Gastric cancer

The role of polyps in the condition development

The role of polyps in the formation of malignant gastrointestinal neoplasms has been studied well. Adenomatous gastric polyps, especially villous and exceeding two centimeters, can also cause cancer. All polyps are removed at gastroscopy, because only a microscopic study of the entire benign mucous outgrowth can exclude or confirm the beginning of the transition to cancer.
Drugs for the treatment of peptic ulcer from the group of proton pump inhibitors contribute to the formation of scrobiculate polyps with a low probability of degeneration.

The use of nonsteroidal anti-inflammatory drugs for pain relief contributes to inflammation of polypous outgrowths of the mucous membrane, and inflammation means proliferation with a possibility of cell transformation into cancer.

Symptoms of gastric cancer at the time when it can be cured are practically absent or are taken for common and passing stomach distress. Obvious clinical manifestations of the disease often challenge the possibility of radical treatment.

Symptoms of early gastric cancer

At the initial stage, the symptoms of gastric cancer are vague, often there are no obvious signs of trouble at all. If there is a gastric discomfort, its symptoms are not specific for a malignant tumor. The most frequent of them, appetite distortion and its deterioration, can be a sign of any gastric condition, not only cancer.

After the diagnosis, an attempt can be made to retrospectively track the first manifestations of the condition, although it is impossible to say for sure that it was the tumor and not gastritis (dyspepsia) that caused gastric problems. Clinical manifestations of malignant neoplasms are no different from gastritic complaints disturbing all adults from time to time.

The malignant process takes place under the disguise of other gastric conditions, it can be detected during a routine check-up, or an examination for another reason reveals its metastases. Early cancer is usually detected by regular endoscopic examination of a chronic ulcer patient.

Advanced condition symptoms

Clinical symptoms depend on the size and location of the cancer in the organ.

When the formation is located at the entrance, a lump is felt that interferes with food advancement through the esophagus, and belching with eaten food appears. The patient avoids solid food and switches to liquid food.

When cancer is located at the pylorus, food is retained in the stomach, and vomiting may occur with just a slight overeating.

If a large infiltrate resides in the middle of the stomach, in its body, the patient is satiated with smaller portions of food compared to usual. The feeling of satiety and weight remains longer.

With a growth through the anterior gastric wall, the node is palpable in the pit of the stomach, but there is no obvious pain. Pains occur after cancer growing through the posterior gastric wall and its spreading to other abdominal organs. Girdling or lower back pain is a sign of tumor invasion into the pancreas.

During this period, the patient starts losing weight, feels increasing weakness and lassitude from chronic undernutrition, hunger is accompanied by a persistent aversion to food.

Metastatic stage symptoms

Every malignant condition has its «favorite» localization of metastases. Gastric cancer mainly spreads in the abdominal cavity by implantation and through the lymphatic system, tumor seedings in the lungs and bones are not typical for it.

• Development of icteric skin color against the background of a moderate increase in body temperature, persistent nausea, and increasing weakness is a sign of hepatic metastatic damage.
• Abdominal enlargement accompanied by weight loss indicates ascites, formation of free fluid in the abdominal cavity.
• Vomiting with brown masses and black watery faeces are manifestations of bleeding from a major gastric vessel destroyed by tumor masses.
• Ovarian enlargement and tumor conglomerates of the supraclavicular lymph nodes are typical symptoms of the condition.
• Diagnostics of gastric cancer has changed little in the XXI century, it is also based on endoscopy, only made more perfect. Very much depends on the qualifications of endoscopy physicians, because the entire history of the condition is very short.

The first stage of gastric cancer diagnostics

The diagnostics does not begin with an oncologist, gastric cancer is primarily detected by a therapist or surgeon visited by the patient with gastric discomfort complaints. It is also possible that pathological changes are discovered quite accidentally during examination for another conditions, and these changes are metastases, because gastric pathology can only be detected by targeted examination, since abdominal ultrasound does not show either the stomach or the intestine.

The patient visits an oncologist with a suspicion of a malignant tumor, with findings of the endoscopic examination performed at a polyclinic and specimen slides of histopathological preparations obtained by biopsy of the tumor piece. At this stage of diagnostics, the malignant process advancement is not assessed and, accordingly, it is still impossible to select the optimal treatment.

The second diagnostics stage

The examination is necessary to develop cancer treatment tactics. It is necessary to find out the size of the tumor in the organ, and to determine to what extent it has managed to spread throughout the body. Therefore, the endoscopic examination will be performed again, since there is no other way to find out the true state of affairs.

Today, a more up-to-date endosonography, an esophagogastroduodenoscopy combined with ultrasound, allows seeing how the tumor is located inside the gastric wall, where the cancer borders lie, and whether the tumor conglomerate invades the neighboring organs.

During the examination, not only is the possibility of stomach removal is evaluated, but life-threatening complications are also predicted, such as bleeding and perforation (wall rupture).

Diagnostic laparoscopy

Laparoscopy, an endoscopic examination of the abdominal cavity, is not necessary for all patients. It is certainly required for a large tumor or a cancerous node growing through the stomach wall. With a high degree of malignancy, laparoscopy will allow to identify peritoneal carcinomatosis, that is, metastatic nodules on the mucous membrane lining the internal organs. It is not possible to detect peritoneal dissemination in no other way except for direct visual examination using optics.

Detection of metastases on the peritoneum radically changes the tactics of treatment. With such metastases, only palliative surgery is performed, eliminating the symptoms of pain, and a radical intervention is no longer possible.

If a laparoscopic examination is not performed, then at the first stage of abdominal surgery, the surgeon will conduct an audit, hidden metastases will be detected, and the initial surgical plans will change. With gastric cancer, laparoscopy allows avoiding an unnecessary intervention, and therefore is included in the standard of mandatory preoperative diagnostics.

