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Gastric Cancer is one of the most frequent malignant tumors
in El Salvador, which is responsible for numerous causes of deaths per
year.
| Internationally: Adenocarcinoma of the stomach is the second
most common cancer worldwide. |
.Risk for gastric (stomach) cancer increases with
age. Evidence suggests that high salt intake, a diet low in fresh fruits
and vegetables, and infection with H. pylori are associated with an
increased risk of gastric cancer; whereas diets high in whole grain cereals,
carotene, and
green tea are associated with a reduced risk of this cancer.
Early detection is often difficult because the symptoms are often
vague. They include weakness, fatigue, decreased appetite, indigestion,
abdominal pain and bloating. The detection of blood in the stool may indicate
a gastric cancer, but can also be caused by many other things. People
with continuous gastric symptoms should seek medical attention.
Gastric cancer is one of the most frequent cancers not only in
El Salvador but also in the majority of the countries of Latin America
as well as in Japan.
| Gastric Cancer is the second most common cause
of cancer-related death in the world. Many Asian countries, including
Korea, China, Taiwan, and Japan, have very high rates of gastric cancer.
More than 22,000 new cases will be diagnosed this year in the United
States, making gastric cancer the fourteenth most common cancer in
this country. while in the US, the incidence of stomach cancers has
actually decreased over the past decade, accounting for approximately
21,000 new cases and 13,000 cancer-related deaths last year. Some
of this decrease may be attributable to widespread antimicrobial therapy
for eradication of Helicobacter pylori, which harbors
a strong association with gastric cancer and the decreased use of
salted and smoked foods. |
| Other risk factors associated with increased incidence of
gastric cancers include cigarette smoking, alcohol abuse, and nitrosoamine
intake. Benign adenomas, which are the gastric counterpart of colorectal
adenomas, are also associated with a risk of progression to cancers.
The vast majority (90-95%) of gastric cancers are gland-forming adenocarcinomas.
Other less common tumors of the stomach include lymphomas, carcinoids
and gastric stromal tumors. Epidemiologic studies have shown that
the two major histologic subtypes of gastric adenocarcinomas - the
intestinal (well differentiated) type and diffuse (poorly differentiated)
type - arise by distinct pathways. The intestinal type is strongly
associated with Helicobacter pylori, and usually arises on a backdrop
of chronic gastritis, gastric atrophy, and intestinal metaplasia.
In contrast, poorly differentiated adenocarcinomas are usually not
associated with these changes.Clinically, the latter often present
with diffuse thickening of the stomach wall, rather than a discernible
mass (linitis plastica). The intestinal adenocarcinomas have a better
prognosis than the diffuse variant, most of which have spread beyond
the confines of the stomach at the time of diagnosis. As with other
cancers, stage is the most important determinant of outcome. In Japan,
intensive screening modalities have led to the emergence of a new
variant called early gastric cancers, in which the primary tumor is
restricted to the mucosa or submucosa, irrespective of metastasis,
at the time of detection. |
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| Endoscopic and video clip view of Doughnut shaped
Gastric Carcinoma of the antrum in a 44 year- old male .Click
on the image to download the video clip to appreciate in full screen
wait to be downloaded and press Alt and Enter. |
Obtaining a high curability rate depends on early diagnosis. When diagnosed
in an early phase Gastric Cancer is almost completely curable. The
major importance of Endo- scopy, is the possibility of early detection.
With Endoscopy, and specially with the introduction of high resolution
videoendoscopes We now count with a diagnostic tool that permits exact
and complete visualization of the upper G.I. tract or Colon, including
the possibility to store the film on Video tapes of different formats
like VHS, UMATIC, BETACAM or DIGITALIS.
Unfortunately, patients who have stomach cancer rarely have symptoms in
the early stages of the disease. This is one of the reasons why stomach
cancer is so difficult to detect early.
The signs and symptoms of stomach cancer include:
Unintended weight loss and lack of appetite.
Abdominal pain.
Vague discomfort in the abdomen, usually above the umbilicus (navel).
A sense of fullness in the upper abdomen, just below the chest bone after
eating a small meal. Doctors call this early satiety.
Heartburn, indigestion, or ulcer-type symptoms Nausea Vomiting, with or
without blood.
Swelling of the abdomen due to accumulation of fluid and cancer cells.
Doctors call this malignant ascites.
Gastric cancer is the second most common cause of cancer-related
death in the world. Many Asian countries, including Korea, China,
Taiwan, and Japan, have very high rates of gastric cancer. More than
22,000 new cases will be diagnosed this year in the United States,
making gastric cancer the fourteenth most common cancer in this country.
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| Age: Most patients are elderly at diagnosis. The
median age at diagnosis is 65 years (range 40-70 y). The gastric cancers
that occur in younger patients may represent a more aggressive variant.
