GASTRIC CANCER

GASTRIC CANCER
How and Where does the Stomach Work?

The stomach is an expandable sack located mostly under the left lung, between the
muscular "diaphragm" which pushes up the lung, and the coiled small intestine. The
stomach is close-by important organs in the abdomen. To it's right is theliver, to it's lower
left is the spleen, and underneath it is the pancreas . The esophagus enters the stomach at
the "gastro-esophageal" junction, while the small intestine exits it at the lowermost
"antrum".

The front of the stomach rests on the abdominal wall, and lower parts of it also contact the
upper left kidney and "transverse" colon. You can see that the stomach is in the midst of
many vital organs, and infections or cancers can spread to these organs. Important areas of
the stomach itself (besides the antrum and gastro-esophageal junction) are the "greater
curvature" (basically the left wall of the stomach), the "lesser curvature" (the right wall),
the "fundus" (main body of the stomach) and the "cardia" (uppermost portion). The
stomach has a delicate inner lining, made up of "columnar epithelial cells", and acid
secreting cells called "parietal cells" . This lining is protected chemicals
called"prostaglandins''.

The stomach has an impressive blood supply, mainly from the "celiac artery" which comes
off of the main artery, the aorta . There is also venous drainage of blood to the spleen and
liver. A secondary drainage system, called the"lymph system", filters the blood in normally
pea-sized lymph nodes. These are connected to lymphatics in other abdominal areas by
"lymph channels" . Lymph nodes are full of white blood cells that help purify the blood
serum; lymph nodes often enlarge when they detect spread of diseases.The point is that the
stomach's rich blood supply and many drainage paths can act as conduits for spread of
infections or cancers.

Of course, the main purpose for the stomach is digestion of foods, a process that begins
with the saliva in the mouth. The stomach activates Vitamin B12 from our diet, secretes
hydrochloric acid to break down food, and churns the food into pulp. It can also directly
absorb substances like alcohol and caffeine. The stomach is susceptible to an increase in the
concentration of hydrochloric acid brought on by stress, certain foods, and the effects of
tobacco smoke. While the stomach is normally protected against it's own acid by an inner
membrane, breakdown of this membrane leads to inflammation of the stomach, called
"gastritis". An area that loses it's membrane is also at risk to get an actual hole, called an
"ulcer".

An ulcer may be shallow, and heal quickly, or it may be very deep and even "perforate" the
outer stomach wall. Perforation is a surgical emergency. Fortunately, there are many
medications now available which help reduce stomach acid concentration (i.e. Zantac,
Pepcid, Tagamet), helping ulcers heal and preventing formation of new ones. Also, soothing
protectants (Carafate) and even artificial prostaglandins can be given. These medications
are often given preventively ("prophylactically") when the body is under great stress, such
as after major surgery. While most stomach problems are minor ones, such as a mild virus
or indigestion, occasionally serious disease strikes the stomach.

What is Stomach Cancer?

The stomach is composed of various "cells", which are intricately combined together into
"tissues" which form the "organ" . These cells divide to produce new ones, and grow very
rapidly during womb life, early childhood and puberty. In adulthood, new cells are
produced only to replace those that die of old age, injury or disease. Normally, division of
cells is under very tight control. This control is exerted by the "genes" inside each cell,
which are housed in long clumps forming "chromosomes", which are visible under a light
microscope. The genes themselves are made up of DNA, the master genetic code material. If
the genes are damaged, say by chemicals or radiation, the control over cell division may be
lost in one particular cell. Ultimately, cancer is considered a disease of the DNA. Stomach
cancer starts in a single lung cell . That cell starts dividing haphazardly, making millions
and billions of copies of itself. It takes up the nourishment needed by other cells, depriving
them so the cancer can continue to grow. Quickly growing cells can clump up to form a
"tumor".

A tumor simply means a swelling, it can be caused by inflammation or infection. A

"benign" tumor only grows in it's local area (although it may get quite large)-- it cannot
spread and is not cancer. By contrast, a tumor which can spread to other body areas is
called "malignant" and this is cancer . The process of cancer spread to other areas is called
"metastasis", so only malignant tumors (i.e. cancer) can metastasize. Theoretically, cancer
can spread to any area of the body, and it often grows better in it's area of spread than in
it's area of origin ("primary site"). It is this capacity for spread that makes cancer so
dangerous. If not treated successfully, it ultimately kills by debility, anemia, infection, and
compromise of normal body functions.

