Gastric Cancer

Definition/Description

  • Gastric cancer (also known as stomach cancer) is characterized by rapid or abnormal cell growth within the lining of the stomach, forming a tumor.[1]

Gastric Cancer.jpg
[2]
  • There are several different types of gastric cancer. This is because there are different types of cells which make up the stomach. Therefore each particular cell has its own type of cancer.


  • Adenocarcinoma

This is the most common type of gastric cancer (95% of gastric cancers[3]). This particular type of stomach cancer originates in the lining of the stomach, and effects the glandular cells of the stomach. It is believed that the majority of stomach cancer cases are caused by Heliobacter pylori bacteria.[3]

  • Carcinoid

This type of stomach cancer effects the stomach's hormone producing cells. Carcinoid cells reproduce very slowly, and are incredibly rare. After the cancer has progressed a significant amount, a patient may have symptoms such as flushing of the face and chest, trouble breathing, and diarrhea.  This is believed to be caused by hormones from the stomach.[3]

  • Gastrointesinal Stromal Tumor

This type of stomach cancer originates in the nervous tissue surrounding the stomach, and is very rare.[3]

  • Lymphoma

Rarely, cancer will spread from the lymphnodes within and around the stomach, causing gastric cancer.[3]



  • As common with any type of cancer, gastric (stomach) cancer can present in various stages, ranging from mild to severe. 
Stage Classification of Stomach Cancer [4][5]
Stage 0 Stage I Stage II Stage III Stage IV
Abnormal cells discovered within inner lining (mucosa) of stomach wall, aka carcinoma in situ.

A) Cancer has spread to submucosa, which is the stomach layer immediately following the inner lining or mucosa.

B) Cancer has invaded submucosa as well as 1-2 lymph nodes near the stomach.

A) Cancer may have spread through several layers of the stomach including the muscularis propria (main muscle layer) and subserosa and found in 3-6 nearby lymph nodes.

B) Cancer continues to spread through layers of the stomach, potentially reaching all layers. It has invaded 7+ lymph nodes and may have begun to grow in other nearby organs or tissues.

A) Similar to IIB, cancer continues to invade layers of stomach and nearby lymph nodes; can involve nearly all muscle layers and a few lymph nodes, or a couple muscle layers and many lymph nodes.

B) Cancer growth in nearby organs or tissues really begins to accelerate.

C) Cancer has spread through all layers of stomach and 7+ nearby lymph nodes, or cancer has invaded nearby organs and 3+ lymph nodes.

Cancer has metastisized to distant organs or body parts.

Prevalence

Estimated new cases and deaths from stomach cancer in the United States in 2012:[6]

New cases: 21,320
Deaths: 10,540

Characteristics/Clinical Presentation

Behavior of Gastric Cancer
Localized
25%
Regional
31%
Distant Metastatic
32%
Unstaged 12%
  • Signs and symptoms tend to arise later in the disease process, time frame is variable.
  • Subjective presentations: Indigestion, bloating, nausea, heartburn, blood in stool, unexplained weight loss, vomiting, difficulty swallowing
  • Objective gatherings: Enlarged stomach, swollen lymph nodes, palpable mass, skin conditions, jaundice[7][8]


All of these signs and symptoms should be carefully examined by the physical therapist when treating a patient. Also, look for signs of referred pain. The stomach's referral pattern is in the epigastric region, the left upper quadrant, and within the midscapular region. You should stop treatment and refer your patient to a doctor immediately if you recognize a number of these signs and symptoms associated with these areas of pain.[9]

Associated Co-morbidities

  • A Study conducted by Heemskerk et al investigated associated co-morbidities upon history intake of 235 patients diagnosed with gastric cancer between 1992-2004.
  • 138 of the 235 patient had at least one co-morbidity
Co-morbidities[10]
Co-morbidity No. of Patients %
Cardiovascular 87 37
Pulmonary 24 10
Diabetes 19 8
Other carcinoma 20 9
Previous GI surgery 18 8
BMI > 30 12 5
Clotting disorder 2 1
Other 11 5


Medications

There are many medications that are used for gastric cancer, each one prescribed by the patient's physician. Before a specific medication is prescribed to the patient, the physician should go through an extensive overview of the history of the patient, looking for history of allergic reactions to certain drugs. The patient should also be warned of adverse side effects that could effect the patient's everyday activities.


