Gastric cancer

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Abstract

Gastric cancer is one of the most common cancers and one of the most frequent causes of cancer-related deaths. The incidence, diagnostic studies, and therapeutic options have undergone important changes in the last decades, but the prognosis for gastric cancer patients remains poor, especially in more advanced stages. Surgery is the mainstay of treatment of this disease, even if it is associated with a high rate of locoregional and distant recurrence. There is ongoing debate regarding the role of adjuvant treatment In advanced disease, palliation of symptoms, rather than cure, is the primary goal of patient management. Several combination therapies have been developed and have been examined in phase III trials; however, in most cases, they have failed to demonstrate a survival advantage over the reference arm. This review summarizes the most important recommendations for the management of patients with gastric cancer.

Section snippets

Incidence and mortality

Stomach cancer is one of the most common cancers in Europe ranking fifth [1] after lung, prostate, colorectal and bladder cancers in men and breast, colorectal, lung and cancer of the corpus uteri in women. In Europe, each year there are some 192,000 new cases, representing about 23% of all malignant neoplasms [2]. The male-to-female ratio in incidence rates is about 1.6:1 [2].

The incidence of stomach cancer is higher in lower social classes, but has for many years been declining steadily by

Histogenesis

Gastric carcinomas do not arise de novo from normal epithelium, but occur through successive changes. These are well-characterized for the intestinal type of human gastric cancer, whereas, lesions predisposing to the development of the diffuse type of gastric cancer are not yet well understood. The development of the intestinal type gastric cancer includes the transformation of the normal mucosa into a mucosa that resembles intestinal epithelium (intestinal metaplasia). The presence of

Signs and symptoms

Unfortunately, most patients with gastric cancer at an early stage have mild or no symptoms. The main reason for late diagnosis is that patients typically present with vague and non-specific symptoms: mild upper gastrointestinal distress (heartburn), flatulence, abdominal fullness prematurely after meals, excessive belching, and at this point only rarely nausea/vomiting and pain occur. Approximately 30% of all patients with EGC have a long history of dyspepsia, which is indistinguishable from

Criteria for stage classification

Treatment decisions are usually made in reference to the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (UICC) [76], [77].

TNM Classification [77]

Primary tumour (T)

TX: primary tumour cannot be assessed
T0: no evidence of primary tumour
Tis: carcinoma in situ: intraepithelial tumour without invasion of the lamina propria
T1: tumour invades lamina propria or submucosa
T2: tumour invades muscularis propria or subserosa
T2a: tumour invades muscularis propria
T2b: tumour invades subserosa
T3:

Prognostic and risk factors

Although its incidence in developed countries has declined over the last three decades, gastric cancer remains the second most common cancer worldwide [100]. Prognosis continues to be poor, with 5-year survival rates of approximately 20% [101], [102], [103]. Recurrence following surgery is a major problem, and is often the ultimate cause of death. Tumour remaining in a patient after gastric resection with curative intent is categorized by a system known as R classification and indicates the

Overall treatment strategy

Surgical resection of the primary tumour and regional lymph nodes is the treatment of choice for gastric cancer. The extent of disease, the operative procedure, and patient selection are crucial in optimizing outcome. Adjuvant therapy (mainly, chemotherapy ± radiotherapy) still warrants further evaluation for high-risk (T3-4, N+) gastric cancer patients. Neoadjuvant therapy may reduce tumour mass enabling resection with potentially curative intent. When the disease is metastatic, treatment of

Late sequelae

Early recurrence of gastric cancer is difficult to identify and there are few opportunities to salvage patients with recurrent disease. It is unusual to see local-regional failure as the only component of relapse and in most cases relapse is associated with distant progression of disease and the disease is so not curable. Most of the local failures are distributed in the gastric bed (more than 75%), followed by the anastomosis or stump, and in the regional lymph nodes [223], [336]. Locally

General aims

In a general population of patients treated curatively for gastric cancer, approximately 40–60% of them will develop a recurrence. About 75–80% of these will occur within 2 years, and in nearly 98% of patients within 5 years from surgery [342], [343]. Local-regional disease as the only site of failure occurs in 23–56% of patients; by contrast, distant organ metastases as single site of relapse is quite rare (6%), and are generally found in the setting of advanced locoregional or peritoneal

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