How Common is Stomach Cancer?

Stomach cancer is the most common cancer in the world (after skin cancer). In the U.S.A. it
is much less common, with 25,000 new cases per year causing 14,000 deaths. This means it
is about 3% of new cancers in the U.S.A. each year. Stomach cancer hasdecreased 5-fold in
the U.S.A. over the past 50 years. It is more common in males, extremely rare in children,
and the average patient is 55 years old.

What Causes, or Increases the Risk for Stomach Cancer?

As for any cancer, the exact reason why one person gets stomach cancer and another does
not remains unknown . However, several things have been noted, when looking at groups of
patients, that increase cancer risk. These "risk factors" are:

1. Lack of Refrigeration is seen in countries with a high level of stomach cancer, as used
to be the situation in the U.S.A. prior to 1940 (when cases were very high). Preservatives
like nitrates, which were commonly used before refrigerators, may be contributory.
2. Increased Smoked and Salted Food intake appears related to stomach cancer, and may
be related to lack of refrigeration in third-world countries today.
3. Low Fruits and Vegetables in the diet, and high fat, is related to many "aerodigestive"
(mouth, throat, lungs and gastrointestinal system) cancers, possibly by depriving the body
of vitamins like"A" and "E" which appear protective for cancers. On the other hand, lots
of fruits and vegetables appear to lower risk.
4. Chemical "Carcinogens" l ike rubber by products, coal tar and asbestos have increased
cancers in industrial workers. However, Alcohol and Tobacco do not seem to increase
stomach cancer risk.
5. Long Standing Ulcers, especially those on the lower curvature, may become malignant
over time. A common bacteria, called Heliobacter Pylori, is found in many ulcers and may
increase cancer risk over time. Overall, however, less than 2% of ulcers ever become
cancerous.
6. Prior Stomach Surgery, where part of the stomach is removed ("partial gastrectomy")
for bleeding ulcers, has about a 5% chance of stomach cancer after a "latent period" of as
much as 40 years.
7. Achlorhydria means no stomach acid, this is seen in a rare syndrome called
"achlorhydria-gastric polyposis"-- these patients have a 30% chance of getting stomach
cancer. Any ulcer in a patient with no stomach acid has almost a 100% chance of being
cancerous!
8. Rare Genetic Diseases such as Plummer-Vinson syndrome (10% lifetime risk)
and Peutz-Jeghers syndrome with multiple polyps have a higher risk. Any polyps in the
stomach that are "villous" (as opposed to the more common harmatomatous type) have
increased risk for becoming cancerous, just like for colon cancer. However, villous polyps in
the stomach are quite rare. Pernicious anemia is caused by the failure of parietal cells in
the stomach to secrete the "intrinsic factor" needed by the intestine to uptake vitamin B12;
then cancer risk is increased.
9. Race-- Even after equalizing all of the above factors, Orientals, Blacks and Hispanic
individuals get stomach cancer more commonly than Whites. This may be due to some pre-
existing genetic susceptibility to stomach cancer.

What is the Location of Stomach Cancers?

Overall, 50% are in the lower stomach ("pyloris and antrum"), 20% are in the body of the
stomach ("fundus"), 20% are in the lesser curvature, 10% at the cardia, and 3% at the
greater curvature. The lower stomach ("distal") is more commonly involved in Black
individuals, while the upper stomach ("proximal") is more common for Whites.

Staging

The staging of a cancer basically describes how much it has grown before the diagnosis has
been made, documenting the extent of disease. Unfortunately, gastric cancer often presents
as a more advanced disease because of lack of early diagnosis, due mainly to the lack of
specific associated symptoms. Before the staging systems are introduced, here’s some
background on how cancers grow and spread, and therefore become more advanced in
stage.

Cancers cause problems because they spread and can disrupt the functioning of normal
organs. One way gastric cancer can spread is by local extension to invade through the
stomach wall and into adjacent structures. These surrounding structures include the soft
tissues and fat surrounding the stomach as well as other organs such as the spleen,
pancreas, large intestine, small intestine, liver, and large blood vessels.

