- Causes and factors of gastric cancer
- Classification of gastric cancer
- Symptoms of stomach cancer
- Diagnosis of gastric cancer
- Stomach cancer treatment
- Prognosis of gastric cancer
- Prevention of gastric cancer
Unfortunately, the number of patients in oncologic dispensaries is growing every day. Moreover, upon entering the hospital one can see not only “people over 60”, but also relatively young men and women. The only good news is that the population began to take more care of their health, i.e. more often seek help from specialists.
Modern possibilities of medicine make it possible to detect malignant cells and tumors at the earliest stages, so the fight against such illnesses has become much more efficient and safer.
One of the leading positions in the frequency of occurrence in the structure of cancer is stomach cancer. The disease is extremely unpleasant and dangerous, it is often fatal. It is about her, we will talk in detail.
Stomach cancer is ubiquitous. Every person can face such a problem. However, in general, the incidence and mortality rate in the world is decreasing.
Nevertheless, these figures remain extremely high in Japan, Iceland, Chile, USA, Russia and in many other countries. Stomach cancer ranks high seventh in the overall structure of oncological diseases in terms of the number of deaths.
Stomach cancer in men is somewhat more common than in women. In addition, the risk of facing this pathology is higher among members of the Negroid race and among the poor.
Causes and factors of gastric cancer
As a rule, gastric cancer occurs due to the effect on the human body of several factors at once. Let's look at the most significant of them:
- Environmental exposure (radiation, hazardous production, etc.) The results of numerous studies confirm the fact that when a group of people migrates from a higher incidence zone to one where this level is significantly lower, the incidence rates of gastric cancer are significantly reduced. Moreover, in the second generation, this dependence is only confirmed;
- Nutrition, or exogenous alimentary factor. The risk of developing stomach cancer increases with the abuse of fried, fatty, spicy and canned foods. When this occurs, damage to the protective mucous layer, and carcinogenic (those that cause cancer) substances easily enter the cells. However, there is the opposite side of the issue. If you eat fresh fruits, vegetables, fiber and vitamins (especially beta carotenes and / or vitamin C), the risk of developing this disease is significantly reduced;
- Helicobacter pylori. It has long been known that this infection provokes the development of gastritis and, subsequently, gastric ulcers. But they in turn lead to atrophy and intestinal metaplasia - precancerous conditions. Scientists have shown that the risk of developing gastric adenocarcinoma is 3.5–3.9 times higher with Helicobacter pylori infection in humans;
- Other infectious agents - for example, the Epstein-Barr virus - cause the appearance of poorly differentiated lymphoid infiltration tumors (lympho-epithelium-like cancers);
- Alcohol use and smoking. These two factors are now becoming increasingly relevant, due to the high urbanization of the population.
- Genetic predisposition. In recent years, experts increasingly associate the facts of gastric cancer with heredity. The chances of encountering this disease are especially high in those people whose immediate relatives (closely related relationships of the first order) suffered from a similar pathology.
- Medicines. Long-term use of certain drugs can trigger the development of gastric cancer. One of the most dangerous are medicines used to treat rheumatic diseases.
In addition to all of the above causes of gastric cancer, there are other factors. And special attention should be paid to precancerous diseases:
- Gastric ulcer ;
- Regular antral gastritis ;
- Polyps and polyposis of the stomach;
- Chronic atrophic gastritis;
- Illness of the operated stomach;
- Pernicious anemia;
- Menetrie disease.
Classification of gastric cancer
To date, the following classifications of gastric cancer are generally accepted:
- Papillary adenocarcinoma;
- Tubular adenocarcinoma;
- Mucinous adenocarcinoma;
- Adenocellular cancer;
- Signet-cell cancer;
- Small cell cancer;
- Squamous cell carcinoma;
- Undifferentiated cancer;
- Other forms of cancer.
Macroscopic by Borrmann:
- Type 1 - polypous or mushroom;
- Type 2 - ulcerative with clear edges;
- Type 3 - ulcerative-infiltrative;
- 4th type - diffuse infiltrative;
- Type 5 - unclassifiable tumors.
Macroscopic types of gastric cancer at an early stage:
- Type I is sublime, i.e. when the height of the tumor exceeds the thickness of the mucous membrane;
- Type II - superficial;
- IIa - raised;
- IIb - flat;
- IIc - in-depth;
- Type III - ulcerated (peptic ulcer)
However, the TNM classification is the most popular worldwide , which is used by doctors to formulate a diagnosis:
To properly assess the degree of damage to the body, you need to know the anatomical structure not only of the stomach itself, but also of all nearby tissues and organs.
