History

Fact Explanation
Dyspeptic symptoms Early satiety, postprandial fullness, bloating, abdominal distension, vomiting.Due to the mass effect of the tumor and gastric outlet obstruction seen in the tumors of the distal stomach. [1]
Pallor , malena, haematemesis. Caused by iron deficiency anemia, if the tumor frequently bleeds. [1]
Dysphagia and epigastric fullness. Due to obstruction caused by the tumor. [2]
Recurrent vomiting. If pylorus is involved it may lead to gastric outlet obstruction. Alkalosis may be pronounced or absent. [2]
Loss of appetite and loss of weight. Due to the effect of tumor metastasis in to the liver. [2]
Jaundice. Due to intrahepatic (due to tumor metastasis to the liver) or extra-hepatic (local spread into the bile ducts) obstruction. [2]
References
  1. MABULA JB, MCHEMBE MD, KOY M, CHALYA PL, MASSAGA F, RAMBAU PF, MASALU N, JAKA H. Gastric cancer at a university teaching hospital in northwestern Tanzania: a retrospective review of 232 cases World J Surg Oncol [online] :257 [viewed 20 July 2014] Available from: doi:10.1186/1477-7819-10-257
  2. MACONI G, MANES G, PORRO GB. Role of symptoms in diagnosis and outcome of gastric cancer World J Gastroenterol [online] 2008 Feb 28, 14(8):1149-1155 [viewed 20 July 2014] Available from: doi:10.3748/wjg.14.1149

Examination

Fact Explanation
General examination- Wasting. Due to loss of appetite with advanced cancer. [1]
General examination- Pallor. Due to iron deficiency anemia as a result of Chronic bleeding, lack of iron in the diet and lack of iron absorption causes iron deficiency anemia. [1]
General examination- Mild Jaundice. Caused by hepatic metastasis or metastasis around the porta hepatis.[2]
General examination- Troisier's sign. Secondary deposits in the supra clavicular lymph glands causes a palpable supraclavicular gland which is called the Virchow's gland. [1]
Respiratory system examination - Signs suggestive of pleural effusion. Reduced respiratory movements, stony dull on percussion, reduced vocal resonance and absent or reduced breath sounds. Presence of pleural effusions suggest pulmonary metastases. [2]
Abdominal examination- scaphoid abdomen or distended abdomen with succussion splash. Scaphoid abdomen as a consequent of weight loss and paradoxically there can be generalized abdominal distension due to ascites. Succussion splash due to outlet obstruction. [2]
Abdominal examination- Hepatomegaly. In advanced disease - its surface can be knobby and irregular. [1]
Abdominal examination- Sister Mary Joseph nodule. Palpable nodule bulging into the umbilicus. Periumbilical metastasis of gastric cancer. [3]
Abdominal or pelvic examination -Krukenberg's tumors. Metastatic nodules may be felt in the pelvis and the ovaries. [3]
Rectal examination -Blumer's shelf palpable metastatic nodules. Metastatic nodules may be felt in the pelvis and the ovaries - Krukenberg's tumors. Shelf like tumor palpable in the anterior rectal wall. Indicates that a tumor has metastasized to the Pouch of Douglas. [4]
References
  1. MABULA JB, MCHEMBE MD, KOY M, CHALYA PL, MASSAGA F, RAMBAU PF, MASALU N, JAKA H. Gastric cancer at a university teaching hospital in northwestern Tanzania: a retrospective review of 232 cases World J Surg Oncol [online] :257 [viewed 20 July 2014] Available from: doi:10.1186/1477-7819-10-257
  2. MACONI G, MANES G, PORRO GB. Role of symptoms in diagnosis and outcome of gastric cancer World J Gastroenterol [online] 2008 Feb 28, 14(8):1149-1155 [viewed 20 July 2014] Available from: doi:10.3748/wjg.14.1149
  3. IAVAZZO C, MADHURI K, ESSAPEN S, AKRIVOS N, TAILOR A, BUTLER-MANUEL S. Sister Mary Joseph's Nodule as a First Manifestation of Primary Peritoneal Cancer Case Rep Obstet Gynecol [online] 2012:467240 [viewed 20 July 2014] Available from: doi:10.1155/2012/467240
  4. JUN SY, PARK JK. Metachronous Ovarian Metastases Following Resection of the Primary Gastric Cancer J Gastric Cancer [online] 2011 Mar, 11(1):31-37 [viewed 20 July 2014] Available from: doi:10.5230/jgc.2011.11.1.31

