Gastric cancerGastric cancer is a malignant tumor disease of the stomach and affects 15.000 people in Germany alone. Gastric cancer usually originates from degenerated glandular cells in the gastric mucosa. In addition to these classic "adenocarcinomas", there are other types of tumors in the stomach such as "leiomyosarcomas", which originate from the muscle tie in the stomach wall, "gastrointestinal stromal tumors" (GIST), which are soft tie tumors, and "MALT lymphomas", which are malignant diseases of the lymphatic tie.
This text is limited to "classic" gastric carcinoma, which originates in the gastric mucosa.
Causes and risks for the development of stomach cancer
A clear cause for stomach cancer to develop is not yet known. Numerous Risk factors can, however, alone or in combination, promote the development of gastric cancer. The most important risk factors for stomach cancer include:
– Infection with Helicobacter pylori Among the risk factors, an infection with the bacterium Helicobacter pylori is probably the most important one. Helicobacter pylori is found in the stomach of every second person worldwide. The bacterium contributes to the conversion of nitrates into nitrites, which can cause a certain type of gastritis, called "type B gastritis". If the inflammations recur, i.e. become chronic, this can lead to the formation of gastric ulcers and promote the development of tumors. Gastritis caused by the bacterium Helicobacter pylori can be reliably treated with medications. These medications therefore not only treat the symptoms caused by the gastric mucosal inflammation. They also reduce the risk of stomach cancer. – Smoking and excessive alcohol consumption – Frequent consumption of heavily salted, cured, smoked or heavily grilled foods Such foods contain nitrates, from which carcinogenic nitrosamines can form in the stomach. – If there is a high incidence of stomach cancer in families (parents, siblings, children), it is not always easy to distinguish the influence of family eating habits from the genetic influence. – Previous gastric surgery – Specific gastric diseases Certain gastric polyps, pernicious anemia, autoimmune gastritis and Menetrier syndrome (giant folded stomach) also increase the risk of cancer. – Certain hereditary predispositions to cancer (carcinoma predisposition syndromes), such as predisposition to hereditary diffuse gastric carcinoma (HDGC) or hereditary nonpolyposis colorectal carcinoma (HNPCC). So-called HDGC plant carriers and HNPCC patients have an increased risk of gastric cancer compared to the general population. Here regular gastroscopies are particularly important, in order to recognize stomach cancer at an early stage. – Higher age
Who is affected?
The median age of onset is about 72 for men and 75 for women. Men are affected slightly more often than women.
Stomach cancer is one of the few cancers whose incidence has decreased in Western countries in recent decades. Some scientists attribute this to the preferred preservation methods of refrigeration and freezing. As a result, less food is consumed that has been preserved by salting, curing or smoking.
Symptoms of stomach cancer
In the early stages, stomach cancer causes few or no symptoms. Therefore, the disease is often first detected in a diagnosed at a later stage. The chances of recovery are best if the tumor is detected early and can be operated on. Often, however, the disease is not discovered until the tumor has progressed beyond the stage where cure rates are greatest.
If symptoms do occur, they are often very nonspecific. In case of repeated abdominal complaints, medical advice should always be sought, especially in case of difficulty in swallowing, frequent vomiting, loss of appetite, unclear weight loss, blood in the stool, black stool or unclear anemia.
If you notice the following symptoms, you should seek medical advice immediately:
– You feel a newly developed aversion to certain foods, for example, meat. – Your body reacts sensitively to foods that you have previously tolerated well. – You suffer from symptoms such as lack of appetite, heartburn, bloating or nausea. – You are suffering from weight loss. – You experience pain or a feeling of prere in the upper abdomen. – You feel tired, listless, your performance is limited. This may be a sign of anemia, which can develop because of chronic blood loss. – Immediate medical attention in case of vomiting blood, black stools or water retention in the abdominal area.
How does the doctor make the diagnosis?
The doctor will Medical history, by first asking questions about symptoms and previous illnesses and asking about possible signs of a stomach tumor. A physical examination focuses on any changes in the abdomen and palpable enlargement of the lymph nodes. If a disease of the stomach is suspected, it is usually necessary to look inside the organ.
