Definition

Stomach cancer is cancer that occurs in the stomach — the muscular sac located in the upper middle of your abdomen, just below your ribs. Your stomach receives and holds the food you eat and then helps to break down and digest it.

Gastric cancer or stomach cancer that begins in the mucus-producing cells on the inside lining of the stomach (adenocarcinoma). Adenocarcinoma is the most common type of stomach cancer.

Stomach cancer is much more common in other Eastern world, particularly in China, Japan and Korea

Symptoms

Signs and symptoms of stomach cancer may include:

Fatigue
Feeling bloated after eating
Feeling full after eating small amounts of food
Heartburn that is severe and persistent
Indigestion that is severe and unrelenting
Nausea that is persistent and unexplained
Stomach pain
Vomiting that is persistent
Weight loss that is unintentional

When to see a doctor

If you have signs and symptoms that worry you, make an appointment with your doctor. Your doctor will likely investigate more common causes of these signs and symptoms first. The doctor who are expert in investigation of upper GI disorders are Upper GI surgeon and gastroenterologist.

Causes

Doctors aren’t sure what causes stomach cancer. There is a strong correlation between a diet high in smoked, salted and pickled foods and stomach cancer. As the use of refrigeration for preserving foods has increased around the world, the rates of stomach cancer have declined.
In general, cancer begins when an error (mutation) occurs in a cell’s DNA. The mutation causes the cell to grow and divide at a rapid rate and to continue living when a normal cell would die. The accumulating cancerous cells form a tumor that can invade nearby structures. And cancer cells can break off from the tumor to spread throughout the body.

Types of stomach cancer

The cells that form the tumor determine the type of stomach cancer. The type of cells in your stomach cancer helps determine your treatment options. Types of stomach cancer include:

Cancer that begins in the glandular cells (adenocarcinoma).The glandular cells that line the inside of the stomach secrete a protective layer of mucus to shield the lining of the stomach from the acidic digestive juices. Adenocarcinoma accounts for the great majority of all stomach cancers.
Cancer that begins in immune system cells (lymphoma).The walls of the stomach contain a small number of immune system cells that can develop cancer. Lymphoma in the stomach is rare.
Cancer that begins in hormone-producing cells (carcinoid cancer). Hormone-producing cells can develop carcinoid cancer. Carcinoid cancer in the stomach is rare.
Cancer that begins in nervous system tissues. A gastrointestinal stromal tumor (GIST) begins in specific nervous system cells found in your stomach. GIST is a rare form of stomach cancer.

Because the other types of stomach cancer are rare, when people use the term “stomach cancer” they generally are referring to adenocarcinoma.

Risk factors

Factors that increase your risk of stomach cancer include:

A diet high in salty and smoked foods
A diet low in fruits and vegetables
Eating foods contaminated with aflatoxin fungus
Family history of stomach cancer
Infection with Helicobacter pylori
Long-term stomach inflammation
Pernicious anemia
Smoking
Stomach polyps

Preparing for your appointment

Start by seeing your family doctor or a general practitioner if you have signs or symptoms that worry you. If your doctor suspects you may have a stomach problem, you may be referred to a doctor who specializes in gastrointestinal diseases (gastroenterologist/ Upper GI surgeon). Once stomach cancer is diagnosed you may be referred to a cancer specialist (oncologist) or a surgeon who specializes in operating on the digestive tract.

Because appointments can be brief, and because there’s often a lot of ground to cover, it’s a good idea to be well prepared. Here’s some information to help you get ready, and what to expect from your doctor.

What you can do

Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there’s anything you need to do in advance, such as restrict your diet.
Write down any symptoms you’re experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
Write down key personal information, including any major stresses or recent life changes.
Make a list of all medications, vitamins or supplements that you’re taking.
Note what seems to improve or worsen your signs and symptoms. Keep track of which foods, medications or other factors influence your signs and symptoms.
Consider taking a family member or friend along. Sometimes it can be difficult to absorb all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.
Write down questions to ask your doctor.

Preparing a list of questions can help you make the most of your time together. List your questions from most important to least important in case time runs out. For stomach cancer, some basic questions to ask your doctor include:

What type of stomach cancer do I have?
How advanced is my stomach cancer?
What other kinds of tests do I need?
What are my treatment options?
How successful are the treatments?
What are the benefits and risks of each option?
Is there one option you feel is best for me?
How will treatment affect my life? Can I continue to work?
Should I seek a second opinion? What will that cost, and will my insurance cover it?
Are there brochures or other printed material that I can take with me? What websites do you recommend?