Differential Diagnoses

Fact Explanation
Esophageal cancer. Most esophageal neoplasms present with mechanical symptoms like dysphagia, regurgitation, vomiting and odynophagia. Most patients also present with loss of weight and loss of appetite. [1]
Esophagitis. Irritation or inflammation of the esophagus. Common causes are reflux esophagitis, infectious esophagitis, radiation and chemo-radiation esophagitis. Common symptoms include, heartburn or dyspepsia, water brash, regurgitation also includes upper abdominal discomfort, nausea, bloating, and fullness. [1]
Esophageal stricture. Narrowing or tightening of esophagus causing swallowing difficulties. [1]
Gastric ulcer. A distinct breach in the lining of the gastric mucosa or duodenal mucosa. Epigastric pain is the most common symptom in both gastric and duodenal ulcers. But in gastric ulcers pain increases with meals whereas in duodenal ulcers pain is relieved by the meals. [2]
Gastritis. This includes the inflammatory changes in the gastric mucosa. These can be autoimmune gastritis, Type B gastritis due to Helicobacter pylori, erosive gastritis, reflux gastritis, stress gastritis and other forms of gastritis. [3]
References
  1. FORDE PM, KELLY RJ. Genomic Alterations in Advanced Esophageal Cancer May Lead to Subtype-Specific Therapies Oncologist [online] 2013 Jul, 18(7):823-832 [viewed 20 July 2014] Available from: doi:10.1634/theoncologist.2013-0130
  2. GRAHAM DY. History of Helicobacter pylori, duodenal ulcer, gastric ulcer and gastric cancer World J Gastroenterol [online] 2014 May 14, 20(18):5191-5204 [viewed 20 July 2014] Available from: doi:10.3748/wjg.v20.i18.5191
  3. Gastritis Gut [online] 1995, 37(Suppl 1):A33-A38 [viewed 20 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1397980

Investigations - for Diagnosis

Fact Explanation
Upper GI endoscopy and biopsy. Flexible endoscopy and biopsy is the gold standard in diagnosing gastric carcinoma. Chromoendoscopy and magnifying endoscopy are promising image-enhanced endoscopic techniques for characterization. The proposed criteria for a cancerous lesion are as follows: conventional endoscopic findings of 1) a well-demarcated lesion and 2) irregularity in color/surface pattern; vessel plus surface classification using magnifying endoscopy with narrow-band imaging findings of 1) irregular micro-vascular pattern with a demarcation line or 2) irregular micro-surface pattern with a demarcation line. Conventional endoscopy and subsequent image-enhanced endoscopy can both contribute to the detection of early gastric cancer. Normally carried out under sedation. Biopsy of the ulcerated lesion should include a least of 6 specimens taken from around the lesion owing to variable malignant transformation.
References
  1. YAO K. The endoscopic diagnosis of early gastric cancer Ann Gastroenterol [online] 2013, 26(1):11-22 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959505

Investigations - Fitness for Management

Fact Explanation
Full blood count (FBC). To identify anemia which can be due to 1) poor iron absorption, 2) nutritional deficiencies due to symptoms of gastric carcinoma (loss of appetite, abdominal fullness) 3) bleeding from the site of the lesion. Anemia has to be corrected in order to undergo surgical procedures needed. [1]
Serum electrolytes. electrolyte imbalances needed to be excluded to confirm fitness for surgery. [1]
Chest X-Ray and lung function tests. To confirm fitness for surgery. chest X-Ray can also detect metastatic lesions to lung which is important in staging the cancer spread. [2]
Echocardiography (ECG). It allows for screening of as-yet undetected cardiac disorders. It also serves as a control should perioperative cardiac complications occur. ECG should be performed for patients who: 1)Are >40 years old. 2)Have relevant cardiac disorders (e.g. coronary artery disease, heart insufficiency, heart rhythm disturbances or valve disorders). 3)Have a pacemaker (PM) or implanted cardioverter/defibrillator (ICD). 4)Have newly developed pulmonary or cardiac symptoms. 5))Are receiving preoperative chemotherapy or chemoradiotherapy. [2]
Liver function tests. To detect the nutritional status of the patient and state of liver function. Low albumin levels will need to be corrected before surgery as hypoalbuminemia can cause impaired wound healing after the surgery. [1]
International normalized ratio (INR) Activated partial thromboplastin time (aPTT). Should be performed for all patients prior to gastrointestinal surgery. [2]
References
  1. AHMED A, UKWENYA A, MAKAMA J, MOHAMMAD I. Management and outcome of gastric carcinoma in Zaria, Nigeria Afr Health Sci [online] 2011 Sep, 11(3):353-361 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3261017
  2. GRADE M, QUINTEL M, GHADIMI BM. Standard perioperative management in gastrointestinal surgery Langenbecks Arch Surg [online] 2011 Jun, 396(5):591-606 [viewed 19 July 2014] Available from: doi:10.1007/s00423-011-0782-y

