Gastric cancer
The stomach is part of the digestive system. Food passes through the esophagus into the stomach at the level of the diaphragm, which is the breathing muscle that separates the abdomen from the chest. The stomach extends from the diaphragm to the duodenum, which is the first portion of the small intestine.
Cancer of the stomach is called gastric cancer. Gastric adenocarcinoma is the most common cancer of the stomach and it arises from the cells (columnar epithelium) lining the surface of the stomach. The primary risk factor associated with gastric cancer is infection with the bacterium, Helicobacter pylori (H. pylori). H. pylori can be treated with antibiotics, which may reduce the risk of gastric cancer.(1)
There has been a marked decline in the incidence of gastric cancer in the United States and many other industrialized nations over the past 20-30 years. However, there has been an increase in cancers arising at the junction of the esophagus with the stomach. Approximately 21,000 new cases of gastric cancer are diagnosed in the United States each year, with approximately 10,500 yearly deaths from gastric cancer.(2)
Gastric cancer is more common and is a major cause of cancer-related death in Asian countries such as Korea, China, Taiwan and Japan. Thus, much of the knowledge about treatment, especially surgery, comes from these countries. The incidence of gastric cancer is so high in these countries that they perform routine screening by esophagoscopy for detection of early gastric cancer. Early detection programs, such as those implemented in Japan, are not practiced elsewhere in the world because of the lower incidence of gastric cancer. For this reason, gastric cancer is detected at a later stage (extent of spread) in the U.S. and Europe than in Japan.
Surgery is the primary treatment of gastric cancer. Two main factors affect outcome following surgery for gastric cancer, the depth of the penetration of the primary cancer into the wall of the stomach and the presence or absence of spread of cancer to regional or adjacent lymph nodes. The site of the primary cancer also influences outcome, as upper stomach cancers are associated with a worse outcome than cancers of the middle and lower stomach.
STAGING OF GASTRIC CANCER
If possible, it is important to determine how much the cancer has spread before initiating treatment in order to select the best treatment option. Of particular concern is the presence of cancer in lymph nodes, spread of cancer to distant sites or local extension of cancer into surrounding structures, all of which might make attempts to remove all of the cancer with surgery impossible. Unfortunately, in many cases the true extent of spread of gastric cancer can only be determined at the time of surgical resection. Frequently, more advanced cancer is found during surgery than was detected through diagnostic procedures.
Computed Tomography (CT): Patients with gastric cancer generally undergo (CT) scans of the chest, upper abdomen, and sometimes the pelvis.
Gastroscopy: A gastroscopy is an examination performed through an endoscope, which is a flexible tube inserted through the esophagus that allows the physician to visualize, photograph and biopsy (sample) the cancer. All patients have a gastroscopy with a biopsy to determine the histology or appearance of the cancer under the microscope.
Endosonography: Endosonography refers to an ultrasound test performed through an endoscope. Ultrasound tests utilize sound waves to detect different densities of tissue, including cancer. Endosonography can detect spread of cancer into various layers of the stomach, adjacent organs and lymph nodes.
Laparoscopy: Laparoscopy is a procedure that involves the insertion of an endoscope through a small incision in the abdomen. Laparoscopy is an important tool for staging and has proven to be more reliable than CT scanning in detecting spread of cancer to the liver and the lining of the abdomen (peritoneum). Ultrasonography can be performed through the laparoscope, thereby improving the accuracy of diagnosis. Another procedure, called peritoneal lavage, involves the infusion of fluid into the abdomen. Peritoneal lavage can increase the accuracy of diagnosis of peritoneal spread. Typically, patients who have cancer cells in the fluid from peritoneal lavage have a worse outcome.
Positron Emission Tomography (PET): Positron emission tomography (PET) scanning may also be used in the preoperative staging of gastric cancer. For gastric cancer staging, combined PET-CT tends to produce better results than PET alone.
The current methods of clinical staging of patients with gastric cancer are not perfect and are constantly changing as new and more reliable tests are developed. At this point, the results of surgery are much more reliable in determining the extent of cancer spread than tests performed before surgery. In order to learn more about the most recent information available concerning the treatment of gastric cancer, click on the appropriate stage.3
Stage 0: Cancer in situ is cancer that is limited to the surface layer of cells lining the stomach, which is called the epithelium.
Stage IA: Cancer invades beneath the surface layer of cells, but not into the muscle wall and there is no lymph node or distant spread of cancer.
Stage IB: Cancer invades beneath the surface layer of cells, with spread to 1-2 lymph nodes, or invades into the muscle of the wall of the stomach without regional lymph node or distant spread of cancer.
Stage II: Cancer invades beneath the surface, with spread to 3 or more lymph nodes; into the muscle of the wall of the stomach, with spread to 1-6 lymph nodes; into the next-to-the-last layer of the stomach, with spread to no more than 2 lymph nodes; or into the outermost layer of the stomach but not to the lymph nodes.
Stage III: Cancer has spread to adjacent structures and/or regional lymph nodes.
Stage IIIA: Cancer invades the muscle of the wall of the stomach and 7 or more lymph nodes, the next-to-the-last layer of the stomach and 3-6 lymph nodes, or the outermost layer of the stomach (the serosa) and 1-2 lymph nodes.
Stage IIIB: Cancer invades the next-to-the-last layer of the stomach and 7 or more lymph nodes, the outermost layer of the stomach and 3-6 lymph nodes, or adjacent structures and few (1-2) or no lymph nodes.
Stage IIIC: Cancer involves the outermost layer of the stomach and 7 or more lymph nodes, or adjacent structures and 3 or more lymph nodes.
Stage IV: Cancer has spread to distant sites.
Recurrent Cancer: The cancer has returned after primary treatment.
REFERENCES
1. Fuccio L, Zagari RM, Eusebi LH et al. Meta-analysis: can Helicobacter pylori eradication treatment reduce the risk for gastric cancer? Annals of Internal Medicine. 2009;151:121-8.
2. American Cancer Society. Cancer Facts & Figures 2010.
3. AJCC Cancer Staging Manual, Seventh Edition.
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