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Mucosectomy EMR: Endoscopic
Treatment for early gastric carcinoma.
Endoscopic mucosal resection, also known as endoscopic resection,
is defined as the resection of
a fragment of the digestive wall including the mucosal membrane
and the muscularis mucosae. This resection most frequently
removes a part or even all of the submucosa. Mucosectomy is
a curative endoscopic procedure which is for intramucosal
cancers (also called in situ cancers).Treatments for stage
IA ( T1N0 ). EMR is indicated for patients with small mucosal
cancer with no lymph
node metastases.
Weight loss and persistent abdominal pain are the most
common symptoms at initial diagnosis.
Weight loss usually results from insufficient caloric
intake rather than increased catabolism, and may be attributable
to anorexia, nausea, abdominal pain, early satiety, and/or
dysphagia.
The abdominal pain tends to be vague and mild early
in the disease, but more severe and constant as the
disease progresses.
Dysphagia is a common presenting symptom in patients
with cancers arising in the gastric cardia or at the
esophagogastric junction.
Patients may also present with nausea or early satiety
from gastric outlet obstruction or gastric stasis related
to tumor infiltration of the stomach wall. Occult gastrointestinal
bleeding with or without iron deficiency anemia is common,
while overt bleeding (ie, melena or hematemesis) is
seen in only 20 percent of cases. The presence of a
palpable abdominal mass is the most common physical
finding and generally indicates long-standing, advanced
disease
A pseudoachalasia syndrome may occur as the result of
involvement of Auerbach's plexus due to local extension
or to malignant obstruction near the gastroesophageal
junction. For this reason, gastric cancer needs to be
considered in the differential diagnosis for older patients
presenting with achalasia |
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Prognosis and staging
The prognosis is related to the stage of the disease at the
time of diagnosis and to the histologic grade of the carcinoma.
Pathologic staging is based on the tumor, nodes, and metastases
(TMN) stage.
• T stage - Extent of penetration through the gastric
wall
o Tis - Carcinoma in situ, intraepithelial tumor
o T1 - Tumoral extension to submucosa
o T2 - Tumoral extension to the muscularis propria or subserosa
o T3 - Tumoral penetration of the serosa
o T4 - Tumoral invasion of the adjacent organs
• N stage - Number and site of draining lymph nodes involved
(see also N staging below)
o N0 - No lymph nodes involved
o N1 - Metastases in 1-6 regional lymph nodes
o N2 - Metastases in 7-15 regional lymph nodes
o N3 - Metastases in >15 regional lymph nodes
• M stage - Presence of metastases
o M0 - No distant metastases
o M1 - Distant metastases
Staging and 5-year survival
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| Stage |
TNM Stage |
5-Year Survival |
| 1 |
T1N0M0, T1N1M0, or T2N0M0 |
88% |
| 2 |
T1N2M0, T2N1M0, or T3N0M0 |
65% |
| 3a |
T2N2M0, T3N1M0, or T4N0M0 |
35% |
| 3b |
T3N2M0 |
35% |
| 4 |
T4N1-3M0, TxN3M0, or TxNxM1 |
5% |
*Tx indicates any T stage; Nx, any N stage.
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SURGICAL TREATMENT OF GASTRIC CANCER
SUMMARY: The management of stomach cancer patients
is discussed under the following headings: incidence, etiology (cancer
developing after previous operation for benign ulcer), epidemiology,
pathology (fungating tumors; ulcerating tumors; diffuse or infiltrating
tumors), histology (histologic classification; Broders' classification;
site of origin; spread of gastric carcinoma; extension of carcinoma
from other organs to the stoma), symptoms, physical examination, roentgenologic
diagnosis (polypoid tumors; infiltrative cancer; the peptic ulcer
syndrome; cancer of the stomach after gastric surgery; demonstration
of metastases), gastroscopy (endoscopy), cytology, laboratory studies,
exploratory laparotomy (preoperative evaluation; evidence of metastasis;
preparation of the patient for operation), definitive treatment (surgical
treatment), results (TNM classification; factors affecting survival),
management of the patient with incurable gastric cancer (effectiveness
of noncurative operations in affording palliation; duration of life;
relief of symptoms; mortality rate; long-term results; prospects for
the future), malignant tumors of the stomach other than carcinoma
(malignant lymphoma; end results), and nonlymphomatous sarcomas (diagnosis;
treatment; end results). The subheading dealing with diffuse or infiltrating
tumors gives consideration to diffusely infiltrating cancer, superficial
spreading carcinoma, and linitis plastica. That dealing with histologic
classification gives consideration to carcinoma in situ, adenocarcinoma,
and gelatinous or mucoid adenocarcinoma. That dealing with endoscopy
gives consideration to Type I (protruded type), Type II (superficial
type), and Type III (excavated type) tumors. That dealing with surgical
treatment gives consideration to local excision, surgical treatment
of benign gastric ulcer, and surgery for palliation. That dealing
with diagnosis of nonlymphomatous sarcomas gives consideration to
roentgenologic diagnosis, gastroscopy, and cytology.