Investigations - Followup

Fact Explanation
Upper GI endoscopy. Endoscopy is invasive but is the gold standard technique for intraluminal recurrence. [1]
Multidetector computed tomography (MDCT). MDCT is widely considered the method of choice in the assessment of tumor response to treatment.[1]
References
  1. HALLINAN JT, VENKATESH SK. Gastric carcinoma: imaging diagnosis, staging and assessment of treatment response Cancer Imaging [online] , 13(2):212-227 [viewed 19 July 2014] Available from: doi:10.1102/1470-7330.2013.0023

Investigations - Screening/Staging

Fact Explanation
Screening- Serum Bio-markers. Carbohydrate antigens CA72-4 and CA19-9, and carcinoembryonic antigen (CEA) are bio-markers related to gastrointestinal tumor. [1]
Screening- Screening for H. pylori H. pylori infection is a major pathogenic factor in gastric cancer. Serum detection for H. pylori antibody can be used as a screening method for populations with high risk of gastric cancer, and people who have H. pylori infection should be inspected further. [1]
Staging-Endoscopic ultrasound (EUS) Allows more precise preoperative assessment of the tumor stage. It is regarded as the modality of choice for local staging. Depth of cancer invasion through the gastric wall and presence/absence of regional lymph node involvement are the two important factors influencing survival in resectable gastric cancer. Five layers of the gastric wall can be identified and depth of invasion of the tumor can be assessed with 90% accuracy in the 'T' tumor staging. Gastric carcinomas are identified on EUS as areas of focal thickening, irregularity or disruption of the layers. Enlarged lymph nodes can be identified with an accuracy of about 80%.With the use of EUS-guided fine-needle aspiration (EUS-FNA) for nodal staging, the accuracy has improved and the sensitivity, specificity and positive predictive value of EUS-FNA are reported to be 92%, 98% and 97%, respectively. EUS is not designed to detect distant metastases. [2]
Staging- Chest radiograph To detect metastatic lesions in the lung. [2]
Multidetector computed tomography (MDCT). The presence of gastric wall thickening associated with carcinoma can be easily detected by CT but it lacks sensitivity in detecting smaller but curable lesions. EUS has low sensitivity for nodal staging and additional EUS biopsy is invasive and impractical for routine use. MDCT is commonly used for nodal staging and, if lymphadenopathy is suspected. CT is preferred for detection of metastasis (CT of abdomen, pelvis and chest). [3]
Magnetic resonance Imaging (MRI) MRI scanning does not offer any specific advantage in assessing the stomach. Currently, the use of MRI for staging of Gastric carcinoma is limited to special circumstances when patients are allergic to iodinated contrast media, there is concern about radiation exposure with CT or invasiveness of EUS, or as a problem-solving tool when both CT and EUS are inconclusive. [3]
References
  1. YUAN Y. A survey and evaluation of population-based screening for gastric cancer Cancer Biol Med [online] 2013 Jun, 10(2):72-80 [viewed 19 July 2014] Available from: doi:10.7497/j.issn.2095-3941.2013.02.002
  2. YOSHINAGA S, ODA I, NONAKA S, KUSHIMA R, SAITO Y. Endoscopic ultrasound using ultrasound probes for the diagnosis of early esophageal and gastric cancers World J Gastrointest Endosc [online] 2012 Jun 16, 4(6):218-226 [viewed 19 July 2014] Available from: doi:10.4253/wjge.v4.i6.218
  3. HALLINAN JT, VENKATESH SK. Gastric carcinoma: imaging diagnosis, staging and assessment of treatment response Cancer Imaging [online] , 13(2):212-227 [viewed 19 July 2014] Available from: doi:10.1102/1470-7330.2013.0023

