Stomach cancer

Occurrence of stomach cancer

The stomach cancer on a case rate and a mortality takes the second place among all malignant tumours. At men a stomach carcinoma tap in 2 times more often, than at women. Typical age - 50-75 years.

Aetiology of stomach cancer

The cause of illness is unknown. Notice rising of frequency of a cancer among members of one family (on 20 %), and also among persons with group of blood A that assumes presence of a genetic component. Certain etiological value chronic diseases mucous a stomach have, deficiency of vitamin C, preservatives, nitrosamines.

Risk factors (according to Philip Rubin)

• Diet: it is considered, that the use salty, smoked, a spicy food raises risk of development of stomach cancer. Nitrosamines being in nutrition in a stomach can be transformed to carcinogens.
• Environment: the raised risk of development of stomach cancer becomes perceptible at persons contacting to asbestos, nickel, at workers on rubber manufacture. It is considered, that infection Helicobacter pylori also raises risk of disease.
• Alcohol and tobacco use on development of stomach cancer statically is not proved.
• Presence of group of blood A - has historical value as epidemiological researches have not been confirm this statement.
• Peptic ulcer. Transformation of good-quality ulcers in carcinomas occurs was rarely. However in a kind of that carcinomas canker, the diagnosis a peptic ulcer is often made. The malignancy occurs in is long existing callous gastric ulcer.
• Polyps and stomach polyposes. All polyps except a glandular adenoma are not precancerous conditions. All polyps of a stomach should be investigated histologically, and all polyps in the sizes more than 2 centimetres should be removed.
• Risk of development of stomach cancer in 2.5 times above at the persons who have transferred earlier a resection concerning a peptic ulcer. The cancer develops within 15-40 years after a resection.

Precancerous conditions

1. Atrophic gastritis
2. Stomach adenomatous polyps - frequency of a malignancy makes 40 % at polyps more than 2 sm in diameter. The majority of polyps of a stomach - hyperplastic, and them do not carry to precancerous diseases.
3. Condition after a stomach resection (especially in 10-20 years after a resection on the Billroth 2).
4. Immunodeficiencies, especially variable not classified immunodeficiency (risk of a carcinoma - 33 %)
5. Pernicious anaemia

Precancerous diseases of a stomach

1. Atrophic gastritis
2. Adenomatous polyps and stomach polyposes
3. Chronic callous gastric ulcer

Classification of stomach cancer

Histological classification

Macroscopicly allocate:

1. Polypiform cancer (exophytic) - in the form of a polyp
2. The saucer-shaped cancer (exophytic) - as a tumour is blasted in the centre the saucer form - the saped, big edges with a crater in the centre is formed.
3. It is ulcerous - infiltrative
4. Diffusively - infiltrative (linitis plastica, a plastic linitis). At this form of disease widespread tumoral infiltration of mucous and submucosal covers is observed.

Histologically allocate following types of malignant tumours of a stomach:

Adenocarcinoma - the most frequent form (95 %)

• The papillary adenocarcinoma is presented by narrow or wide epithelial excrescences on a connective tissue basis
• Tubular adenocarcinoma - the branched out tubular structures concluded in a stroma.
• The mucinous adenocarcinoma - contains a slime significant amount.
• Is cricoid-cellular cancer. Tumour cells contain a lot of slime.

Lymphosarcoma, leiomyosarcoma, undifferentiated sarcoma - less than 1 %.

TNM classification

Classification by disease stages

Clinical implications of stomach cancer

Complaints

1. Pain in epigastric area is observed at 70 % of patients
2. Anorexia and weight loss are characteristic for 70-80 % of patients
3. Nausea and vomiting at a lesion of distal departments of a stomach. Vomiting - result of obstruction of the gatekeeper a tumour, but can be a consequence of the broken peristalsis of a stomach
4. Dysphagia at a lesion of cardial department
5. Feeling of early saturation. The diffusive stomach cancer often proceeds with feeling of fast saturation as the stomach wall cannot normally be stretched
6. Gastroenteric bleeding at stomach carcinomas occurs was rarely (less than 10 % of patients)
7. Lymph node palpated in the left supraclavicular area specifies in a metastasis
8. Delicacy and fatigability arise again (including at chronic blood loss and anemias)

Diagnostics of stomach cancer

Complaints

Survey data

As a rule, the data received during physical research, testify to late stages of disease:

1. At a stomach palpation formation in epigastric area is defined
2. Palpation in supraclavicular area Virchow's node
3. Knot palpation in the left axillary area - Irish's node
4. Capotement at a stomach palpation (at a cancer pyloroantral part)
5. At rectal research it is possible to define presence Blumer's shelf or Schnitzler shelf. Also it is possible to find out an ovary tumour - Krukenberg shelf

Data of laboratory research

In blood quite often define a carcinoembryonic antigen, and also activity augmentation beta-glucuronidases in a stomach secret. The achlorhydria in reply to the maximum stimulation at a stomach ulcer specifies in a malignant ulceration.

Data of tool research

X-ray inspection

Serial pictures of the top part GASTROINTESTINAL TRACT allow to tap a neoplasm, an ulcer or a thickened not extensible stomach in a kind of "a leather bag" (a diffusive stomach cancer). Simultaneous contrasting by air enlarges informativeness of a X-ray inspection.

Endoscopy (esophagogastroduodenoscopy)

Endoscopy and with a biopsy and the cytologic research provides 95-99 % diagnostics of stomach cancer.

Laparotomy

Is primary procedure for an establishment of a stage of disease and possibility of radical operation.

Ultrasonography and Computed tomography

Ultrasonography and Computed tomography for an abdominal cavity are necessary for revealing of metastasises in a liver, a peritoneum etc.