In addition to the questions that you’ve prepared to ask your doctor, don’t hesitate to ask questions as they occur to you during your appointment.

Diagnosis and staging of cancer

Tests and procedures used to diagnose stomach cancer include:

A tiny camera to see inside your stomach (upper endoscopy). A thin tube containing a tiny camera is passed down your throat and into your stomach. Your doctor can look for signs of cancer. If any suspicious areas are found, a piece of tissue can be collected for analysis (biopsy).
Imaging tests. Imaging tests used to look for stomach cancer include computerized tomography (CT) scan and a special type of X-ray exam sometimes called a barium swallow.

Determining the extent (stage) of stomach cancer

The stage of your stomach cancer helps your doctor decide which treatments may be best for you. Tests and procedures used to determine the stage of cancer include:

Imaging tests. Tests may include CT and positron emission tomography (PET).
Staging surgery. Your doctor may recommend surgery to look for signs that your cancer has spread beyond your stomach within your abdomen. Exploratory surgery is usually done laparoscopically. This means the surgeon makes several small incisions in your abdomen and inserts a special camera that transmits images to a monitor in the operating room.
Other staging tests may be used, depending on your situation.

Stages of stomach cancer

The stages of adenocarcinoma stomach cancer include:

Stage I. At this stage, the tumor is limited to the layer of tissue that lines the inside of the stomach. Cancer cells may also have spread to a limited number of nearby lymph nodes.
Stage II. The cancer at this stage has spread deeper, growing into the muscle layer of the stomach wall. Cancer may also have spread to more of the lymph nodes.
Stage III. At this stage, the cancer may have grown through all the layers of the stomach. Or it may be a smaller cancer that has spread more extensively to the lymph nodes.
Stage IV. This stage indicates that the cancer has spread to distant areas of the body.

Treatments and drugs

Your treatment options for stomach cancer depend on the stage of your cancer, your overall health and your preferences.

Surgery

The goal of surgery is to remove all of the stomach cancer and a margin of healthy tissue, when possible. Options include:

Removing early-stage tumors from the stomach lining. Very small cancers limited to the inside lining of the stomach may be removed using endoscopy in a procedure called endoscopic mucosal resection (ESD). The endoscope is a lighted tube with a camera that’s passed down your throat into your stomach. The doctor uses special tools to remove the cancer and a margin of healthy tissue from the stomach lining.
Removing a portion of the stomach (subtotal gastrectomy).During subtotal gastrectomy, the surgeon removes only the portion of the stomach affected by cancer.
Removing the entire stomach (total gastrectomy). Total gastrectomy involves removing the entire stomach and some surrounding tissue. The esophagus is then connected directly to the small intestine to allow food to move through your digestive system.
Removing lymph nodes to look for cancer. The surgeon examines and removes lymph nodes in your abdomen to look for cancer cells.
Surgery to relieve signs and symptoms. Removing part of the stomach may relieve signs and symptoms of a growing tumor in people with advanced stomach cancer. In this case, surgery can’t cure advanced stomach cancer, but it can make you more comfortable.

Laparoscopic Gastrectomy: What You Need to Know

What is it?

A laparoscopic gastrectomy is a surgery where the surgeon removes part or all of your stomach. It is done using small incisions and a camera, which makes the surgery less invasive compared to traditional open surgery.

How is it performed?

Small incisions are made in your abdomen.
A laparoscope (a thin tube with a camera) is inserted through one of the incisions to allow the surgeon to see inside your abdomen.
Special surgical instruments are inserted through the other incisions to remove the affected part of your stomach.
The remaining part of your stomach (if any) is then reconnected to your digestive system.

Advantages of Laparoscopic Gastrectomy:

Minimally Invasive:

Smaller incisions lead to less postoperative pain and reduced scarring
Shorter hospital stay and quicker recovery compared to open surgery

Reduced Risk of Complications:

Lower risk of infection due to smaller incisions
Reduced blood loss during surgery
Better Cosmetic Outcome
Smaller scars compared to the larger incision needed for open surgery

Disadvantages of Laparoscopic Gastrectomy:

Technical Complexity:

The procedure requires specialized surgical skills and experience. Longer operative time compared to open surgery in some cases.
Potential for Conversion to Open Surgery:
If complications arise or if the surgeon encounters difficulties, the procedure may need to be converted to an open surgery.

