What is it and who gets it?

Gastric cancers constitute % 95 of all gastric malignant lesions. Every year, 800 thousand new cases are added and 650 thousand cases are lost due to this disease. It is the second most common cause of cancer-related deaths in the world, after lung cancer. The incidence of stomach cancer has decreased by in the last 70 years in the USA. It is most commonly seen in countries such as Costa Rica, Chile, Japan and China. While the rate is 100 per 100 000 in Japan, this rate is 10 per 100 000 in the USA.

Stomach cancer is twice as common in men. Incidence and mortality increase in parallel with age. Peak age is in the 7th and 8th decades.

What are the Risk Factors?

Low socioeconomic status, low amounts of protein, vegetables and fruits in the diet, smoking, consumption of high amounts of salty, roasted and canned foods, A blood group, Helicobacter Pylori infection, chronic atrophic gastritis, intestinal metaplasia, permissive anemia, stomach made for benign diseases. resection, Menetrier disease, stomach polyps.
High amounts of nitrates and nitrites are found in foods that are overly salty, cooked on embers, and canned foods. Nitrates turn into nitrites and N-nitrosamines, which are known to be active cancer precursors. Salt also plays a role in the development of chronic atrophic gastritis.

• Low fat, low protein, and low vitamins A and C in the diet increase the risk.
• Although smoking has been shown to increase the occurrence of stomach cancer, alcohol has not been shown to have such an effect.
• The risk of cancer increases in those who have previously had a stomach resection. Especially in cases who were operated 20-25 years ago due to stomach and less frequently duodenal ulcers, tumor in the stomach can develop.

Ways to Prevent Stomach Cancer

There is no definitive recommendation. Avoiding smoking and alcohol, eating foods rich in fruits and vegetables, avoiding roasted, barbecued or smoked foods, eating protein-rich and vitamin-rich foods, avoiding stress and fatigue.

What are the Complaints and Findings?

(such as early satiety, postbrandial fullness, nausea). In a study conducted in the USA with 18,365 cases, the most common findings were weight loss, abdominal pain, nausea, vomiting, loss of appetite, dysphagia, and early satiety, respectively. The pain is usually dull, constant and not relieved by food. Anemia may occur in % 40 of the cases. Although many tumor markers are elevated, there is no specific marker that can be detected at an early stage.

What are Diagnostic Tests?

1. Endoscopy: Gastroscopy and biopsy are the most appropriate methods for the diagnosis of stomach cancer. The location, size and degree of spread of the tumor can be determined by endoscopy.
2. Computed Tomography: Computed tomography of the abdomen and pelvis should be performed before surgery. Lung tomography is required for tumors close to the esophagus (proximal).
3. Chest radiography: It is effective in detecting metastasis of stomach cancer. In addition, it can be used to determine the functional status of the patient.
4. Barium double contrast upper gastrointestinal system radiography: Its diagnostic value is not as high as endoscopy. In the problem of differentiating ulcer from cancer, endoscopy is absolutely necessary since biopsy cannot be taken.

Barium upper GI radiography and double contrast (air and barium) GI films are used as standard methods in diagnosis, although less than in the past. In these radiographs, deterioration of mucosal integrity, ulceration and filling defect can be seen. Since ulcerated stomach cancers cannot be completely differentiated from benign peptic ulcers radiologically, endoscopy must be performed. It is more beneficial to perform both examinations in combination. In this way, the endoscopist can better focus on the suspected areas in the radiological study.

Byopsy can be taken with endoscopy and tissue diagnosis can be made. Local invasion of the tumor, the status of neighboring organs and distant metastases can be detected by computed tomography and magnetic resonance performed with oral or IV contrast. However, it may be difficult to see lesions smaller than 1 cm with tomography and it may not show the condition of the lymph nodes very effectively. For this reason, endoscopic ultrasonography (EUS) is used. With EUS, both the depth of tumor invasion and the extent of spread of the lymph nodes can be determined more accurately. In recent years, local and peritoneal involvement is evaluated using laparoscopy and combined laparoscopic US, and it is decided whether to perform curative resection.

