Source: Cancer Resource Room

What is Stomach Cancer?
A cancer that starts in the stomach is called stomach or gastric cancer. Cancers are formed by abnormal cells that grow and divide without control. These cancer cells replace normal cells and form a tumor or lump. As a tumor gets bigger, it can grow into nearby tissues and organs. Cancer cells can spread to other parts of the body through the blood or lymph vessels. Stomach cancer starts in the cells that line the inside of the stomach. Tumor cells grow there, invade through the layers of the stomach, and spread to lymph nodes and other tissues.

What is the stomach? What does it do?
The stomach is like a sack. It is hollow so it can fill with food, liquids, and digestive “juices.” It stretches when it is full and shrinks when it is empty. The stomach is muscular so it can churn and mix food to break it down for digestion. The esophagus brings food from the mouth to the stomach; the duodenum connects the stomach to the small intestine where nutrition is absorbed.

There are five layers of tissue that make up the stomach.

1. inside lining (mucosa)—makes digestive “juices”
2. support tissue for lining (submucosa)—contains the blood supply and lymph drainage for lining layer
3. muscle (muscularis)—for churning and mixing
4. support tissue for covering layer (subserosa)—attaches covering to muscle layer
5. outside covering layer (serosa)—protects inner layers

Stomach cancer usually starts in the lining layer. It grows larger and deeper through the other layers, spreading to nearby tissues and lymph nodes. The stomach can keep working even though a cancer has started in one part of it. This means a stomach cancer can get quite large or deep before it is diagnosed.

Not all stomach cancers are the same. Ninety-five percent are called adenocarcinomas (gland-forming cancers). The other five percent are divided among a few rare forms of stomach cancer.

• lymphoma
• squamous cell carcinoma
• anoacanthoma
• carcinoid tumor
• leiomyosarcoma

What are the symptoms of stomach cancer?
Symptoms of stomach cancer are caused by the tumor taking up space inside the stomach and disturbing its normal functions. Some symptoms are caused by cancer cells invading the layers of the stomach or spreading to other tissues next to the stomach. Stomach cancer usually grows for some time before it causes any symptoms. And the symptoms caused by stomach cancer are similar to some common stomach problems. What makes symptoms from cancer different are (1) having a variety of symptoms for several weeks, (2) having the same symptoms for several weeks, and (3) older age (more than 50 years old). When symptoms occur they include:

• abdominal discomfort or pain
• weight loss (without dieting) or poor appetite
• feeling full after eating a small amount of food
• weakness or tiredness (due to anemia—a low blood count)
• nausea and vomiting
• bloody or black, sticky bowel movements
• heartburn or indigestion

These symptoms often have other causes and should be checked by a doctor.

How is stomach cancer diagnosed?
A patient’s medical history and physical exam are the first steps in making a diagnosis of any disease. The medical history includes many details of a person’s health. In particular, the history will focus on the digestive tract—changes in eating habits, changes in bowel movements, abdominal pain or bloating, and how food affects any of the symptoms. In the case of stomach cancer, the patient’s history may include information about other diseases, such as pernicious anemia, atrophic gastritis, gastric ulcer disease, polyps of the digestive tract, or previous stomach operations.

The physical exam will focus on areas of discomfort in the abdomen, the presence of a mass (a lump) in the abdomen, an enlarged liver, fluid or swelling in the abdomen, any skin color change (yellow jaundice), or enlarged lymph nodes. The stool must be checked for blood.

After the history and physical exam, some diagnostic tests may be ordered. Blood tests and a chest x-ray check a patient’s general health. Some special blood tests called “markers” can be a clue that someone has stomach cancer. Blood tests that may be done include:

• Blood count- to check for anemia
• Liver enzymes -for possible spread to the liver
• Marker proteins- (CEA, aFP, beta-HCG, CA 19-9, CA 125) may increase

Special tests that are useful in diagnosing stomach cancer are:

1. Upper GI series (barium contrast study)—an x-ray test in which the patient swallows a liquid containing barium. The barium, a white liquid, goes down to the stomach and lines the inside layer of it. X-rays are then taken of the abdomen. They can show small changes in the smooth inner surface of the stomach. An upper GI is done in the radiology department of a hospital. The test is painless, but the barium liquid is unpleasant to drink. Barium can cause constipation and makes a person’s bowel movements white colored for a few days.
2. CT scan—x-rays made in thin cross-sections of the stomach and surrounding tissues. This set of x-rays can show a tumor in the stomach, as well as its spread to nearby tissues and lymph nodes.
3. Endoscopy—a flexible tube with a tiny camera in it is passed down the patient’s throat. The camera transmits pictures of the inner stomach to a TV screen. If an abnormal spot of tissue is “seen” with the camera, a small clipper inside the end of the tube takes a sample of the tissue for diagnosis. This sample is called a biopsy. The entire stomach can be viewed by endoscopy, from the esophagus to the duodenum. Many biopsy samples can be taken during an endoscopy. The procedure is done using sedation (a strong relaxing medication) given through an IV. The stomach has to be empty for several hours before the test. After the endoscopy, the patient feels sleepy from the medication, may have a mild sore throat from the tube, but is fine after the medicine wears off. It will take several days to get the results from the biopsy.

