Max Hospital, Patparganj, New Delhi
Specialist Clinic, Rajouri Garden, New Delhi
Max Hospital, Vaishali, Ghaziabad
Max Hospital, Patparganj, New Delhi
Specialist Clinic, Rajouri Garden, New Delhi
Max Hospital, Vaishali, Ghaziabad
20 Apr, 2023
Stomach cancer, also known as gastric cancer, is a type of cancer that affects the stomach. It is the fifth most common cancer worldwide and the third leading cause of cancer-related deaths. Stomach cancer occurs when the cells in the lining of stomach grow out of control and form a tumour.
There are several different types of stomach cancer, the most common type being adenocarcinoma. Other less common types of stomach cancer include lymphoma, sarcoma, neuroendocrine tumours, and gastrointestinal stromal tumour (GIST). The below mentioned discussion pertains to adenocarcinoma of the stomach.
The exact cause of stomach cancer is not known, but there are several factors that may increase the risk of developing stomach cancer. These factors include a diet high in smoked or pickled foods, a family history of stomach cancer, Helicobacter pylori infection, and smoking. People who have had stomach surgery, such as a partial gastrectomy (partial removal of stomach) for non-cancerous conditions, are also at an increased risk of developing stomach cancer.
Symptoms of early stomach cancer can be vague and easily mistaken for less serious causes like infection or simply indigestion. Diagnosing stomach cancer in early stages is challenging for this reason. However constant pain or bloating especially after eating (indigestion), heartburn or dyspepsia, nausea, vomiting, and loss of appetite should prompt a patient to seek help of a specialist. As stomach cancer becomes advanced, symptoms like weight loss, anaemia, fatigue or vomiting make the disease more noticeable. Diagnostic testing must be performed if you are experiencing any of these symptoms to rule out stomach tumours.
Diagnosis of stomach cancer usually involves a combination oftests. Usually the first test done for evaluation of the abovementioned symptoms is an upper gastrointestinal endoscopy in which the evaluating doctor will use an endoscope put through the mouth to evaluate the food pipe and the stomach from inside whether there is a tumour or not, and if there is a tumour, the exact location within the stomach, its distance for the junction of oesophagus and stomach, and duodenum. At this time, a biopsy, which involves taking a small sample of tissue from the stomach for evaluation, would also be done. Sometimes, further advanced testing would be advised on the biopsy samples e.g. IHC in doubtful cases and tests for assessing benefit of targeted therapy (Her2 neu, PDL-1, MSI, Kras, &Nras testing).
Staging is a process that involves determining the extent of the cancer and whether it has spread to other parts of the body. It is important in determining the best treatment approach that suits each patients unique needs. Once the diagnosis is strongly suspected or confirmed, further evaluation with a CT chest and abdomen (with intravenous contrast) or more preferably a PET- CT (with intravenous contrast) would be done to do ‘staging for stomach cancer’. Sometimes even a diagnostic laparoscopy is done in the process of staging stomach cancer especially in patients being planned for chemotherapy prior to surgery as very tiny deposits can be present in mesentery and liver in nearly 15-20% patients even when the PETCT does not show them, and this may totally changethe treatment plan for the patient.
The TNM system is used worldwide to describe stages of stomach cancer:
T: How deep is the penetration of stomach tumour into the various layers of wall of stomach
N: Whether tumour has spread to nearby lymph nodes
M: Whether cancer has metastasised to other parts of the body like liver or bone
Acombination of these three parameters helps decide stage of stomach cancer adenocarcinoma
Stage 0: In this stage, the cancer involves only the inner lining of the stomach and has not spread to the other layers of stomach or other parts of the body.
Stage I: In this stage, the cancer has spread beyond the inner lining of the stomach, but it has not yet reached nearby lymph nodes or other organs.
Stage II: In this stage, the cancer has spread to nearby lymph nodes or other organs near the stomach.
Stage III: In this stage, the cancer has spread to nearby organs or lymph nodes further away from the stomach.
Stage IV: In this stage, the cancer has spread to distant organs, such as the liver or lungs.