WHAT ARE THE TREATMENT METHODS FOR STOMACH CANCER?

SURGICAL TREATMENT:

In stomach cancers Although surgical resection is accepted as the only treatment model to cure cases, debates continue regarding the extent of resection required for curative resection. Two types of resection are frequently used in stomach cancers.

1. Subtotal gastrectomy in most distal (lower 1/3) cancers and in very selected proximal cancers and
2. Total gastrectomy. (Gastrectomy = Removal of the stomach)

Norveç Mide Kanser Araştırmasına göre proksimal gastektomide morbidite ve mortalite sırası ile %52 ve 16 iken total gastrektomi sonrası ise %38 ve 8 dir. Bu nedenle proksimal lezyonlarda total gastrektomi tercih edilmektedir. Tümörün lokalizasyonu, tümörün horizontal yayılımı, komşu organ tutulumu tümör rezeksiyonunu genişliğinde rol oynamaktadır. Temiz, negatif bir sınır elde etmek için en az 6 cm lik bir proksimal mide çıkartılması gerekir. 4-6 cm.lik bir rezeksiyonda pozitif kenar kalma riski % 10; 2 cm.lik bir rezeksiyonda bu risk % 30. dur. Bu nedenle orta ve üst 1/3 tümörlerde total gastrektomi gerekmektedir. Distal 1/3 tümörlerde subtotal gastrektomi yeterlidir. Yapılan çalışmalarda negatif marjinin sağlandığı olgularda total gastrektomi ile arasında survi farkı bulunmamıştır. Ayrıca morbidite ve mortalite subtotal gastrektomide daha düşüktür. Kardia ve gastroözefagiyel bölge tümörleri yemek borusu tümörleri grubunda incelenmektedir.
It is stated that spleen and/or pancreatic tail resection has no curative benefit and is accompanied by high morbidity and mortality. Resection is recommended only if there is direct invasion of these organs.

D1 AND D2 DISSECTION:

Unlike the West and the USA, the Japanese practice extended lymph dissection and radical surgery. The common approach in the world and in our country is surgery (D1 dissection) in which the lymph stations (1-6) close to the stomach (perigastric) are removed. In the type of surgery recommended especially by Japanese surgeons, the surgery performed by removing the peritoneal layer covering the pancreas along with the lymph stations (1-12) far from the stomach and the anterior part of the transverse colon mesocardium is called D2 dissection. During surgery, the greater omentum is separated from the transverse colon mesentery and duodenum. The anterior leaf of the transverse colon is peeled off. The right gastroepiploic artery is ligated at the lower border of the pancreas.

The pancreatic capsule is completely peeled off. In this way, the region of the hepatic artery and gastroduodenal artery is reached. Lesser omentum; HDL is released through the esophageal hiatus and the lower part of the liver. The left and lower part of HDL is cleared. The right gastric artery is ligated. The left gastric artery is then ligated at the celiac outlet. 7-8-9-10-11 and 12th lymph nodes are cleaned. If total gastrectomy is performed, the esophagus area is ascended and the 1st and 2nd lymph nodes are cleaned. Afterwards, 11 splenic hilus lymph nodes are cleaned. The Japanese recommend routine splenectomy for D2 dissection for effective clearance of lymph nodes 10 and 11. The Japanese perform splenectomy and sometimes distal pancreatectomy in total gastrectomy cases, that is, in middle and upper region tumors, to provide better lymphatic cleaning. Again, the Japanese recommend resection if there is adjacent organ involvement.
The difference between Japan and the West: the difference in staging, early detection, differences in patient body structures, and the difference in experience gained by Japanese surgeons due to the fact that they perform more surgeries.

In these countries, if there are no signs of lymph metastasis, D1 dissection is generally performed, that is, according to the Japanese classification, only N1 (perigastric lymph nodes) are dissected.
However, most Japanese and Germans perform at least D2 dissection in such a situation, and perform D3 or even D4 dissection depending on clinical and operative findings.
Japonlar ve bazı batı (GGCSG) serilerinde Evre II ve Evre IIIA mide kanserlerinde D1/D2 karşılaştırmışlardır. Evre II olgularında %50; Evre IIIA %30 daha yüksek 5 yıllık survi sağlamışlardır.
In all retrospective and 1-2 prospective studies conducted in the West, it was not enough to change the trend that D2 is superior to D1. However, D1 and D2 were compared in two large prospective randomized studies from Europe and a narrower prospective study from South Africa. In these studies, morbidity and mortality were found to be higher in D2.