Doxorubicin Hydrochloride (DH)

Doxorubicin Hydrochloride is used in conjunction with a number of other medications in order to treat a number of cancers including gastric cancer. It is in the class of drugs called anthracyclines, and it works by stopping or slowing the growth of cancer cells in a person's body.[11]


There are many possible side effects of DH, but those that can effect PT are:[11]

  • nausea
  • vomiting
  • stomach pain
  • diarrhea
  • increased thirst
  • unusual tiredness or weakness
  • dizziness
  • pain, burning, or tingling in the hands or feet


Fluorouracil

Fluorouracil is a type of chemotherapy used in conjunction with other cancer medications which helps to slow/stop the growth of cancer cells. It is in the class of drugs called antimetabolites.[12]

Fluorouracil has many side effects, however some are more severe than others.  There are a number of side effects that should be taken very seriosuly while on fluorouracil, and if your patient shows any of the following, you should stop treatment and send the pt. to their doctor:[12]

  • sores in the mouth and throat
  • diarrhea
  • vomiting
  • swelling, pain, redness, or peeling of skin on the palms and soles of the feet
  • fever, chills, sore throat, or other signs of an infection
  • hives
  • rash
  • itching
  • difficulty breathing or swallowing
  • nosebleeds
  • coughing up or vomiting blood or material that looks like coffee grounds
  • unusual bleeding or bruising
  • pink, red, or dark brown urine
  • red or tarry black bowel movements
  • chest pain


Docetaxel

Docetaxel can be used with other treatments, or can be used alone, in order to treat stomach cancer. It is in the classification of taxanes, which stops the growth and spreading of cancer cells. [13]


Call the doctor immediately if you or your patient shows any of the following signs while on docetaxel:[13]

  • blistering skin
  • numbness, tingling, or burning sensation in the hands or feet
  • weakness in the hands and feet
  • unusual bleeding or bruising
  • nosebleeds


Trastuzumab

Trastuzumab is used if a patient's stomach cancer has spread to other parts of the body. It is in the classification of medications called monoclonal antibodies, and helps stop the growth of cancer cells. Warning: may cause serious or life-threatening heart problems! [14]


Call the doctor immediately if you or your patient shows any of the following signs while on trastuzumab:[14]

  • sore throat, fever, chills, difficulty urinating, pain when urinating, and other signs of infection
  • nosebleeds and other unusual bruising or bleeding
  • excessive tiredness
  • pale skin


Mitomycin C

Mitomycin is a type of antibiotic only used with patients going through chemotherapy.[15]


Call the doctor immediately if you or your patient shows any of the following signs while on mitomycin C:[15]

  • unusual bruising or bleeding
  • pain, redness, or swelling at the injection site
  • fever
  • chills
  • sore throat
  • cough
  • rash
  • itching
  • difficulty urinating
  • swelling of the ankles or feet
  • dizziness
  • shortness of breath or difficulty breathing

Diagnostic Tests/Lab Tests/Lab Values

All of the following tests are done in order to either to diagnose for gastric cancer or to determine what stage the cancer is in, in order to determine the best treatment approach for that patient. Following are a number of diagnostic and special tests.

Endoscopy[16]
This is a diagnostic procedure involving a thin tube with a camera inside of it that is passed through you esophagus into your stomach. This allows your doctor to find any suspicious tissue within your stomach that should be tested for cancer. If your doctor decides to send stomach tissue off to a lab to check for cancer, this is called a biopsy in which test can be done to determine if the suspicious tissue is malignant or benign.

Gastroscopy.gif
[17]

Imaging[16]
-CT scan
-PET
-MRI

Exploratory Surgery[16]
This is performed should the doctor suspect your cancer has spread beyond just the stomach tissue. This procedure is done laparoscopically

Physical Exam[18]
The doctor may check for enlarged lymph nodes, an enlarged liver, increased fluid in the abdomen (ascites), or abdominal lumps felt during a rectal exam.