Thankfully, stomach cancer is becoming more and more treatable with recent advances in surgical techniques and expertise in early diagnosis. Treatment for stomach cancer depends on the stage and location of the cancer, as well as the overall health of the patient. This would typically be determined by a team of healthcare professionals, including a stomach cancer surgeon, medical oncologist and a radiation oncologist.
Surgery(gastrectomy) is the mainstay of treatment of stomach cancer especially in early stages. Other modalities like chemotherapy and occasionally radiotherapy or targeted therapy are alsoused as they help improve outcomes.
It is important to ensure an adequate nutrition, cessation of smoking and alcohol if applicable, deep breathing exercises, spirometry and brisk walking to help keep the chest in good condition. Careful attention needs to be given to co-existing illnesses including but not limited to diabetes, hypertension, cardiac or pulmonary diseases and ensure that these are optimally attended to.
The following presents a simplified stage-wise treatment protocol for stomach cancer:
Stage 0 and I: The recommended treatment is surgery to remove the cancerous tissue along with nearby lymph nodes. Sometimes, very small stage 0 tumours can be treated by endoscopic removal.
Stage II and Stage III: surgery for stomach cancer is useful in this stage. There is recent strong evidence that giving chemotherapy (preferably FLOT) prior to surgery and then following surgery improves outcomes of treatment significantly.. The chemotherapy usually completes over a period of 2-3 months. After an interval of 3-4 weeks, surgery can be performed.
Stage IV: In this stage, the cancer has spread to distant organs, such as the liver or lungs. The recommended treatment is chemotherapy along with some targeted therapy to help shrink the tumour and relieve symptoms. Surgery and radiation therapy may also be used to help control symptoms. Occasionally, selected patients with limited peritoneal disease or isolated limited spread to liver could be considered for surgical removal of primary cancer and the spread disease with outcomes better than treating them with chemotherapy alone. It is important to note that stomach cancer is often detected at a later stage, which can make it more difficult to treat.
Surgery for stomach cancer entails removal of the cancer in the stomach along with a part of surrounding healthy tissue and draining lymph nodes. This surgery is called radical gastrectomy. It may be partial removal of stomach (subtotal/partial gastrectomy) or complete removal of stomach (total gastrectomy)depending on location and extent of tumour in the stomach. Clearance of all surrounding lymph nodes is crucial in stomach cancer surgery. At least 16 lymph nodes should be removed although it is desirable if more than 30 lymph nodes are removed and evaluated at biopsy.
In total gastrectomy, the surgeon will restore normal food passage by joining food pipe to small intestine. In partial gastrectomy, normal food passage is restored by joining food pipe to remaining part of stomach or intestine to remaining part of stomach as the case maybe. Patient is put under general anaesthesia before start of procedure. It takes around 5-6 hours to do a surgery for stomach cancer. After the surgery, patient is awakened and shifted to postoperative recovery room for observation and management.
Minimally invasive laparoscopic surgery can be done safely for stomach cancer. Laparoscopic cancer surgery helps patients experience less pain, early ambulation, lesser wound related complications, lesser pulmonary complications, and faster recovery. Surgeon introduces a laparoscope (a thin lighted tube with camera at its tip) into patients abdomen by small incision. With other special instruments introduced by small incisions, the removal of stomach cancer is performed. The completeness of surgery is similar between the open and laparoscopic/robotic approaches with similar outcomes in terms of cure rates and survival except for very advanced tumours where the open surgery is probably better.
Our team routinely performs surgery for stomach cancer by laparoscopic approach with very good long-term results and recovery.
Robotic surgery can be safely done for stomach cancer. It helps avoid big incisions and facilitate early recovery and better cosmesis. The surgeon operates via robotic console which manipulates various special surgical instruments put in patients abdomen by small incisions as in laparoscopic surgery. The robot displays a highly magnified 3D image of the structures and may further facilitate better removal of cancer in the stomach.