Differential diagnostics of stomach cancer

Peptic ulcer

Subject of differential diagnostics of stomach cancer, mainly, is the explanation of some similar radiological data. First of all, it is a question of differentiation of a good-quality ulcer from malignant (an acetabuliform carcinoma). There is a number of auxiliary agents which spend in this connection. However, there is a consensus with opinion, that these criteria are not absolute and that errors are possible in both directions. The cancer can take cover and under the pretext of a typical good-quality ulcer, in particular at localisation in other place, instead of on a vertical part of small curvature. As already it has been told earlier, about 10-20 % of ulcers which had in the beginning no radiological signs of a malignance, later are shown as a carcinoma. The ulcer size is not criterion of a malignance, for example, huge senile ulcers happen good-quality. Dynamics, secondly other methods of research can help with doubtful cases, first: The niche which at a periodic current repeatedly disappears and recurs, does not happen malignant. At gastroscopic research, also as well as at a X-ray inspection, good-quality and malignant ulcers have the characteristic lines.

Biopsy helps slightly, the main area of its application are diffusive disturbances. At an ulcer would have value a purposeful excision from edges that is technically hard and only occasionally can it will be possible so, that will bring practical results. The differential diagnosis is helped by acidity research as the formula matters: a niche + a histamine achlorhydria = a carcinoma.

Benign changes of an antrum

Antrum often is exposed to changes which in the radiological literature result under various names: an antrum a gastritis, a hypertrophic antral gastritis, an antrum perigastritis, benign illness of an antrum, functional changes or a hypertonia of a gastric antrum. These names designate the prospective reason. Are shown by lumen narrowing, a wall rigidity, peristalsis oppression, notches on any curvature, a rasping relief which sometimes even has pseudo pseudopolypostures character. Apparently, here there is a number of occasions to suspicion on a carcinoma.

At a gastroscopy and a biopsy these conditions share on two groups:

1. Functional changes of an antrum: the picture mucous normal, sometimes an antrum happens туннелевидным, sometimes it is not possible to notice a peristalsis, but these are the usual data which are found out and at normal stomach; hence, there is an appreciable difference between a pathological X-ray pattern and a normal gastroscopic picture.
2. Atrophic-hypertrophic even the polypous form of a chronic gastritis; such picture is defined in particular at patients with a malignant anaemia and is a precancerous condition. "Benign changes of an antrum" concern conditions at which the gastroscopy renders rather useful service. With its help of patients with functional changes it is possible to relieve of a trial laparotomy. On the contrary, revealing of polypous changes mucous is the indication to a preventive resection of a stomach.

Abnormal cords and polyps

Huge cords sometimes hardly can be distinguished from a carcinoma, but the diagnosis happens easy; hence, they are the following indication for a gastroscopy where it has the justification.

Similar situation is observed and at sutural polyps in the operated stomach at which the gastroscopy too posesses a solving word.

Though the gastroscopy cannot judge histological character of other polyps with confidence, but the macroscopical kind in most cases allows to make the assumption of probable high quality or a malignance.

Treatment of stomach cancer

Treatment of stomach cancer depends on prevalence of a tumour in a stomach, degree of a lesion of regional lymph nodes and presence of the remote metastasises.

Basic method of treatment is surgical treatment, however, also apply a combination of chemotherapy and surgical treatment, chemotherapy and radial treatment.

Surgical treatment of stomach cancer

Operation is a choice agent. The 5-year-old survival rate is observed in 12 % of cases. At superficial localisation of a tumour can reach 70 %. At a cancer in a stomach ulcer the forecast is a little bit better (5-year-old survival rate makes 30-50 %).

Subtotal distal resection of a stomach. Carried out at tumour localisation in distal parts of a stomach, together with a stomach delete big and an omentulum, regional lymphonoduses.

Subtotal proximal resection of a stomach with big and small epiploons, regional lymphonoduses at a lesion of cardial part of a stomach.

Gastrectomy is carried out at a lesion of a body of a stomach or at the infiltrative tumours located in any of its parts.

Combined gastrectomy at contact germination of a tumour in interfacing organs (for example, in a pancreas). Carry out their excision in the uniform block.

Excision of regional lymph nodes at operations concerning stomach cancer conducts to augmentation of life expectancy of patients, therefore the lymphadenectomy is shown all patients.

Palliative resection of a stomach are shown at development of a gastrostenosis or a bleeding from a breaking up tumour.

Chemotherapy

The chemotherapy suppresses malignant growth in 25-40 % of cases, but influences life expectancies a little. A question on expediency adjuvant therapy after operative treatment of potentially curable tumours disputable enough; however, at application scheme FAM (5-ftoruratsil, adriamycin, a mitomycin) will reach a certain positive effect.

Radial therapy

Intraoperative radial therapy which raises 5-year-old survival rate at patients with stomach cancer of 2-3 stages (according to the Japanese authors) is used only. Randomized research of the American national institute of a cancer www.nih.gov/icd has not shown augmentation of 5-year-old survival rate at use of an intraoperative irradiation.

The standard approach in treatment of stomach cancer in the USA is the following scheme (Philip Rubin, Clinical Oncology).

Forecast

Forecast after operative treatment substantially depends on depth of germination by a tumour of a wall of a stomach, degree of a lesion of regional lymph nodes and presence of the remote metastasises, but the forecast as a whole remains bad enough. If the tumour does not sprout a serous cover of a stomach at not an involvement of regional lymph nodes the 5-year-old survival rate at such patients makes approximately 70 %. This value catastrophically decreases, if the tumour sprouts a serous cover or amazes regional lymph nodes. By time of statement of the diagnosis only 40 % of patients have potentially curable tumour.