In the stomach, the following anatomical parts are distinguished:
- Antral department;
- Pyloric department;
In determining the tactics of treatment, the important point is the presence of regional lymph nodes affected by the tumor process.
Regional gastric nodes for gastric cancer are: perigastric nodes, which are located along the minor (1, 3, and 5) and large (2, 4a-b, 6) curvature, along the common hepatic (8), left gastric (7), splenic (10 -11) and celiac (9) arteries, hepatoduodenal nodes (12).
If intraperitoneal lymph nodes are affected (retro-pancreatic, paraaortic), then they are considered to be distant metastases.
And now for review we present you the clinical classification of TNM:
T - primary tumor:
- Tx - not enough data to assess;
- T0 - the primary tumor is not visualized;
- Tis - in situ carcinoma or intraepithelial tumor with a high degree of dysplasia;
- T1 - the tumor affects not only its own mucous plate, but also the muscle plate or submucosal layer;
- T1a - a tumor affects its own lamina or muscle plate of the mucous membrane;
- T1b - tumor affects the mucous layer;
- T2 - tumor lesion of the muscular layer;
- T3 - the tumor affects the subserous layer;
- T4 - the tumor perforates (a perforated hole is formed) the serous membrane and / or affects adjacent structures;
- T4a - the tumor invades the serous membrane
- T4b - the tumor spreads to neighboring structures
N - regional nodes:
- NX - not enough data;
- N0 - there are no signs of damage to the regional lymph nodes;
- N1-metastases in I-II regional lymph nodes;
- N2 - metastases in III-VI regional lymph nodes;
- N3 - metastases in VII and more regional lymph nodes;
- N3a - metastases in VII-XV regional lymph nodes;
- N3b - metastases in the XVI or more regional lymph nodes
M - distant metastases:
- M0 - no data for the presence of distant metastases;
- M1 - distant metastases are determined.
Another classification according to which tumors are divided according to the degree of differentiation of tissues. The higher it is, the more actively the cancer develops.
Histopathological differentiation (G):
- G4 - undifferentiated cancer;
- G3 - low degree of differentiation;
- G2 - the average degree of differentiation;
- G1 - a high degree of differentiation;
- GX cannot be assessed.
Symptoms of stomach cancer
Unfortunately, stomach cancer is hard enough to detect in the early stages, because it does not have any specific first signs, only based on which, one could state with confidence the fact that we are talking directly about a malignant tumor.
Symptoms of gastric cancer are extremely diverse and can resemble many other diseases. Moreover, these are not necessarily signs of gastrointestinal damage, very often the symptoms are similar to those observed in diseases of other systems. So, often there are changes characteristic of damage to the central nervous system (central nervous system), associated with a decrease in immunity or metabolic disorders and weight loss.
Very rarely, people immediately notice a series of changes that may indicate the development of a malignant tumor. It largely depends on the size and location of the tumor, as well as its type and degree of differentiation.
Nevertheless, it is customary to single out a few common signs inherent in any pathological process, one way or another connected with the occurrence of malignant and / or benign tumors. It is worth remembering about local symptoms inherent in such diseases, which are caused by germination in the walls of the stomach, damage to surrounding tissues, and, accordingly, violation of the evacuation of gastric contents and the functioning of nearby organs.
Common symptoms of the cancer process
As mentioned above, there are a number of symptoms inherent in almost all oncological diseases. These include:
- drastic weight loss;
- lack of appetite;
- apathy, constant fatigue;
- increased fatigue;
- anemic color of the skin.
The above symptoms are characteristic of any cancer. That is why for the purpose of early detection of gastric cancer (in the absence of other clinical symptoms), scientists dealing with oncology of the stomach and the entire gastrointestinal tract suggested using a complex of symptoms called the "syndrome of small signs" in the process of diagnosis.
With the help of this technique it is possible to suspect quite easily, and in the future to identify the malignant process. And this in turn will allow time to start treatment and prevent the spread of tumor cells to other organs.
What does the concept of “small signs syndrome” include?
- Unpleasant discomfort in the upper abdomen;
- Flatulence (or bloating) after eating;
- Unconditioned lack of appetite, which subsequently leads to a rapid decrease in body weight;
- Drooling, nausea down to vomiting;
- Heartburn - when a tumor is located in the upper half of the stomach.
In general, patients become apathetic, constantly feel bad and
very quickly tired.