Upper GI Series[18]
These are X-rays of the esophagus, stomach, and first part of the intestine taken after you drink a barium solution. The barium outlines the stomach on the X-ray, which helps the doctor, using special imaging equipment, to find tumors or other abnormal areas


Etiology/Causes

Research is still being conducted as to what actually causes stomach cancer. However, its has been shown to correlate with the following demographics and medical histories...[19][20]

  • Diets high in sodium
  • Men are two times more as risk than women
  • African-Americans and Asians are at greater risk
  • Blood group A
  • Middle age to elderly
  • Family history of stomach cancer
  • Helicobacter pylori
  • Any other past medical history of gastrointestinal complications or surgery
  • Toxin exposure and smoking


Stomach conditions can often times serve as precursors to cancer. For example,atrophic gastritis is when the stomach glands have decreased and are inflamed. Another disease contributing to the progression of stomach cancer may be intenstinal metaplasia. This occurs when cells within the lining of the intestine invade the stomach and take the place of stomach cells. Both conditions may occur secondary to the presence of the Helicobacter pylori infection, which is said to convert food particles into chemicals that cause mutations within the DNA of stomach cells, leading to cancer. Thus, consumption of foods high in antioxidants is said decrease the risk of stomach cancer by blocking the action of these chemicals on the stomach. [21]


H. Pylori.gif
[22]


Systemic Involvement


Surgery Side Effects

The major surgery that patients with gastric cancer recieve is called a gastrectomy, which is where part or all of the patient's stomach is removed. When this happens, many changes will occur in the patient's diet because their body starts to process food differently. For instance, when the entire stomach is removed, the patient will not be able to absorb the vitamin B12[23] If this happens, the patient will become anemic[24], and therefore must recieve injections of B12. The patient must also slowly resume a normal solid diet, starting with intravenous feeding and progressing to solids. Often times these patients also have cramps, nausea, diarrhea, and dizziness shortly after eating because food and liquid enter the small intestine too quickly[23] Finally, bile may back up from the small intestine to the esophagus or the part of the stomach that wasn't removed, and can cause stomach pain[23].


Chemotherapy Side Effects

There are many side effects of chemotherapy that can be detrimental to a person's quality of life. The reason being is because the role of chemotherapy is to kill any rapidly dividing cell, not just cancer cells. Therefore, patient's undergoing chemotherapy for gastric cancer can expect to lose there hair[23]. They may also have oral problems such as sores and decreased taste buds[23]. Since the digestive tract is also included in rapidly dividing cells, patients may also have digestive problems including stomach aches, nausea, vomiting and loss of appetite[23]. Probably more importantly than all of this, though, the patient's immune system is often compromised due to the chemo's nature to kill off red and white blood cells[23].


Radiation Side Effects

Radiaton has very similar side effects to chemotherapy. On top of this, it can cause patients to develop skin problems such as rashes and easier cuts[23]. Patients can also expect to be extremely fatigued during their radiation treatment[23].

Medical Management (current best evidence)

Medical management of stomach cancer is dependent on its stage. The most common form of intervention is surgery, mainly emphasizing removal or part or all of the stomach. Radiation or chemotherapy may also be indicated should the cancer have metastisized to lymph nodes or other structures. Three common surgical interventions include endoscopic mucosal resection, subtotal (partial) gastrectomy, and total gastrectomy. Endoscopic mucosal resection is indicated when the cancer has not spread beyond the inner lining of the stomach. The surgeon removes the cancerous cells via a long tube which travels down the esophagus and into the stomach. A subtotal or partial gastrectomy is when only part of the stomach is removed. In this case, the cancer has spread significantly to the point in which it cannot be treated endoscopically. In addition, this procedure may involve the removal of a portion of the esophagus, small intestine, or nearby lymph nodes. A total gastrectomy is when the cancer has invaded the entire stomach and it needs to be removed completely. Patients that have underwent a total gastrectomy must eat more often and in very small amounts. Palliative treatment is often times indicated for patients in the severe stages of gastric cancer (III and IV). The cancer has invaded the body to the point where a complete cure it is difficult. Palliative treatment aims to subside the effects of cancer as much as possible without actually curing it. For example, a stage III or IV tumor can put pressure against the esophagus, making it difficult to eat. A palliative treatment technique for this may involve the placement of a stent in the esophagus, or lazer beam therapy to vaporize that portion of the tumor.[25][26]


