Gastric Cancer

And
How to Prevent it
Benny Philippi, MD
Digestive Surgery Division, Department of Surgery
Faculty of Medicine Universitas Indonesia
OBJECTIVES

 Anatomy
 Epidemiology
 Risk Factors
 Clinical Presentation
 Diagnosis
 Management
 Prognosis
 Prevention
ANATOMY
EPIDEMIOLOGY

 Infrequent before 40 years of age.

 Twice as frequent in men than in women.
 Leading cause of death from cancer worldwide.
 Japan has the world highest Rate of gastric cancer.
EPIDEMIOLOGY
EPIDEMIOLOGY

Incidence of Gastric Carcinoma:

 Japan 70 in 100,000/year
 Europe 40 in 100,000/year
 UK 15 in 100,000/year
 USA 10 in 100,000/year
 It is decreasing worldwide.
 RISK FACTORS

Predisposing: Environmental: Genetic:

1. Chronic peptic ulcer 1. H.pylori infection 1. Blood group A

(give rise to 1%) Sero(+) patients 2. HNPCC:
2. Smoking. have 6-9 folds risk Heriditory non-
3. Alcohol. 2. low socioeconomic polyposis colon
cancer.
Status
3. Diet (prevention)
CLINICAL PRESENTATION

Most patients present with

advanced stage….
why?
They are often asymptomatic in
early stages.
CLINICAL PRESENTATION

 Dysphagia: more common

with proximal gastric tumors
 Occult GI bleeding very
common, overt bleeding
<20%.
SIGNS

 Palpable abdominal mass: most

common physical finding
 If cancer spreads via lymphatics…
 Left supraclavicular node
(Virchow’s)
 Periumbilical node (Sister Mary
Joseph)
 Left axillary node (Irish)
 Enlarged ovary (Krukenberg's
tumor)
 Ascites
 DIAGNOSIS

 EGD (Esophagogastroduodenoscopy)
 Gold standard
 Single biopsy from ulcer -> sensitivity ~
70%
 Brush cytology increases sensitivity of
single biopsies, aid in multiple biopsies
unclear
DIAGNOSIS

Barium studies
 False negative in as many as
50% of cases
 Sensitivity as low as 14% in
early cases
 May be superior to EGD for
linitis plastica
 EGD may be normal while
“leather-bottle” will be apparent
on radiograph
MANAGEMENT

 Surgery: Total or Subtotal Gastrectomy

 Chemotherapy

 Radiotherapy
TOTAL (RADICAL) GASTRECTOMY
SUB-TOTAL GASTRECTOMY

 Similar to total one except that the PROXIMAL PART of the stomach is preserved
PROGNOSIS

Two important factors influencing survival in resectable

gastric cancer:
 Depth of cancer invasion
 Presence or absence of regional Lymph Node involvement
 5 years survival rate:
 10% in US
 50% in Japan
PREVENTION

Early detection of cancer through

screening
This is done in populations where the
disease is a major health problem.
PREVENTION

 Currently screening programs

in Japan, Venezuela, Chile due to high incidence

 Mostly barium studies, EGD is concerning findings

 Some use serum pepsinogen testing for high risk with EGD
confirmation
 H. pylori: sensitivity 88%, specificity 41% (Japan)
 Japan study: 5-year survival 74-80 in screened group, 46-
56% for non-screened group
SMOKING AVOIDANCE OR CESSATION.

 Smoking cessation returns the risk to that of the general population

after 20 years.
 Smoking increases the risk of Gastric Cancer by 50% to 60%
 It is estimated that smoking tobacco is responsible for 11% of all
Stomach Cancers worldwide.
 Tobacco use decreases the levels of Carotenoids and Vitamin C which
act as protective agents against this disease
SMOKING AVOIDANCE OR CESSATION
(CONT.)

Tobacco use is associated with

Helycobacter pylori infection which in
turn leads to Atrophic Gastritis.
DIETARY FACTORS

 Consumption of fruit, vegetables and fiber has

shown, in the majority of controled studies
published, a protective effect against Gastric Cancer.
 This effect is probably due to Vitamin C or carotenes.
DIETARY FACTORS

 Nitrates and nitrites found in salted,

smoked and dried foods lead to atrophic
Gastritis which in turn leads to Gastric
Cancer.
CONCLUSION

The best primary prevention strategies are:

 Smoking avoidance or cessation.
 Diets rich in fruit, vegetables and fiber.
 Avoidance of salted, smoked and poorly
preserved foods.
 Erradication of H. pylori.
CONCLUSION

Mass screening is a viable

strategy in high risk
populations.
THANK YOU