Gastric Cancer

Definition
2nd most common
cause of cancer
related deaths
worldwide
Difficult to treat as
usually present with
advanced disease
50% involve the
pylorus, 25% the
lesser curve, and 10%
the cardia

Risk factors
95% occur over 55 years, rises steeply from age of 60
Men:Women, 1.8:1
Strongly associated with poor socio-economic status
Barretts oesophagus
H pylori can double the risk of gastric cancer in infected
individuals, unclear relationship
Diets low in fresh fruit and vegetables
Smoking
Atrophic gastritis, pernicious anaemia
Familial risk 2-3 fold increased risk to first-degree relatives
Blood group A (RR 1.2)

Presentation
Nonspecific with dyspepsia, weight loss, vomiting, dysphagia, anaemia
70% of early GC only have symptoms of uncomplicated dyspepsia
Clinical diagnosis inaccurate, all at-risk patients with dyspepsia should
be considered for endoscopy
Majority of patients present with advanced disease and alarm symptoms
Treatment with PPIs may delay diagnosis by appearing to heal malignant
ulcers, however, such a delay does not affect survival or long-term
outcome
Signs suggesting incurable disease

Epigastric mass
Hepatomegaly
Jaundice
Ascites
Troisiers sign (enlarged Virchows node)
Acanthosis nigricans

Referral guidelines
Immediate
Significant acute GI bleeding

Urgent 2 week
Dyspepsia+

Chronic GI bleeding
Progressive dysphagia
Unintentional weight loss
Vomiting
Iron-deficiency anaemia
Epigastric mass
Suspicious barium meal result

Aged 55+ with unexplained and persistent recent-onset dyspepsia

Not necessary for less than 55 with absence of alarm symptoms

Dysphagia
Without dyspepsia, but unexplained weight loss or iron deficiency anaemia, and the
possibility of upper GI cancer recognised
Without dyspepsia, but with persistent vomiting and weight loss
Unexplained upper abdominal pain and weight loss
Upper abdominal mass without weight loss
Obstructive jaundice

Investigations
Endoscopy
Biopsies can be taken
Small lesions evaluated more fully than possible
with radiological studies
Withhold PPIs until after endoscopy, as they can mask
results

All gastric ulcers should be biopsied as even

malignant ulcers may appear to be healing
Should also have follow up until healing with
repeat biopsy

Staging
Spread is local,
lymphatic, bloodborne and
transcoelomic (eg
to ovaries)
Initial staging
should include
spiral CT of thorax
and abdomen to
determine
metastatic status
Assessment of
operability made
by endoscopic
ultrasound if
absent

Tumour, node, metastasis (TNM) staging

TX, NX or MX indicates 'not assessed'
T0 - no evidence of primary tumour.
Tis - carcinoma in situ (intraepithelial).
T1 - invades lamina propria or submucosa.
T2 - invades muscularis propria or subserosa (not
visceral peritoneum).
T3 - penetrates visceral peritoneum but not
adjacent structures.
T4 - invades adjacent structures (spleen, colon,
etc.).
N0 - no LN metastasis.
N1 - 1-6 lymph nodes.
N2 - 7-15 lymph nodes.
N3 - more than 15 lymph nodes.
M0 - no distant metastasis.
M1 - distant metastasis, in portal lymph node,
mesenteric, retroperitoneal or more distant.

Management

Total Gastrectomy

Proximal tumours

Roux-en-Y

Surgical anastomosis
of the distal divided
end of the small
bowel to another
organ (stomach,
esophagus)
The proximal end is
anastomosed to the
small bowel below
the anastomosis.

Subtotal Gastrectomy

Distal tumours

Roux-en-Y

Typically, it is between
stomach and small bowel that
is distal (or further down the
gastrointestinal tract) from
the cut end

Billroth I

An operation in which the

pylorus is removed and the
proximal stomach is
anastomosed directly to the
duodenum.

Billroth II

Greater curvature of the

stomach is connected to the
first part of the jejunum in a
side-to-side manner

D2 lymphadenectomy

Curable should undergo

Distal pancreas only when direct invasion

and chance of curative procedure

Resection of the spleen and splenic hilar

nodes should only be considered in patients
with tumours of the proximal stomach
located on greater curvature/posterior wall of
stomach

Chemotherapy and
radiotherapy
Perioperative combination chemotherapy
has become standard of care
Adjuvant chemotherapy without
radiotherapy after surgery is not
currently standard procedure in the UK
Postoperative chemotherapy not
standard practice in UK
5-FU is most effective chemotherapeutic
agent

Palliative care
Multidisciplinary
Needed for obstruction, pain, or haemorrhage and
involves judicious use of drugs, surgery and
radiotherapy
Palliative chemotherapy for QoL
No indication to recommend second-line chemo
May be benefit for subtotal gastrectomy for distal
obstructing tumours
Blood transfusions may be appropriate for symptomatic
anaemia
Coeliac plexus nerve blocks may be effective in
controlling resistant pain

Prognosis
Overall survival is 15%
11% leave for at least ten years
Younger people tend to survive longer
5 year survival for under 50 is 16-22%
compared to 5-12% for over 70

Prevention
Diet with high intakes of fruit and vegetables
smoking cessation and reduction of alcohol are
likely but not proven
Control of obesity
Surveillance endoscopy in Barretts oesophagus
and in investigation of dyspepsia remains to be
confirmed
H. pylori is likely important
COX-2 may be a biomarker for gastric carcinoma
and its measurement in gastric biopsies may be a
useful secondary preventative strategy