Genel görüş mide kanserlerinde %20 oranında küratif rezeksiyon mümkün olabilmektedir. Özellikle evre II, IIIA ve seçilmiş IIIB olgularında D2 disseksiyon standart olarak uygulanmaktadır. D2 disseksiyon ile kabul edilebilir morbidite ve mortalite sağlanması için bu konuda deneyimli cerrah olarak 15-25 arasında D2 rezeksiyon yapmak gerektiği bildirilmektedir.

Erken mide kanserinde yalnızca mukoza tutulmuş ise lenf nod tutulumu %0-5 ve 10 yıllık survi %95 dir. 3cm. den küçük mukozaya sınırlı, lenfatik ve mikrovasküler invazyon olmayan bu tümörlerde endoskopik mukozal rezeksiyon, lokal rezeksiyon yapılabilir.

Submukozaya sınırlı tümörlerde lenf nod metastaz riski %10-25 ve rezeksiyon sonrası 5 yıllık survi %92dir. D1 yapılan olgularda 10 yıllık sürvi % 55 iken D2 yapılan olgularda 10 yıllık survi % 80 olarak bildirilmiştir.

Palliative Surgery:

Diffüz metastatik hastalıklarda bazen kanama, obstrüksiyon ve perforasyon nedeni ile %20-30 olguda palyatif rezeksiyon veya palyatif girişim yapılabilir. Çıkarılamayacak durumdaki mide kanserindeki kanamalarda endoskopik koaguloterapi veya endoskopik laser terapi yapılabilir. Palyatif rezeksiyon yapılabilen her durumda palyatif by-pass yöntemine tercih edilmelidir. Çünkü daha iyi palyasyon sağlar. Proksimal lezyonlarda endoskopik laser tedavisi veya endoprotezler kullanılabilinir. Yeni endostentler ile migrasyon ve perforasyon riski daha düşük olarak ortaya çıkmaktadır.

Radiotherapy:

Stomach cancer radiotherapy It is resistant. EBRT (external beam radiotherapy) can be performed in local recurrence or metastatic lesions. It does not contribute to survival. Adjuvant RT alone does not contribute to survival after curative resection. In the study of the British Stomach Cancer group, no survival advantage was achieved between those who received adjuvant RT and those who did not receive RT in cases who underwent curative resection. In a study conducted by the National Cancer Institute, there was no significant survival advantage between patients who received intraoperative radiotherapy (IORT) after curative resection and those who did not receive IORT.

Chemotherapy:

En sık kullanılan ilaç 5 FU dur. Paclitaxel (Taxol), taxotere, mitomycin ve cisplatin diğer ilaçlardır. Amerikan Klinik Onkoloji topluluğunun 2000 yılındaki toplantısında küratif rezeksiyon sonrasında adjuvan KRT(5FU ve lökovorin takiben 4000 cGy EBRT) uygulanması ile % 28 oranında survi avantajı sağlandığı bildirilmektedir. Güney Batı Onkoloji grup çalışmasında reazktabıl mide kanserinde yalnız cerrahi yapılanlarda ortalama yaşam süresi 27 ay, cerrahi+KT+RT yapılanlarda 37 ay bulunmuştur. Yine bu çalışmada 3 yıllık sürvi yalnız cerrahi yapılanlarda %41, cerrahi+KT+RT yapılanlarda %50 olarak bulunmuştur.

WHAT ARE THE TRACKING METHODS?

Most relapses occur in the first 3 years. A complete FM and tests should be performed every 4 months for the first year and every 6 months for the next 2 years. Complete blood count, liver function tests, chest X-ray, and abdominopelvic CT are among the tests to be performed. Checking with endoscopy should be done once a year.