Local symptoms of gastric cancer
- As a rule, they are observed with a decrease in the functional activity of the stomach and are noted in the region of the duodenum and stomach joints in the antrum. Patients often feel a sense of heaviness in the abdomen. And because the food hardly passes through the gastrointestinal tract, and sometimes even stagnates there, an eructation of air often accompanied by a putrid odor appears.
- With a tumor localized in the initial sections of the stomach, the patient feels difficulty in swallowing, dysphagia is observed. This symptom is explained as follows: the initial volume of food is not able to pass unhindered to the stomach, it stagnates and hampers the free flow of new servings of food through the esophagus.
- Often there is increased salivation, which is associated with trauma to the passing nearby nerve.
Diagnosis of gastric cancer
Diagnosis for any cancer should be comprehensive with the mandatory examination of the entire human body. Only then can the doctor accurately make a final diagnosis and begin treatment.
So, for a cancer of the stomach, an examination plan should include:
- Clinical examination;
- Digital rectal examination;
- Standard laboratory tests, such as determination of blood group, Rh factor, seroreaction for syphilis , complete blood count (OAK), urinalysis (OAM), biochemical blood tests (protein, creatinine, bilirubin, urea, AlAT, AcAT, alkaline phosphatase , glucose, amylase, electrolytes - Ca, Na, K and Cl)),
- Coagulogram according to indications;
- Functional tests, (ECG, ultrasound vascular doppler sonography, examination of respiratory function, echocardiography, etc.)
- Consultations of narrow specialists;
- Fibrogastroscopy with a biopsy of the tumor, followed by morphological study of this material;
- Ultrasonography of abdominal organs, retroperitoneal space, small pelvis and supraclavicular zones (in case of suspected metastatic lesion).
- X-ray examination of the stomach
- X-ray examination of the lungs. In difficult cases, CT scan of the chest, as well as the organs of the small pelvis and abdominal cavity is also performed;
- Endoscopic Ultrasound Examination (EUSI) Of greatest importance if you suspect early gastric cancer.
- Laparoscopy to exclude dissemination of tumor cells in the peritoneum.
Stomach cancer treatment
Today, the treatment of gastric cancer is quite a complex and not fully resolved oncology problem. Nevertheless, doctors around the world adhere to the following algorithm for the treatment of this pathology:
Algorithm for treating patients with gastric cancer:
So, the main method of dealing with this pathology is surgical intervention. And the indication for it is to establish a diagnosis of operable gastric cancer in the complete absence of any contraindications to surgery.
The main radical operations for stomach cancer are:
- Subtotal distal resection of the stomach (operation Billroth II);
- Subtotal proximal gastrectomy;
The choice of the technique used depends on the location of the tumor, its macroscopic type, as well as on the histological structure.
The main condition for the radicalization of the operation is the removal of the stomach or its corresponding part together with the regional lymph nodes and the surrounding fiber by a single block.
The volume of lymph node dissection:
- D3 - removal of lymph nodes №1-12;
- D2 - at least 14 (usually about 25) regional lymph nodes are removed;
- D1 - removal of perigastric lymph nodes (No. 1-6).
To determine the radicality and adequacy of the operation, there is a control for the absence of tumor cells along the intersection of the organs of the esophagus, the stomach or the duodenum.
The indication for performing a distal subtotal gastrectomy is the presence of an exophytic tumor or a small infiltrative tumor in the lower third of the stomach.
The indication for the implementation of the proximal subtotal gastrectomy is the presence of early gastric cancer in its upper third without a tumor going to the cardiac pulp or the abdominal segment of the esophagus.
In all other cases of gastric cancer , gastrectomy is indicated , which is associated with the biological characteristics of the spread of cancer cells.
In an exophytic tumor, the line of resection of the stomach in the proximal direction should lie 5 cm from the visible border of the tumor, and in the endophytic form, 8-10 cm. The distal border of the resection should lie no less than 3 cm from the visible or palpable border of the tumor. Since endoscopic and X-ray determination of tumor boundaries with diffuse-infiltrative growth is difficult, the decision to perform subtotal gastrectomy should be made with great caution and only on the basis of the results of clinical and instrumental examination (fibrogastroscopy, x-ray, endosonography), as well as intraoperative morphological study of the boundaries resection.
When a tumor grows into adjacent organs (spleen, intestine, liver, diaphragm, pancreas, adrenal gland, kidney, abdominal wall and retroperitoneal space), they do not appear to be removed as a single unit without signs of distant metastasis.
