In 2013, 13,200 new cases of stomach cancer were estimated in Italy, the fifth most popular in men and eighth in women. The male to female ratio is 1.6:1. Unfortunately, the symptoms of stomach tumor are often vague and nonspecific (nausea, difficulty in digestion, lack of appetite, early satiety, weight loss).

STAFF

At the IEO stomach cancer is treated by a multidisciplinary team consisting of specialists in:

• Abdomino - pelvic surgery
• Gastrointestinal and Neuroendocrine Cancer Medical Treatment
• Endoscopy
• New Drugs and Early Drug Development for Innovative Therapies
• Department of Pathology and Laboratory Medicine
• Department of Medical Imaging and Radiation Sciences

A Mediterranean diet with plenty of fruit and vegetables and little grilled or smoked salted meat seems to have a protective effect. Avoiding cigarette smoking helps, as there is a  relationship between smoking and stomach cancer. There is a clear relationship between gastric infection with Helicobacter pylori and stomach cancer. In the event of symptoms and confirmed presence of the bacterium, it may be useful to prescribe specific antibiotic therapy.

However, there is also a type of stomach cancer that is not related to Helicobacter pylori. It tends to occur in the upper part of the stomach at the passage between the esophagus and stomach, and its incidence is increasing (as opposed to the other type which is decreasing). This other type of stomach cancer is often related to gastroesophageal reflux disease, Barrett's esophagus and obesity.

Based on careful evaluation of the results of scientific research, it has been possible to identify stomach cancer specific risk factors and protective nutritional factors. Experts have classified the results into four levels: "convincing evidence", "probable evidence", "limited evidence" and one last level that collects the effects for which evidence of association with the tumour is “highly unlikely." The following are probable and convincing evidence for the recommendations:

Risk Factors

• salt in food (probable evidence)
• preserved and processed foods rich in salt (probable evidence)

Protective factors

• fruits and vegetables (probable evidence)
• in particular, garlic, onion, shallots, leeks (probable evidence)

In rare cases, there is a familial predisposition. Some alterations in certain genes are the cause for the onset of cancers in the stomach and other organs. At IEO, study and research programmes have been active on this specific topic for years.

There is no targeted prevention because stomach cancer causes are not fully known. The reduction in incidence over the past 60 years seems to be linked to an improvement in the techniques of food preservation and a better overall quality of nutrition, with increased consumption of fresh foods and less salted and smoked meat. Stomach cancer diagnosis is generally based on gastroscopy and biopsies performed during this procedure.

Prevention is based on the preferential use of fresh foods, and stopping tobacco smoking. There are at least 3 cases of gastric cancer in a family – even in successive generations - so a genetic investigation could be useful. Initially there will be an interview, and a family pedigree reconstruction by specialised personnel with a specific expertise in hereditary cancers. Appropriate genetic tests will be performed in selected cases. Stomach cancer can be successfully cured through minimally-invasive techniques at the early stages.

Stomach cancer is usually diagnosed when it is already at an advanced stage. Therefore early detection makes a big difference as with most cancers. When stomach cancer is diagnosed at advanced stages, many effective treatments are still possible, thanks to the integration of techniques and professional expertise available in advanced oncology Centres.

With modern endoscopic techniques, pre-cancerous lesions and some types of initial stomach cancer can be treated effectively, but surgery has a fundamental role in locally-advanced stage. Increasingly, the integration of surgery with chemotherapy, radiotherapy, and the new biological therapies makes it possible to induce prolonged stomach tumour remission in cases that up to ten years ago would not have been operable or would have relapsed early.

It is essential that procedures and medical-surgical integrated therapies are performed in centres that can document a high number of stomach cancer patients treated per year, where various groups of specialists involved in the process of diagnosis and treatment (endoscopist, radiologist, pathologist, surgeon oncologist, medical oncologist, nutritionist), work well together by following a multidisciplinary approach.

We have all this expertise at IEO, as well as an active partnership in optimising stomach cancer diagnosis and treatment plans. According to data from the Ministry of Health (AGENAS 2013), IEO ranks among the top 4 national centres and is in first place in Lombardy for the number of patients treated annually with surgery for stomach cancer.

In the case of early diagnosis, i.e. when the stomach cancer is small and confined, surgery alone may be sufficient. Depending on the location and extension of the stomach cancer, the intervention may be limited only to subtotal gastrectomy or total gastrectomy will be required, including removal of the lymph nodes adjacent to the stomach cancer in both cases.

If conducted in accordance with the appropriate indications, the efficacy of partial gastrectomy on the stomach cancer is comparable to that of total gastrectomy and allows better scope for postoperative nutritional adaptation. In forms at early stages, it is also possible to perform surgery with minimally-invasive techniques (laparoscopy, robot), with clinical benefit in terms of the post-operative recovery time.

After stomach removal, the possible negative effects on the nutritional and overall health are effectively prevented through recommendations and personalised diet plans, managed by qualified dietary staff on discharge and during successive follow-ups.