Identification of cancer metastases

• X-ray polypositional examination of the stomach from several angles will reveal the spread of the tumor upwards to the esophagus and downwards to the duodenum, which is not always possible to follow even on CT.
• In the abdominal cavity, ultrasound helps find out the involvement of the liver and peritoneum in the process, and determine the size of the visible lymph nodes.
• The standard of diagnostics requires a CT scan of the abdominal cavity allowing to discover very small metastases even in «quiet nooks» where ultrasound does not reach.
• Gastric cancer, in addition to the liver and peritoneum, has typical zones of metastatic spreading to the supraclavicular lymph nodes, ovaries, and navel. Therefore, an ultrasound of the cervico-supraclavicular zones and the lesser pelvis is performed with a gynecologist examination.
• To identify metastases in the chest, a CT is performed.

Additional diagnostics

To avoid unpleasant surprises during anesthesia, it is necessary to know the state of the cardiovascular system, and get an anesthesiologist’s consultation.

A malignant gastric tumor greatly disrupts the biochemical balance, so it will be necessary to make a detailed blood test including clotting factors, and to determine by blood elements what nutritive support will be needed before and after the surgery.

Gastric cancer was first successfully operated by Billroth in Austria at the end of the 18th century. Over the past century and a half, therapeutic approaches to most malignant neoplasms have changed, many anticancer drugs have appeared, but only surgery gives hope for a cure of gastric cancer.

Principles for choice of gastric cancer therapy

In gastric cancer, the treatment tactics is determined by the extent of the malignant tumor. According to the treatment strategy focused on the highest life expectancy with acceptable quality, all patients are divided into three groups:

1. The first group can hope for a long life, nine out of ten will live more than five years, because they had been diagnosed with initial cancer that can be cured only by surgery, in some cases even saving the stomach.
2. The second group is the largest, including patients with a rather extensive tumor localized only in the stomach with lesion of the nearest lymph nodes, able to be removed with the loss of part or all of the organ.
3. The third group consists of patients whose existing neoplasms cannot be radically and entirely removed, or whose general condition is so weak that it does not allow for surgery.

Surgical treatment of gastric cancer

Only surgical tumor removal gives hope for a cure. The range of interventions recommended by the standards includes resection, removal of a part of the stomach, and gastrectomy, its complete removal. With a minimal mucosal lesion, innovative endoscopic operations are used that preserve the organ, and with it, a good quality of long life.

With a small cancer, the common and most often used tactics is stomach resection, and with an advanced tumor, gastrectomy.

Metastases exclude radical treatment, during this period cancer cells are spread throughout the body by blood and lymph, this process is called dissemination. Surgery is absolutely contraindicated with several metastases of gastric cancer in the pulmonary and hepatic tissue. With single and slowly growing tumor nodes, the case conference should discuss whether the part of the lung or the liver affected by metastases should be removed, only if it is possible to completely «clear out» the cancer from the body, as even not a single neoplasm may remain.

It is not possible to remove the lymph nodes affected by cancer outside the abdominal cavity, or tumor seedings on the peritoneum, therefore surgery is contraindicated.

Treatment of advanced gastric cancer

If the examination reveals a large neoplasm, this does not mean that the affected part or the whole organ can be removed. Only diagnostic laparoscopy that reveals hidden foci and metastases in the peritoneum can ensure resectability, so it is included in the standards of cancer treatment.

Invasion of a tumor conglomerate into another organ also does not exclude excision, and such large-scale and serious operations are already performed. The surgical stage is complemented by cycles of chemotherapy.

If the possibility of removal is doubtful, chemotherapy is also prescribed. After several cycles, a second examination is performed to clarify the dynamics, and the possibility of removal is discussed.

If surgical treatment is abandoned due to the excessively large size of the tumor conglomerate or the patient’s poor condition, chemotherapy is performed for metastases.

There is always the possibility of palliative surgery to reduce distressing manifestations of the illness.

If the neoplasm seals off the stomach entrance, depriving the patient of the opportunity to eat, then a gastrostoma is installed, a tube through which specially prepared food is introduced directly into the gastrointestinal tract.

When bleeding from the tumor occurs, manifested by vomiting and liquid faeces on the background of deteriorating condition, the vessel is tied up during endoscopic examination, or other hemostatic manipulations are performed.

This text is based on the materials of NCCN (National Cancer Comprehensive Network).

In most cases when tumor seedings on the peritoneum and ascites are detected, the patient is given up for lost and gets only symptomatic treatment. At the Clinic Medicine 24/7, such patients receive intraperitoneal chemotherapy with hyperthermia, which helps them live longer and better. Sign up for a consultation: +7 (495) 151-14-47

Reference list:

1. Yu. E. Berezov. Surgery of gastric cancer (In Russian) // Moscow, Medicine Publ., 1976, 356 pp.
2. Davydov M. I., Komov D. v. , Lotokov A. M., Komarov I. G., Leskin A. P. Emergency management of complicated stomach cancer (In Russian) // Journal of N. N. Blokhin Russian Cancer Research Center RAMS. 2006, No. 3.
3. Tveritieva A. F., Uteshev N. S., Pakhomova G. v. Bleeding gastric cancer as the problem of emergency surgery (In Russian) // Materials of the International Surgical Congress «Current Problems of Modern Surgery», Moscow, February 22–25, 2003, p. 154.
4. Lyudmila Valeryevna Nikitina Gastric cancer: risk factors, diagnostics of cancer and preceding lesions (In Russian) // Far Eastern Medical Journal. 2010, No. 1.