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The operation you have to remove your stomach
cancer will depend on where in the stomach the cancer is. You may
be offered a
Partial gastrectomy
Total gastrectomy
Oesophagogastrectomy |
| These are all major operations and it takes time to get over them.
Your doctor must be sure you are fit enough to get through a long
operation and anaesthetic and make a good recovery.
If your cancer has spread to another organ, you are less likely
to be offered any of these operations as they will not cure your
cancer. But an operation to remove the tumour may be done if it
is blocking your stomach.
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Partial gastrectomy
If your cancer is at the end of the stomach that connects with the
duodenum you may have only part of your stomach removed. This is called
a partial gastrectomy. After the operation you will have a much smaller
stomach but the valve (cardiac sphincter) between your gullet and
stomach will still be there. The scar from the operation will be across
your abdomen. There are 2 different types of this operation. They
are called Bilroth 1 and Bilroth 2. Bilroth 1 operations are not done
very often these days.
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Removing lymph nodes
During your operation you will have all of the lymph nodes close to
the stomach removed. This is because they may contain cancer cells
that have broken away from the main cancer. Taking them out reduces
the risk of your cancer coming back in the future.
It is not yet clear from clinical trials whether removing more
lymph nodes from the area surrounding the stomach reduces the risk
of the cancer coming back even further. Doctors are waiting for
the results of a clinical trial looking at this in detail.
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What happens if my stomach is removed?
If only part of your stomach is removed you will have to eat small
amounts of food more often, at least for a while, until your system
learns to cope with a smaller stomach capacity. The stomach that is
left will gradually stretch so that you can eat more at a time.
If your whole stomach is removed, you may eventually return to
eating normally, but this will take longer. You will also have to
have injections of vitamin B12 for the rest of your life to prevent
anaemia and nerve problems.
It is common to have diarrhoea for some months after stomach surgery.
This can be very upsetting and you may feel weak for a time. |
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66 year old female who complained of epigastric pain
for about six months.
We performed an upper G.I. tract Video Endoscopy and obtained an image
displayed as a small nodule with a tiny ulcer. The histopatologic
study revealed a Gastric Carcinoma in an early stage.
Please
click on the image to download the video clip .
To appreciate the video we recommended that you configure the media
player in repeat and when the video is running press Alt
+ Enter for Full Screen. |
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| Patient with advanced gastric adenocarcinoma. CT, transverse cross-section,
showing ascitis and hepatic metastasis. |
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| Ulcerated Gastric Carcinoma
of the gastric corpus.
To optain more endoscopic details see the video clip by clicking
on the image. |
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54 years old male. Gastric endoscopy reveled gastric carcinoma
of the corpus.
This tumor is initially asymptomatic. Advanced cases present with
abdominal discomfort or pain, anorexia, nausea, vomiting, anemia due
to loss of blood, dysphagia, weight loss and changes in the bowel
habits. |
62 year old woman with anemia and weight loss, more than 20 pounds
Large carcinoma of the antrun causing hight-grade stenosis
57 years old female who had a history of previous upper gastrointestinal
endoscopies over several years, performed elsewhere.. On her first visit
to our clinic she complained of epigastric pain and disuria. A severe
urinary tract infection was detected and ciprofloxacine was prescribed.
The next morning an upper gastrointestinal Endoscopy was performed and
a tablet of ciprofloxacine taken at 3 am, was found at the cardias (the
endoscopy was performed at 9.11 am) The tablet still being in the esophagus
is not considered normal since foods and medicines travel immediately
to the stomach, after being ingested. Thus suspicion of a disease in this
region is awakened. (See next photography. ).
Same case as previous one, Ulcerated Gastric Carcinoma of the
fundus, retroflexed maneuver.
Infiltrating Gastric carcinoma of the body, that resembles erosive
gastritis.
Brother of a former President of the Republic of El Salvador.
Click on the image to download the video clip.
Ulcerated Gastric Carcinoma at the gastric angle.
Doughnut shaped Gastric carcinoma that obstructed the antrum.
Gastric carcinoma of the fundus
Ulcerated Gastric Carcinoma of the antrum.
94 years old female, Cauliflower like Gastric Carcinoma
77 yeas old male, Gastric Carcinoma of the body.
70 years old male with ulcerated Gastric carcinoma of
the body.
Click on the image to download the video clip.
81 years old male, Antrum Gastric Carcinoma
58 years old female, Ulcerated Carcinoma of the Antrum
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62 years old Female, Carcinoma of Gastric body. A nodule and irregularity
at the union of the gastric fold is observed.