Gastric cancer can also spread by accessing the lymphatic system. The lymphatic
circulation is a complete circulation system in the body (somewhat like the blood
circulatory system) that drains into various lymph nodes. When cancer cells access this
lymphatic circulation, they can travel to lymph nodes and start new sites of cancer. This is
called lymphatic spread. Gastric cancers have a propensity to undergo lymphatic spread
because there are many small lymphatic vessels contained within the stomach wall. The
first lymph nodes that cancer cells spread to are the "perigastric" nodes along the sides of
the stomach itself. They can then spread to lymph nodes adjacent to the liver, spleen,
pancreas, and aorta.

Gastric cancers can also spread through the bloodstream. Cancer cells gain access to
distant organs via the bloodstream and the tumors that arise from these cells are called
metastases. Because of the stomach's blood supply, the most common organ it spreads to is
the liver, though tumors can also spread to the lung or other organs less commonly.

A fourth way gastric cancer can spread is throughout the entire abdomen, the so-called
peritoneal cavity. Although rare, once cancer cells grow outside of the stomach itself, there
is nothing stopping cells from spreading to any surface in the entire abdominal cavity.

There are two accepted staging systems in gastric cancer. They both detail the extent of
disease by describing the growth of tumor in the stomach itself as well as the presence and
extent of spread to the lymph nodes. The TNM systems are used to describe many types of
cancers. They have three components: T-describing the extent of the "primary" tumor (the
tumor in the stomach itself); N-describing the spread to the lymph nodes; M-describing the
spread to other organs (i.e.-metastases).

The "T" stage is as follows:

* Tis-"in-situ cancer"-very superficial tumor, without invasion of the stomach wall

* T1-tumor invades into only the superficial portions of the stomach wall
* T2-tumor invades into the deeper layers of the stomach wall
* T3-tumor extends through the stomach wall into the fat outside of the stomach
* T4-tumor extends outside the stomach wall and invades into other organs

The "N" stage is as follows:

* N0-no spread to lymph nodes

* N1-tumor spread to 1-6 lymph nodes
* N2-tumor spread to 7-15 lymph nodes
* N3-tumor spread to more than 15 lymph nodes

The "M" stage is as follows:

* M0-no tumor spread to other organs

* M1-tumor spread to other organs
How Does Stomach Cancer Grow and Spread?

As mentioned, stomach cancer starts in a single abnormal cell. This cell divides to make
millions and billions of copies of itself, forming a tumor. A malignant tumor erodes into the
lining of the stomach, and into the "submucosal" and "muscular" layers. There, it sheds
cells into the lymph channels which spread to local lymph nodes, causing them to swell
("lymphadenopathy"). Cancer cells shed into the tiny draining veins of the stomach, where
they can travel to the spleen, liver, bone, lung and brain.

The original tumor (called the "primary site") continues to grow, it can penetrate the outer
wall of the stomach to erode into the liver, kidney, pancreas or intestines. The cancer can
actually encase the entire bowel by spreading via the intestinal surfaces ("peritoneal
spread"). The cancer may travel up the stomach to invade the esophagus, or down to
invade the small intestine ("duodenum"). As it invades nerve bundles, it causes pain. While
the cancer may spread to any organ, over 90% of patients succumbing to stomach cancer
have disease remaining in the stomach area ("local disease") at their time of demise.

Most patients with stomach cancer do not get diagnosed until the disease is fairly advanced,
due to lack of specifc symptoms for most stomach cancers. Fortunately, new developments
in treatment offer more hope than ever before for the patient with this disease.

It is critical to be well-educated about stomach cancer. Making the right treatment choices
can make the difference of life or death. Understanding what your choices are gives you the
peace of mind of knowing you have done everything possible to fight stomach cancer
successfully.

Our material explains, in plain English, the definition, types, frequency, symptoms,
evaluation, historical and latest effective treatments for stomach cancer. We describe
surgery, radiation, and chemotherapy, and tell you their side-effects and results. While we
don't promise a cure, we tell you everything you need to know to help make the right
choices today to deal with a stomach cancer problem.