RISK FACTORS: Helicobacter pylori infection, Diet rich in additives (smoked, pickled or salted foods, highly spiced oriental foods), Achlorhydria, Atrophic gastritis/intestinal metaplasia, Pernicious anemia, Prior gastric resection
GENERAL MEASURES
β’ Surgical excision of the tumor with resection of the local lymph nodes offers the only chance for cure. Even
patients who are not felt to have a curable lesion should be offered an attempt at surgical reduction of the tumor since it offers the best form of palliation and improves the likelihood of benefit if chemotherapy and/or radiation therapy is administered. Exception is early (superficial) gastric cancer where nonsurgical ablation (usually endoscopic) may be curative. Gastric cardia tumors may be effectively palliated by nonsurgical means.
β’ Radiation therapy is of little benefi t due to the radioresistancy of gastric tumors and the high doses of
radiation required. It does have use in the palliation of pain, bleeding and obstruction
β’ Preoperative chemotherapy particularly in patients with locally advanced disease may be of benefit
SURGICAL MEASURES
β’ Radical subtotal gastrectomy with gastrojejunostomy or gastroduodenostomy is the usual treatment of choice. A large part of the stomach along with the greater and lesser omentum is removed en bloc. At times a splenectomy and distal pancreatectomy are also performed. Direct extensions are also excised.
β’ Total gastrectomy is indicated only if necessary to remove the local lesion
β’ Local excision or endoscopic laser therapy or electrocautery for palliation of incurable lesion by resection of
bleeding area or area of obstruction
DRUG(S) OF CHOICE
. Chemotherapy has little activity in the treatment of gastric malignancy. Multiple combinations have been tried.The following combinations may offer some palliation or possible prolongation of life:
. Fluorouracil
. Fluorouracil + leucovorin
. Fluorouracil + doxorubicin Β} methotrexate
. Fluorouracil + doxorubicin + mitomycin
. Etoposide + fluorouracil + cisplatin
. Etoposide + cisplatin Β} doxorubicin
. Etoposide + leucovorin + fluorouracil
. Fluorouracil + epirubicin + carmustine
ALTERNATIVE DRUGS
β’ Ondansetron (Zofran), dronabinol (Marinol), metoclopramide (Reglan), and others for nausea control
PATIENT MONITORING Routine, frequent followup is necessary to monitor disease state, assess treatments, monitor for recurrence/metastasis, and assess nutritional status
PREVENTION/AVOIDANCE:
β’ Insufficient data to establish that screening would decrease mortality in US population
β’ Screening may be of benefi t in high prevalence areas
β’ Diets including 5-20 servings of both fruits and vegetables each week reduce the risk of gastric malignancy
by about half
POSSIBLE COMPLICATIONS:
β’ Metastatic disease (especially hepatic, cerebral and pulmonary)
β’ Anemia (especially pernicious)
β’ Pyloric stenosis
EXPECTED COURSE/PROGNOSIS:
β’ The prognosis for gastric carcinoma is not optimistic. Since most lesions do not produce symptoms until
late in their course, gastric carcinomas are usually advanced at the time of diagnosis. Surgery offers the
only chance for a cure.
β’ Overall 5 year relative survival rate 23% (if local disease 58%, regional spread 23%, distant spread 3%)
β’ Early gastric cancers are usually detected as incidental findings or when screening endoscopy is performed
in endemic areas. Five year survival rate is > 40% depending on specifi c staging and tumor differentiation.
β’ Primary gastric lymphoma more treatable than adenocarcinoma of the stomach. 5 year survival rate of 40%
- 60% with subtotal gastrectomy followed by combination chemotherapy.