84 years old male. Ulcerated Gastric Carcinoma of
fundus with signet ring cells.
Photography of Infiltrating and ulcerated Gastric Carcinoma , 70 years
old male.
64 years old male, Ulcerated Gastric Carcinoma
that infiltrate the Gastric antrum.
50 years old female, weight loss of 20 twenty pounds,
doughnut shapde Antrum Gastric Carcinoma.
65 years old male with small irregular ulceration at the
Gastric body, histopatologic study revealed gastric cancer
signet ring cells.
76 years old male who came with his family Doctor
asking for a gastric endoscopy. Enormous tumor of the corpus and fundus
in antrum area. There are gastric polyps, reason why it think that this
carcinoma is degenerated from a polyp " The theory adenoma Carcinoma"
Female 67 years old that had been treated by his internist Doctor, Complaining
of sensation of " small ball " in epigastric. She was sent to undergo
an abdominal ultrasound which was negative. Later a barium enema examination
was performed with emphasis on the hepatic angle, which was negative.
Therefore the internist prescribed a topical oiment for this sensation.
As she did not improve the patient arrived at my clinic, a mass of great
size was felt .
An upper endoscopy examination was performed and a enormous adenocarcinoma
was found. At time of surgery the tumor was considered inoperable due
to its advanced stage of the disease. The ultimate decision as to operability
of the tumor is made at the time of laparatomy.
45 years old Female with Carcinoma of the antrum with obstructive signs.
Nevertheless the Endoscopic diagnostic was delayed because patient had
multiple antiulcer prescriptions for over six months with different doctors
and different treatments without any special medical examination like
endoscopy etc.
This clinical history is repeated frequently since most of these people
believe that they have an ulcer or gastritis or are being told so by their
doctor or any other person, without having undergone any special exams
(i.e. endoscopy). An ulcer or gastritis treated with modern medicines,
improves at the present time in three or four days, and cure is expected
within one month to six weeks..
51 years old male, brother of prestigious pediatric surgeon who
ask to perform an upper endoscopy, we found these antrum carcinoma
the image display above is after one years of the diagnosis, carcinoma
was
inoperable the image is after Chemotherapy and radiations.
Post surgical status of previous case.
Gastric Carcinoma that causes antrum obstruction.
Gastric carcinoma that causes antrum obstruction.
72 years old male with gastric carcinoma of the fundus that causes
bleeding.
73 years old male with small nodule at the antrum. The biopsy
displayed signet ring carcinoma.
78 years old female, Gastric Carcinoma that makes obstruction
at the antrum, bile reflux is observed.
73 years old male with enormous ulcerated gastric carcinoma
of the antrum and gastro angle.
50 years old male with obstructed Gastric Carcinoma
76 years old female with obstructed Gastric Carcinoma of the
Cardias.
69 years old male with progressive dysphagia,weigh loss of twenty
pounds and sialorrea, Carcinoma of the cardias and gastric fundus.
See next images.
Retroflexed manner same case of the previous image, necrotizing
gastric carcinoma of the fundus
Same case of the previous images, carcinomatous band of the corpus.
Advanced Gastric Carcinoma
35 years old Salvadorean Female who was living in the United State
presented jaundice, diagnosed as hepatitis A she was managed on outpatient
basis for fifteen days, during which she worsened and was hospitalized
patient came to El Salvador for a second opinion without providing much
patient
information.
Image of the previous case. Gastric Carcinoma that infiltrates entire
stomach. Fundus is observed at the retroflexed maneuver.
Photograph of the previous case. The corpus is infiltrated and ulcerated.
Same case as above. Carcinoma with elevated margin in the
area of the antrum.
60 years old male, extensive Gastric Carcinoma.
Same case as above. Extensive Gastric Carcinoma.
75 years old female, Ulcerated Gastric Carcinoma. In the area
of the lesser curvature.
67 yeas old female, prepyloric carcinoma.
47 years old male with gastric carcinoma of the antrum.
61 years old male, gastric carcinoma causing high-grade stenosis.
Several ulcers are observed at the corpus and fundus.
Gastric Carcinoma of the Cardias
69 years old male, was seen in the emergency room of the Social security
Hospital for upper GI tract bleeding and was diagnosed as having erosive
gastritis
the patient condition worsen and he ask for a second opinion.
Note: It is necessary to always perform a follow-up endoscopy after initial
emergency room gastroscopy, when dealing with upper GI track hemorrhage
because the blood will diminish the sensitivity of the emergency room
procedure.
Same case as above, Gastric Carcinoma of the cardias extending
into the esophagus, inversion maneuver.
72 years old male with an extensive Gastric Carcinoma.
Patient have long history of dyspepsia, after developing obstructive symptoms
patient consulted general practitioner who refer patient to me for endoscopy.
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