In some cases, it is appropriate to combine chemotherapy and/or radiotherapy with surgery to prevent stomach cancer recurrence in cases at higher risk (adjuvant therapy), or as an alternative to surgery in order to eliminate cancer cells that may have spread around the stomach cancer or in other parts of the body (through the blood and lymphatic circulation).

Clinical trials in progress at IEO are aimed at: 

• earlier identification and increasingly reliable endoscopic diagnostic tools (such as Laser Confocal Endomicroscopy)
• defining the benefits of pre- and perioperative chemotherapy in locally-advanced tumours
• clarifying the role of lymph node removal in locally-advanced forms
• validating the use of new drugs for the treatment of metastases.

Lymphadenectomy in stomach cancer

We analysed 114 patients data of taken from the IEO Cancer Registry, who underwent gastrectomy and lymphadenectomy for N0 adenocarcinoma of the stomach between 2000 and 2005. Since an extended lymphadenectomy has shown survival benefit, we concluded that a lymphadenectomy comprising at least 15 lymph nodes should be conducted in all cases of gastric carcinoma. An article was published in the Eur J Surg Oncol 2011 Apr, 37 (4) :305-11, and a new study is being planned on a larger number of cases.

Diffused hereditary gastric carcinoma

In collaboration with the Division of Cancer Prevention and Genetics, we are conducting a study for researching into the germinal mutation in the CDH-1 gene in patients under 45 with gastric carcinoma with diffuse isotype.

Stomach cancer symptoms are quite resembling those of gastritis or peptic ulcer: nausea, difficult digestion, loss of appetite or difficulty to eat a large amount of food. If these stomach cancer symptoms persist, a gastroscopy is advisable, thus obtaining a direct evaluation of the inner mucosal layer.

Treatment of stomach tumor metastases

A substantial proportion of patients are diagnosed at an advanced stage with synchronous distant metastases. Treating such patients is a therapeutic challenge for physicians, since it is generally accepted that such patients have incurable disease and that treatment is administered with a noncurative intent. Distant metastasis in gastric cancer patients is known to be one of the most important prognostic risk factors, with associated parameters such as depth of invasion and lymph node metastasis.

Patients with resectable metastasis without peritoneal carcinomatosis or limited peritoneal carcinomatosis are primarily targeted.

Bone metastasis is more commonly observed in other cancer types, such as cancers of the breast, lung and prostate, but is rather rare in gastric cancer.

Treatments for stage IV gastric cancer are chemotherapy, radiotherapy, palliative surgery, and best supportive care.

Clinical nutrition for patients with stomach cancer

A state of malnutrition is often found in patients with esophagus and stomach cancer. This may be related to dysphagia (difficulty with sensation or obstruction of the passage of food through the mouth, pharynx or esophagus), cachexia associated with the disease (syndrome characterised by loss of fat and muscle mass) and chemotherapy. In addition to the causes of malnutrition common to all esophagus and stomach cancer patients, there are the nutritional alterations resulting from surgical treatments.

Nutritional alterations resulting from surgical treatment for stomach cancer

During surgery for esophagus or gastric resection, a small probe can be positioned (nutritional jejunostomy) to ensure physiological nutrition in the postoperative period (through the use of Enteral Nutrition - NE) as well as the required amount of nourishment when its introduction through the mouth is poor or inadequate compared to the need. The nutritional jejunostomy is left in place at the time of discharge, and is used in cases where the patient is unable to maintain a proper diet to cover nutritional requirements.

After gastrectomy, the early symptoms include small stomach syndrome (early satiety and gastric distension) and dumping syndrome (occurring after taking the meal and include hypotension, tachycardia, dizziness, tiredness, fainting, feeling cold and profuse sweating are found. Diarrhoea may also be experienced and bilious vomiting may occur in patients who have undergone partial gastrectomy with gastro-jejunal reconstruction.

The later issues include anaemia and malabsorption of calcium. It is necessary to carry out blood tests to assess any possible supplements.

Following esophagectomy, patients may experience a reduced ability to intake large volumes of food and in some patients dumping syndrome may occur.

Information for the diet of patients operated for gastric cancer

Dietary guidelines focus on the consumption of small, frequent meals throughout the day, separating liquids from solids. Eating small bites and chewing well are recommended in order to facilitate swallowing and digestion. For the nutritional management of dumping syndrome, simple sugars have to be limited.

In the presence of diarrhoea, it is advisable to limit simple sugars and drink liquids in small sips. As regards the possible presence of bilious vomiting after intervention for subtotal gastrectomy, treatment is essentially surgical, but in this condition the patient may also benefit from a partition of the diet into small and frequent meals. Following esophagectomy, sticky foods, foods that are fermented and carbonated soft drinks should all be avoided. It is also important that the patient remains sitting for 30-60 minutes after taking the meal and at least 2 hours before going to bed.

For patients who have undergone gastric or esophageal resection, short and long term follow-ups are of crucial importance in order to immediately adapt to the more appropriate dietary pattern, correct any errors present in the diet, prevent weight loss and identify any late symptoms.