Learning Curve:

Surgeons need specialized training to perform laparoscopic procedures effectively.

Postoperative Challenges:

Adapting to dietary changes and potential nutritional deficiencies, especially if a large portion or the entire stomach is removed.
Possible complications include leakage at the surgical site, infection, and bowel obstruction.

Radiation therapy

Radiation therapy uses high-powered beams of energy, such as X-rays, to kill cancer cells. The energy beams come from a machine that moves around you as you lie on a table.

Radiation therapy can be used before surgery (neoadjuvant radiation) to shrink a stomach tumor so that it’s more easily removed. Radiation therapy can also be used after surgery (adjuvant radiation) to kill any cancer cells that might remain around your stomach. Radiation is often combined with chemotherapy. In cases of advanced cancer, radiation therapy may be used to relieve side effects caused by a large tumor.

Radiation therapy to your stomach can cause diarrhea, indigestion, nausea and vomiting.

Chemotherapy

Chemotherapy is a drug treatment that uses chemicals to kill cancer cells. Chemotherapy drugs travel throughout your body, killing cancer cells that may have spread beyond the stomach.

Chemotherapy can be given before surgery (neoadjuvant chemotherapy) to help shrink a tumor so that it can be more easily removed. Chemotherapy is also used after surgery (adjuvant chemotherapy) to kill any cancer cells that might remain in the body. Chemotherapy is often combined with radiation therapy. Chemotherapy may be used alone in people with advanced stomach cancer to help relieve signs and symptoms.

Chemotherapy side effects depend on which drugs are used. The type of stomach cancer you have determines which chemotherapy drugs you’ll receive.

Targeted drugs

Targeted therapy uses drugs that attack specific abnormalities within cancer cells. Targeted drugs used to treat stomach cancer include:

Trastuzumab (Herceptin) for stomach cancer cells that produce too much HER2.
Imatinib (Gleevec) for a rare form of stomach cancer called gastrointestinal stromal tumor.
Sunitinib (Sutent) for gastrointestinal stromal tumor.
Tests of your cancer cells can tell your doctor whether these treatments are likely to work for you.

Coping and support

A cancer diagnosis can be overwhelming and frightening. Once you start to adjust after the initial shock of your diagnosis, you may find it helps to stay focused on tasks that help you cope. For example, try to:

Learn enough to make decisions about your care. Ask your doctor to write down the details of your cancer — the type, stage and your treatment options. Use those details to find more information about stomach cancer and the benefits and risks of each treatment option.
Connect with other cancer survivors. Ask your doctor about support groups in your area. Or go online and connect with cancer survivors on message boards, such as those run by the American Cancer Society.
Stay active. Being diagnosed with cancer doesn’t mean you have to stop doing the things you enjoy or normally do. For the most part, if you feel well enough to do something, go ahead and do it

Prevention

It’s not clear what causes stomach cancer, so there’s no way to prevent it. But you can take steps to reduce your risk of stomach cancer by making small changes to your everyday life. For instance, try to:

Eat more fruits and vegetables. Try to incorporate more fruits and vegetables into your diet each day. Choose a wide variety of colorful fruits and vegetables.
Reduce the amount of salty and smoked foods you eat. Protect your stomach by limiting these foods.
Stop smoking. If you smoke, quit. If you don’t smoke, don’t start. Smoking increases your risk of stomach cancer, as well as many other types of cancer. Quitting smoking can be very difficult, so ask your doctor for help.
Ask your doctor about your risk of stomach cancer. Talk with your doctor if you have an increased risk of stomach cancer. Together you may consider periodic endoscopy to look for signs of stomach cancer.

D2 Gastrectomy: A Specialized Approach for Gastric Cancer Treatment

D2 Gastrectomy

Types of Gastrectomy:

1.Total Gastrectomy: Removal of the entire stomach, often necessary for cancers located in the middle or upper part of the stomach.

Advantage: Maximizes the chance of removing all cancerous tissue.
Disadvantage: Requires significant dietary adjustments post-surgery.

2. Partial Gastrectomy: Removal of part of the stomach, typically sufficient for cancers that are confined to the lower regions.

Advantage: Retains part of the stomach, allowing for more normal digestion.
Disadvantage: May not be an option if the cancer has spread widely within the stomach.