What is a biopsy? What does it mean to the patient?
A biopsy is a small piece of tissue or group of cells used to diagnose a disease. The tissue is taken from a spot suspected of being abnormal. Then the biopsy tissue is looked at under a microscope by a pathologist. The diagnosis is based on the appearance of the tissue and cells. The biopsy result helps in deciding a patient’s treatment.

What if the biopsy shows stomach cancer?
If the biopsy shows stomach cancer, the next step is to find out how much disease there is. In particular, you need to know:

• how widespread is the disease in the stomach
• how many layers has it spread through
• has it spread beyond the stomach into the lymph nodes, into nearby tissues, or to distant lymph nodes and other organs

What tests are used to find the spread of stomach cancer?

• Endoscopic ultrasound—endoscopy (described above) can be done to include an ultrasound probe located at the end of the endoscope tube. The probe sends out a sound wave inside the stomach that is picked up by a sensor on the skin. The sound wave signals make pictures of the stomach and surrounding tissues. The ultrasound radiologist can use the pictures to see changes in the smooth lining of the stomach, thickened layers, enlarged lymph nodes, and spread into nearby tissues.
• CT scans—these are x-rays that show cross-section pictures of the body. CT images let the radiologist see the stomach and other organs in many slices, going across, as well as up and down, the body. An abdominal CT scan shows the stomach, lymph nodes, liver, gallbladder and bile ducts, pancreas, small and large intestines, kidneys, major blood vessels, and part of the spine. The patient may need to drink a contrast solution to help outline the digestive organs. An IV is used to give the patient contrast “dye” that travels through the blood. Contrast dye in the blood makes a person feel very warm for a brief time, and causes a sensation of needing to pee urgently. Both feelings pass quickly. CT scans are not painful but do require lying on a table for about 30 minutes.
• PET scan—Another imaging test for tumors is called a PET scan. Although this test is not used for the diagnosis of stomach cancer, it can be used alone or combined with CT scans to find the spread of the tumor in and around the stomach. PET stands for Positron Emission Tomography. These scans require an injection of glucose (a sugar molecule) that is mildly radioactive. All tissues use glucose for energy, but tumor tissue uses more than normal. The PET scanner picks up the amounts of radioactivity coming from different parts of the body as the glucose is used up. When a tumor is present, it shows on the PET scan because the tumor cells use an abnormal amount of the radioactive glucose.
• Laparoscopy—this procedure lets the surgeon look inside the abdomen with a laparoscope, a thin tube with a small camera in the end. The laparoscope is inserted through a small abdominal incision. It transmits pictures from inside the abdomen to a TV monitor so the surgeon can see what tissues look normal and which do not. This helps plan the patient’s surgery and other treatments. Laparoscopy is done in the operating room with the patient under general anesthesia.
  The information about the patient including the medical history, physical exam, blood tests, x-rays, special scans, and procedures are used to describe the patient’s stage of disease and plan the best treatment for that disease.

What is the stage of a cancer? How is it determined?
The stage of a cancer describes how much cancer there is, what tissue it has invaded, and whether or not it spread to lymph nodes and other parts of the body. The higher the stage, the more complicated the disease. The stage is a combination of the size or extent of tumor growth, the number of lymph nodes involved, and the spread to other sites (metastases).
What are the stages of stomach cancer?

• Stage 0: cancer cells are only in the lining layer (in the mucosa) and have not invaded the outer layers or lymph nodes. May be called, “carcinoma in situ.”
• Stage IA: cancer has invaded from the lining layer into the submucosa, but not as far as the muscle layer. No tumor has spread to lymph nodes.
• Stage IB: cancer has not grown into the muscle layer, but has spread into 6 or fewer lymph nodes. OR cancer has grown into the muscle layer but not into any lymph nodes.
• Stage II: can be: (1) cancer has not invaded the muscle layer, but has spread to 7 to 15 lymph nodes near the stomach. (2) cancer has invaded the muscle layer and subserosa and spread to 6 or fewer lymph nodes. It has not invaded the covering layer or other tissues. (3) cancer has grown through all layers but has not spread to lymph nodes or other tissues.
• Stage IIIA: can be: (1) cancer has grown into the muscle and subserosa, spread to 7 to 15 lymph nodes near the stomach, but not into nearby tissues. (2) cancer has grown through all layers of the stomach, 1 to 6 nearby lymph nodes, but not to other tissues. (3) cancer has grown through the stomach and invaded nearby organs such as the spleen, liver, intestines, or pancreas, but not spread to any lymph nodes.
• Stage IIIB: cancer has grown through the outer layer of the stomach, spread to 7 to 15 nodes, but not spread to any other tissues.
• Stage IV: cancer has grown through all layers of the stomach and into nearby organs, or to more than 15 nodes, or both, or cancer has spread to other parts of the body (liver, lungs, bones, brain).

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