Management - General Measures

Fact Explanation
Patient education. Patient education regarding the cancer, the treatment options, resectability, and possible complications of surgery. [1]
Optimization of nutrition and correction of dehydration. Due to the obstruction and metastasis patients might have early satiety, abdominal fullness and loss of appetite which will lead to nutritional deficiencies and dehydration. Optimization of nutrition and re-hydration will be needed prior to any surgical procedures. [1]
Multidisciplinary management Multimodal treatments to increase the chance of better outcome, longer survival or even cure. Multidisciplinary team includes gastroenterologist, surgeon, oncologist, radiologist and radiotherapist, nutritionist, nurses, social workers. [1]
References
  1. THUMBS A, VIGNA L, BATES J, FULLERTON L, KUSHNER AL. Improving palliative treatment of patients with non-operable cancer of the oesophagus: training doctors and nurses in the use of self-expanding metal stents (SEMS) in Malawi Malawi Med J [online] 2012 Mar, 24(1):5-7 [viewed 20 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3588197

Management - Specific Treatments

Fact Explanation
Radical gastrectomy. It is the gold standard of management of gastric cancer worldwide. But the extent of lymphadenectomy has been debated between the East and West. Radical gastrectomy with extended D2 lymphadenectomy is the accepted standard in Eastern Asia, whereas limited D1 resection with chemoradiotherapy is more frequently used in Western countries. [1]
Subtotal gastrectomy. subtotal gastrectomy sometimes performed for tumors of the distal stomach. [1]
Palliative surgery. For patients suffering from significant obstruction or bleeding, palliative resection is an option. It is not a radical surgery and the aim is to resect the tumor and reconstruction of the gastrointestinal tract. For inoperable tumors situated in the cardia, palliative intubation, stenting can be done. Re-canalization might offer better functional results. [1]
Endoscopic mucosal resection (EMR). A treatment option of early gastric carcinoma with an extremely low possibility of lymph node metastasis, and endoscopic submucosal dissection has also recently become another treatment option with advances in endoscopic instrumentation and techniques. It is a minimally invasive procedure. However, a long-term oncological outcome has not been established. [1]
Neoadjuvant therapy. Neoadjuvant chemotherapy has been frequently used for locally advanced gastric carcinoma. Neoadjuvant chemotherapy aims at down staging patients, improving curative resectability of locally advanced disease, and eventually increasing patient survival. Possible advantages of neoadjuvant therapy +/- adjuvant strategies are: (1) Tumour vascularisation results in higher therapeutic efficacy and downstaging. (2) Excision of chemo irradiated areas can result in lower long-term toxicity. (3) Early systemic therapy allows better control of tumour micrometastases. (4) Operation may not be compromised with higher morbidity and mortality. [2]
Adjuvant chemotherapy. Due to high rates of local recurrences and distant metastases, now a well-established new standard of care for advanced tumors. Mainly in individual patients with large lymph node positive tumors when neoadjuvant therapy could not be done. [2]
H. pylori eradication. Is recommended for patients with previous neoplasia after endoscopic or surgical therapy. [3]
References
  1. LEE JH, KIM KM, CHEONG JH, NOH SH. Current Management and Future Strategies of Gastric Cancer Yonsei Med J [online] 2012 Mar 1, 53(2):248-257 [viewed 20 July 2014] Available from: doi:10.3349/ymj.2012.53.2.248
  2. MOEHLER M, LYROS O, GOCKEL I, GALLE PR, LANG H. Multidisciplinary management of gastric and gastroesophageal cancers World J Gastroenterol [online] 2008 Jun 28, 14(24):3773-3780 [viewed 20 July 2014] Available from: doi:10.3748/wjg.14.3773
  3. LIN YS, CHEN MJ, SHIH SC, BAIR MJ, FANG CJ, WANG HY. Management of Helicobacter pylori infection after gastric surgery World J Gastroenterol [online] 2014 May 14, 20(18):5274-5282 [viewed 20 July 2014] Available from: doi:10.3748/wjg.v20.i18.5274