Doctors avoid splenectomy as much as possible, since the fundamental removal of the spleen does not improve the long-term results of treatment and significantly increases the incidence of postoperative complications and even mortality.
Indications from splenectomy are germination of the tumor, metastatic lesion of the lymph nodes of the spleen gate, intraoperative trauma.
Unfortunately, oncologists all over the world state the fact that the results of treatment of patients with stage 4 gastric cancer still remain extremely unsatisfactory. This problem is still open.
Для ликвидации осложнений, обусловленных распространенным опухолевым процессом, выполняют оперативные вмешательства с паллиативной целью. В зависимости от конкретной ситуации выполняют различные виды паллиативную резекцию желудка, которая может дополняться обходным гастроэнтероанастомозом, гастро- или еюностомой.
Согласно мировым протоколам ХТ при рака желудка применяется лишь на 4 стадии. Однако сегодня стандартных схем химиотерапевтического лечения больных раком желудка IV стадии нет. Чаще всего используются комбинации на основе таких препаратов, как флуороурацил и цисплатин.
Кроме того, существует достаточно много схем, которые включают в себя следующие виды химипрепаратов:
- Кальция фолинат;
Эффективность химиотерапевтического лечения больных распространенным раком желудка остается на низком уровне, в большинстве случаев отмечается частичная и непродолжительная ремиссия опухолевого процесса.
Давайте рассмотрим лечение рака желудка в зависимости от стадии заболевания:
Стадии — 0, Iа.
- дистальная субтотальная резекция желудка;
- проксимальная субтотальная резекция
- лимфодиссекция в объеме D1
Стадии Iб, IIа, IIб, IIIа, IIIб.
- дистальная субтотальная резекция желудка,
- лимфодиссекция в объеме D 2.
Стандарт: различные варианты химиотерапии
- паллиативные оперативные вмешательства;
- эндоскопическая реканализация (диатермокоагуляции опухоли, стентирование);
- Паллиативная химиотерапия (индивидуализированно).
Лечебная тактика у больных с рецидивом рака желудка определяется распространенностью опухолевого процесса. В зависимости от ситуации выполняется радикальное или паллиативное хирургическое лечение. Возможно применение комбинированных методов лечения с использованием различных режимов и схем ионизирующего излучения, химиотерапии.
Прогноз рака желудка
Proved, the prognosis is much more favorable in the early stages. At 0 and I stages, the survival rate is about 80-90%. At later stages, everything changes significantly and depends largely on the type of tumor, the presence of metastases, the general condition of the person, etc. As for the fourth stage, such patients survive in about 7% of cases. However, this is possible only with complete surgical removal of the tumor with further passage of courses of PCT.
Despite the successes of modern medicine in the field of oncology, gastric cancer still remains one of the most dangerous cancer pathologies. This is due to the high risk of recurrence of the disease. And they are very difficult to treat, which is why in most cases re-surgery is required.
In addition, gastric cancer is characterized by an aggressive course and the presence of a large number of metastases localized in the liver and peritoneum (the so-called "implantation metastases"), as well as in the lymph nodes of the abdominal cavity.
Metastases are screenings of the main tumor, which have a similar structure and are able to grow uncontrollably, disrupting the functioning of those organs into which they fell through the bloodstream or lymph flow.
Prevention of gastric cancer
Prevention of gastric cancer should occupy an important place in the life of every person, because This significantly reduces the risk of facing such an unpleasant (and sometimes even fatal) disease.
- Prevention of the development of chronic gastrointestinal diseases. To do this, you need to comply with general sanitary and hygienic standards, eat right and as much as possible protect yourself from all kinds of stressful situations
- Timely detection and treatment of precancerous conditions, such as pernicious anemia, chronic duodenal ulcer and others;
- Elimination of harmful environmental factors. For example, automobile exhaust, industrial waste, etc.
- It is necessary to avoid excessive consumption of nitrates, nitrites, which are found in large quantities in greenhouse plants (tomatoes, cucumbers) and smoked meats.
- Do not abuse the various drugs in the treatment of colds, infectious and other diseases;
- Consume as many fresh and pure fruits and vegetables as possible. They are rich in vitamins, macro-and micronutrients, thereby balancing the diet and are an excellent source of antioxidants;
- And, of course, accustom yourself to daily evening walks and frequent physical training. Hardening procedures are also helpful. So you can strengthen your immunity, get a boost of energy and acquire additional vitality.