What is the presentation and management of carcinoma of the stomach?

Presentation and Management of Carcinoma of the Stomach

Gastric carcinoma typically presents with non-specific symptoms including weight loss, dyspepsia, early satiety, vomiting, and dysphagia, with iron-deficiency anemia often being the only presenting sign; diagnosis requires endoscopic biopsy, and management centers on surgical resection with perioperative chemotherapy for resectable disease. 1

Clinical Presentation

Common Symptoms

• Weight loss (unexplained) is one of the most frequent presenting features 2
• Dyspepsia (persistent indigestion) warrants investigation, especially when it doesn't respond to standard therapy 2
• Early satiety indicates reduced gastric capacity from tumor burden 2
• Vomiting, particularly when persistent or unexplained 2
• Dysphagia suggests tumor involvement of the gastroesophageal junction or proximal stomach 2
• Iron-deficiency anemia may be the only presenting sign and should never be dismissed without investigation 1, 2

Risk Factors to Elicit in History

• Helicobacter pylori infection is the major modifiable risk factor 1, 2
• Male gender (incidence 1.5 times higher than females) 1
• Smoking significantly increases risk 1, 2
• High salt diet is associated with increased risk 1
• Atrophic gastritis or pernicious anemia 1
• Family history of gastric cancer or hereditary cancer syndromes (HNPCC, FAP) 1
• Previous partial gastrectomy 2

Diagnostic Workup

Essential Initial Investigations

• Endoscopy with biopsy is the gold standard for diagnosis and must obtain tissue for histological classification and molecular biomarkers (particularly HER2 status) 1
• Full blood count to assess for iron-deficiency anemia 1
• Liver and renal function tests to determine treatment options 1
• Physical examination including assessment for palpable masses, ascites, and lymphadenopathy 1

Staging Investigations

• Contrast-enhanced CT scan of thorax, abdomen, and pelvis is the primary staging modality to detect lymphadenopathy, metastatic disease, and ascites 1

  • Plain CT scans are inadequate; multiplanar enhanced contrast scanning is required 1
  • Patients should drink 500 mL of water before examination to ensure full gastric distension 1

• Endoscopic ultrasound (EUS) provides accurate assessment of T and N stage in potentially operable tumors and determines proximal/distal tumor extent 1

  • EUS is particularly valuable for early gastric cancer but limited in advanced or stenotic tumors 1, 3

• Diagnostic laparoscopy with peritoneal washings is recommended for all patients with resectable gastric cancer who are candidates for perioperative chemotherapy to exclude occult peritoneal metastases 1

  • Patients with positive cytology (CY+) are uncertain candidates for curative resection 1

• PET-CT is not routinely recommended for initial staging but may improve detection of occult metastatic disease in selected cases 1

  • Often negative in diffuse-type gastric cancer 1
  • More useful for detecting distant metastases than for T/N staging 4

• Assessment of nutritional status should be performed to detect dietary deficiencies in both localized and advanced disease 1

Staging System

• TNM staging according to the 8th edition AJCC/UICC should be documented 1

Management Approach

Multidisciplinary Team Planning

Multidisciplinary treatment planning is mandatory before any treatment decision and should include surgeons, medical and radiation oncologists, gastroenterologists, radiologists, pathologists, dieticians, and nurse specialists 1

Treatment by Stage

Very Early Gastric Cancer (T1a)

Endoscopic resection is recommended if ALL of the following criteria are met: 1

• Confined to mucosa
• Well-differentiated (G1-2)
• Non-ulcerated
• <2 cm in diameter

Endoscopic resection may be considered if no more than two expanded criteria are met (including larger size, superficial submucosal invasion, or presence of ulceration) 1

Localized Resectable Disease (Stage IB and above)

Surgical resection with perioperative chemotherapy is the standard of care: 1

• Perioperative chemotherapy regimen: A triplet regimen including fluoropyrimidine, platinum compound, and docetaxel should be given when possible 1

  • Duration: 2-3 months preoperatively and 2-3 months postoperatively 1
  • This approach improves 5-year survival significantly compared to surgery alone 1

• Surgical resection:

  • Subtotal gastrectomy may be performed if a macroscopic proximal margin of 3 cm can be achieved 1
  • For diffuse/poorly cohesive subtypes, a margin of 5 cm is required 1
  • Lymph node dissection: Minimum of 14 lymph nodes should be recovered, optimally at least 25 1
  • For T1 tumors, D1+ lymphadenectomy (perigastric and local N2 nodes) may be sufficient 1

Stage IB Disease (Alternative Approach)

For patients who undergo surgery without preoperative chemotherapy: 1

• Adjuvant chemotherapy with a doublet regimen (fluoropyrimidine plus oxaliplatin or docetaxel) for 6 months total duration is recommended 1
• However, perioperative approach is preferred as adjuvant chemotherapy is less well tolerated and neoadjuvant therapy allows tumor downsizing 1

Locally Advanced Disease (Stage III)

• Some patients may benefit from preoperative chemotherapy with potential for downstaging and improved resectability 1
• Therapy for incomplete resection (R1) remains palliative, though adjuvant radiotherapy or chemotherapy might be considered individually 1

Metastatic Disease (Stage IV)

Palliative chemotherapy should be considered: 1

• Combination regimens incorporating cisplatin, 5-fluorouracil with or without anthracyclines 1
• ECF regimen (Epirubicin 50 mg/m², Cisplatin 60 mg/m², continuous infusion 5-FU 200 mg/m²/day) is among the most active and well-tolerated combinations 1
• Alternative regimens include oxaliplatin, irinotecan, docetaxel, and oral fluoropyrimidines 1
• HER2 testing should be performed on all gastric/EGJ adenocarcinomas to guide anti-HER2 targeted therapy 1

Critical Pitfalls to Avoid

• Never dismiss persistent dyspepsia as benign, especially in high-risk patients or those with alarm symptoms 2
• Always investigate iron-deficiency anemia thoroughly as it may be the only presenting sign of gastric cancer 1, 2
• Do not rely on plain CT scans for staging; contrast-enhanced multiplanar CT is essential 1
• Do not skip laparoscopy in potentially resectable cases being considered for perioperative chemotherapy, as it prevents futile laparotomy in patients with occult peritoneal disease 1
• Avoid inadequate lymph node harvest during surgery; minimum 14 nodes required for accurate staging 1
• Do not use adjuvant chemotherapy alone for MSI-H gastric cancers, as it cannot be recommended in this subgroup 1

Follow-Up

Symptom-driven visits are recommended rather than intensive routine surveillance, as there is no evidence that regular intensive follow-up improves outcomes 1

• History, physical examination, and blood tests should be performed if symptoms of relapse occur 1
• Radiological investigations should be considered for patients who are candidates for palliative chemotherapy 1