Catholic University in Washington, D.C. recently conducted a study in which records of 232 patients with gastric cancer between the years of 2007-2011 were retrospectively studied. The patients were all admitted at the Bugando Medical Center in Tanzania during this four year period. The most common surgical intervention which accounted for 223 of the patients was a gastro-jejunostomy. This is a procedure in which an anastamosis is made with the stomach and the second part of the small intestine or jejunum via a small tube. Normal function of the outlet from the stomach into the first part of the small intestine (duodenum) is compromised due to the cancer. A gastro-jejunostomy is a form of palliative treatment to allow for proper transition of foods or medications from the stomach to the intestine.[27]

Physical Therapy Management (current best evidence)

Lymphatic Therapy

Since lymphoedema can occur in conjunction with gastric cancer treatment, lymphatic drainage may be indicated. Since physical therapists are certified to perform lymphatic drainage, it is their responsibility to try and minimize the effects of lymphoedema[28].


Exercise

It is important for patients undergoing cancer treatment to stay active. Exercise during cancer treatment can help to minimize fatigue, improve a patient's immune system, reduce the effects of bed rest (such as contractures and muscle atrophy) and increase general quality of life.


Physical Therapy

Physical therapy should be utilized during cancer treatment to help a patient maintain function and to prevent the effects of bed rest. However, some people may choose not to go through PT because of fatigue or pain. After cancer treatment, though, patients can go to physical therapy to try and reverse some of the side effects of treatment, and to try and regain function that may have been lost after cancer treatment.

Differential Diagnosis

Differential Dx[29] Signs and Symptoms
Esophageal Cancer
  • Dysphagia (most common), initially for solids but eventually progressing to include liquids
  • Weight loss (second most common)
  • Bleeding
  • Pain in the epigastric or retrosternal area (or over bony structures, suggesting metastatic disease)
  • Hoarseness
  • Persistent cough
Esophageal Stricture
  • Edema
  • Cellular infiltration
  • Basal cell hyperplasia
  • Vascular changes with a slight increase in type III collagen deposition on healing.
Esophagitis
  • Onset of difficult or painful swallowing (i.e. dysphagia, odynophagia)
  • Heartburn
  • Retrosternal discomfort or pain
  • Nausea, vomiting
  • Fever, sepsis
  • Abdominal pain
  • Epigastric pain
  • Hematemesis (occasionally)
  • Anorexia, weight loss (depends on chronicity and severity of underlying illness)
  • Cough
Gastric Ulcers
  • Dyspepsia, including belching, bloating, distention, and fatty food intolerance
  • Heartburn
  • Chest discomfort
  • Hematemesis or melena resulting from gastrointestinal bleeding
  • Symptoms consistent with anemia (e.g. fatigue, dyspnea) may be present
Gastritis, Acute
  • Gnawing or burning epigastric distress, occasionally accompanied by nausea and/or vomiting
  • Pain may improve or worsen with eating
Gastritis, Atrophic
  • Dehydration (primary cause of morbidity and mortality)
  • Malnutrition (typically a sign of a chronic process)
  • Abdominal pain
  • Borborygmi
  • Perianal erythema
Gastritis, Chronic
Gastroenteritis, Bacterial
Gastroenteritis, Viral
Lymphoma, Non-Hodgkin
  • Rapidly growing and bulky lymphadenopathy
  • Splenomegaly
  • Hepatomegaly
  • Large abdominal mass
  • Testicular mass
  • Skin lesions
Malignant Neoplasms of the Small Intestine
  • Nausea
  • Vomiting
  • Intestinal obstruction

Case Reports/ Case Studies

1) The Management Of Double Neoplasms: A Case Of A Patient With Small Cell Lung And Gastric Cancer Successfully Treated With Chemotherapy. By: Rossi, David, Alessandroni, Paolo, Fedeli, Stefano Luzi, Fedeli, Anna, Giordani, Paolo, Catalano, Vincenzo, Balzelli, Anna Maria, Casadei, V., Catalano, Giuseppina, Internet Journal of Oncology, 15288331, 2005, Vol. 3, Issue 1

Recent Related Research (from Pubmed)

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