Most patients would be nursed in post operative recovery or ICUfor observation for a day or sometimes more time depending on their recovery. There would be some tubes placed in abdomen which would be removed over the next few days. Patients undergoing partial or total gastrectomy are usually allowed gradually increasing amounts orally depending on whether a partial or total gastrectomy has been done and the patient’s tolerance of oral intake. Most patients undergoing total gastrectomy would also have a feeding access through which liquid feeds would be started from day 1-day 3 onwards depending on protocol of the treating institution. Importantly, the liquid feeds must be given slowly, about 200-300 ml over about 1-2 hours, at 3–4-hour interval as needed. The tube must be flushed with water about 50 ml slowly after each field to ensure that the particulate matter in the feed does not deposit in the tube and block it.
Most patients would be discharged to home care between postoperative day 4-7, Most patients would be taking oral diet (with feeds supplementation in patients undergoing total gastrectomy) and be able to comfortably walk around and able to do activities of self-care at discharge.
Patients would usually be offered adjuvant chemotherapy once they completely recover in 2-6 weeks’ time.
Patients are encouraged to walk and do deep breathing exercises. Gradually oral diet is increased as per tolerance.
For patients undergoing total gastrectomy,there are a few precautions which need to be added. Patients are advised to maintain a 30 degrees head end elevation when lying down. An upright posture for about half an hour after meals should also be maintained. Feeding tube feeds would be continued till patient is able to take adequate amounts orally and reduced once this is achieved.
Smaller more frequent meals, dietary vitamin supplements,high protein low carb diet, Avoiding water at mealtime helps ensure small residual stomach does not get filled up with water and patient is able to get adequate calories and protein in the diet.
Surgery for stomach cancer maybe associated with a few complications including but not limited to cardiorespiratory issues, and sometimes leak from the joint between stomach or food pipe and small intestine. With careful attention to detail intraoperatively and postoperatively, the treating team would be able to prevent and manage most of these. The incidence of these tends to be low, and most patients recover well and hence benefit from surgery. Overall risk to life would vary from 0.5-2% depending on risk factors such as cardiorespiratory status, exercise capacity and nutritional status etc.
Surgeons do their best to remove all the cancer. However sometimes some cancer cells have already spread to other parts of body but are too small to be recognized by usual imaging techniques (micro metastasis). Extra treatment like chemotherapy, radiation therapy, targeted cancer therapy is recommended as needed after surgery to patients with stomach cancer if any such risk is detected. This is called adjuvant treatment. It helps kill any remnant cancer cells in body and prevents coming back of tumour (recurrence). Follow up comprises a 3 monthly clinical examination, evaluation for symptoms, and a PET-CT to rule out disease recurrence in the 1st year. Frequency of tests/follow up can be reduced once time has elapsed since diagnosis and treatment.
Prevention of stomach cancer involves making certain lifestyle changes, such as eating a healthy diet avoiding smoked and pickled foods, quitting smoking, and treating Helicobacter pylori infection if present. Consuming fresh fruits and vegetables can help keep a healthy lining of stomach wall thereby preventing development of any tumours or cancers in the stomach. Regular screening for stomach cancer is also recommended for people who are at an increased risk, such as those with a family history of the disease.
The results of treatment for stomach cancer depend on patients’ general health condition and extent of disease with much better outcomes for early stage cancers compared to advanced cancers.
The following are the stage-wise prognosis for gastric cancer with appropriate treatment:
|
Prognosis of stomach cancer |
|
|
Stage |
5- year survival (laregley implying cure) |
|
0 |
>90% |
|
I |
80-90% |
|
II |
30-60% |
|
III |
10-30% |
|
IV |
<5% |
It is important to note that these are general survival rates and individual outcomes may vary depending on a number of factors, including the individual's overall health and response to treatment.
Without treatment, most patients would not survive beyond 6-18 months from diagnosis and there is a lot of benefit in getting modern multimodality treatment. It must be noted that results of treatment for gastric cancer have improved tremendously over the years. Laparoscopic and robotic techniques of surgery for stomach cancer enable much faster recovery and much less complications.
If you are experiencing any symptoms that could be related to stomach cancer, it is important to see a doctor for further evaluation.Early detection and treatment can improve the chances of a successful outcome.
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