need to be removed.

Gastric bypass (gastrojejunostomy): Tumors in the lower part of the stomach may eventually grow large enough to block food from leaving the stomach. For people healthy enough for surgery, one option to help prevent or treat this is to bypass the lower part of the stomach. This is done by attaching part of the small intestine (the jejunum) to the upper part of the stomach, which allows food to leave the stomach through the new connection.

Endoscopic tumor ablation: In some cases, such as in people who are not healthy enough for surgery, an endoscope (a long, flexible tube passed down the throat) can be used to guide a laser beam to vaporize parts of the tumor. This can be done to stop bleeding or help relieve a blockage without surgery.

Stent placement: Another option to keep a tumor from blocking the opening at the beginning or end of the stomach is to use an endoscope to place a stent (a hollow metal tube) in the opening. This helps keep it open and allows food to pass through it. For tumors in the upper (proximal) stomach, the stent is placed where the esophagus and stomach meet. For tumors in the lower (distal) part of the stomach, the stent is placed at the junction of the stomach and the small intestine.

Feeding tube placement: Some people with stomach cancer are not able to eat or drink enough to get adequate nutrition. A minor operation can be done to place a feeding tube through the skin of the abdomen and into the distal part of the stomach (known as a gastrostomy tube or G tube) or into the small intestine (jejunostomy tube or J tube). Liquid nutrition can then be put directly into the tube.

Chemotherapy

Chemotherapy may be used to treat stomach cancer at any stage. Radiation therapy may be given at the same time as chemotherapy (chemoradiation).

Radiation therapy

Radiation therapy may be used to treat stomach cancer at any stage. The type of radiation therapy used most often is external beam radiation therapy. Chemotherapy may be given at the same time as radiation therapy (chemoradiation).

Targeted therapy

Trastuzumab (Herceptin) and ramucirumab (Cyramza) are targeted therapy drugs used to treat advanced, metastatic, or recurrent stomach cancer.