Potential Complications:

Short-term: Infections, bleeding, complications from anesthesia.
Long-term: Nutritional deficiencies, changes in weight, need for dietary modifications, and issues with stomach function like dumping syndrome (rapid gastric emptying).

Steps of D2 Gastrectomy surgery:

Preparation and Incision: After general anesthesia, the surgeon makes an incision in the abdomen to access the stomach.
Assessment: The surgeon examines the stomach and surrounding areas for the extent of cancer spread.
Resection: Depending on the tumor’s location, part or all of the stomach is surgically removed.
Lymph Node Dissection: This is a critical step where at least 15 lymph nodes are removed along the major arteries supplying the stomach. The ‘D2’ refers to this comprehensive removal of lymph nodes, enhancing the procedure’s curative potential by targeting areas where cancer could spread.
Reconstruction: The digestive tract is reconstructed by connecting the remaining part of the stomach to the esophagus and small intestine. Techniques vary based on whether a partial or total gastrectomy is performed.
Closure: The incision is closed with sutures or staples.

Qualifications of the Surgeon:

Performing a D2 gastrectomy requires a surgeon who is not only trained in general surgery but also specialized in upper gastrointestinal surgeries, particularly gastric cancer. Surgeons performing this procedure undergo rigorous training to handle the complexities of gastric anatomy and cancer treatment protocols. They are skilled in precise surgical techniques and managing potential complications associated with extensive lymph node dissection.

Importance of Qualified Surgeons:

– Precision in Cancer Removal: Skilled surgeons ensure comprehensive removal of the cancerous tissue and lymph nodes, crucial for reducing recurrence.

– Minimizing Complications: Expertise in D2 dissection minimizes risks associated with this major surgery, such as infections or improper lymph node removal.

– Recovery: Experienced surgeons implement advanced techniques that aid in faster recovery and better post-surgical outcomes.

Recovery and Follow-Up:

Recovery from a D2 gastrectomy can be intensive. Initial hospital stay may last a week or more, with close monitoring for complications. Patients usually experience a significant recovery period at home, where they adjust to dietary changes and regain strength. Regular follow-ups are critical to monitor healing, manage any nutritional deficiencies, and detect any signs of cancer recurrence.
Conclusion:

D2 gastrectomy is a cornerstone of curative surgery for gastric cancer, demanding high precision and expertise. Choosing a surgeon who is specifically trained and experienced in gastric cancer surgeries is crucial for ensuring the best outcomes.
Overall, this surgery aims to remove the cancer effectively while attempting to preserve as much normal function as possible. Each patient’s case is unique, and the specific type of surgery is tailored based on the location, stage of the cancer, and overall health of the patient.**

Indocyanine green (ICG) navigation

Indocyanine green (ICG) navigation is a technique used in gastric cancer surgery to enhance visualization, enabling surgeons to better identify and preserve vital structures and improve the accuracy of tumor removal. Here’s how it is generally used:

1. Visualization of Blood Flow: ICG, when injected intravenously, binds to plasma proteins and remains within the vasculature. Under near-infrared light, ICG fluoresces, allowing surgeons to assess the blood flow to various parts of the stomach and surrounding tissues. This is crucial to ensure adequate blood supply to tissues, particularly when reconstructing the digestive tract after tumor removal.

2. Lymphatic Mapping and Sentinel Lymph Node Identification: ICG can help in the mapping of lymphatic drainage from the gastric tumor. This aids in the identification of sentinel lymph nodes (the first lymph nodes to which cancer is likely to spread from a primary tumor). By accurately identifying and analyzing these nodes, surgeons can better assess the spread of cancer and make more informed decisions about the extent of lymph node removal.

3. Tumor Delineation: ICG can assist in delineating the margins of the tumor, helping surgeons achieve a more precise resection with adequate margins, which is critical in reducing the risk of cancer recurrence.

4. Enhanced Visualization in Minimally Invasive Surgery: In laparoscopic and robotic surgeries, ICG navigation provides real-time, enhanced visual feedback that can improve the surgeon’s ability to operate more precisely in a minimally invasive manner.

The use of ICG navigation in gastric cancer surgery has shown potential in improving surgical outcomes by reducing complications, increasing the likelihood of complete tumor resection, and preserving healthy tissue. This technology represents a significant advancement in the surgical management of gastric cancer, contributing to more personalized and effective treatments.

Stomach Cancer