A Gastroscopy (gastroscopy) makes this possible. The patient swallows a type of tube (gastroscope), which the doctor advances from the mouth through the esophagus, across the stomach and into the duodenum. This tube-like device has light, camera and channels for instruments. At the front end, the gastroscope is equipped with a light source and a small video camera, so it can be used to examine the inner wall of the stomach on a monitor. With the help of a small forceps, the doctor can take tie samples, which are later used under the microscope to examine, for example, an inflammation, an infestation with Helicobacter pylori, but also whether tumor cells are present. The growth type of the tumor can be determined in the laboratory on the basis of the tie sample from the gastroscopy ("Lauren classification"). Determine the degree of differentiation of the tumor cells ("grading"). The two main types in the Lauren classification are the intestinal carcinoma of the stomach, which tends to grow in a polyp-like and superficial manner and that diffuse gastric carcinoma, that grows into the stomach wall, is often difficult to distinguish from the surrounding area and spreads to the lymph nodes at an early stage.
If it is determined during the examination of the tie samples that it is stomach cancer, the stage and spread of the disease is recorded in several further examinations (staging). The following examinations are used:
– Ultrasound of the abdomen – endosonography: this involves inserting an ultrasound probe into the stomach, which is also done by mouth, as in gastroscopy. This examination can be used to determine exactly how far the tumor has already penetrated the stomach wall. – Computed tomography of the chest, abdomen and pelvis – X-rays of the chest – Scintigraphy of the bones: A skeletal scintigraphy may be performed if you have symptoms that indicate daughter tumors (metastases) in the bone (for example, bone pain). In this examination, the patient is injected with a weakly radioactive substance (the so-called "tracer") into a vein. This substance is temporarily deposited in the bone. Because bone remodeling is increased in the marginal areas of metastases, more tracer accumulates here and these areas appear darker on the scintigram. – There are also certain tumor markers that the doctor can determine in the blood. However, these values have no significance for the diagnosis, but serve at best as comparative values after therapy has been carried out, in order to be able to determine the success of the treatment.
Stomach cancer can spread via the lymphatic system, the bloodstream or directly to neighboring organs. Metastases are therefore often found in the liver or in the lymph nodes of the abdomen and lungs, for example. Metastases can also form in the ovaries (Krukenberg tumor) or in the so-called Douglas space between the uterus and the rectum. The aforementioned investigations can be used to determine the stage. Diagnose the type of tumor. This is important because further treatment depends on this.
Therapy for stomach cancer
The extent, growth type, and location of the tumor determine the extent of surgery. Tumors that are still confined to the innermost layer of the stomach wall (mucosa) can be removed during a gastroscopy (endoscopic resection). In this case, only the tumor. The directly adjacent tie is removed. In the case of deeply ingrown tumors, either part or all of the stomach including surrounding lymph nodes must be removed (gastrectomy) – possibly also the lower part of the esophagus or the spleen and part of the pancreas. To restore the passage of food, the rest of the stomach or the end of the esophagus is connected to the small intestine. If possible, the surgeon forms a so-called substitute stomach with a section of the small intestine.
An additional (both before and after surgery) Chemotherapy Improves survival of patients with locally advanced tumors located in the transition area between the esophagus and stomach, or when the tumor causes recurrent gastric bleeding or narrowing of the digestive tract.
If the tumor has spread into the peritoneum (Peritoneal carcinomatosis), it may be possible to prolong survival in some patients by surgically removing the affected peritoneal parts combined with so-called hyperthermic intraperitoneal chemotherapy (in which the drugs are administered directly into the abdominal cavity). Such treatment is preferably carried out in the context of clinical trials.
If the tumor cannot be removed completely, surgery is not performed. In this case, treatment with drugs (chemotherapy, possibly combined with targeted agents) can relieve symptoms and prolong survival. The aim of a palliative therapy approach is primarily to maintain the quality of life and alleviate discomfort.
The Immunotherapy with so-called checkpoint inhibitors is also being intensively researched in gastric cancer. There are signs that these agents could become established as another treatment option. In particular, research is being done to determine which subgroups of gastric cancer patients will benefit from immunotherapy.
It is important in stomach cancer patients to Nutrition further to be secured. If the stomach is severely narrowed by the tumor, insertion of a plastic or metal tube (called a stent) can help restore food passage. Alternatively, surgery can be performed to bypass the narrowed area. If neither of these succeeds, artificial feeding may be necessary – for example, via a thin tube inserted through the abdominal skin into the stomach or small intestine (feeding fistula, PEG tube = percutaneous endoscopic gastrostomy).
Many patients suffer from digestive problems after surgery. However, these can be at least partially prevented with appropriate measures. In patients who have undergone surgery, the level of vitamin B12 in the blood should be monitored. If the values are too low, the vitamin must be added. Nutritional status should also be assessed regularly (weight control).
The chances of recovery from gastric carcinoma depend on the stage and spread of the tumor. In the early stages, when the tumor is still confined to the mucous membrane, the chances of cure are good. However, if the tumor cannot be completely removed due to its size or if it has already metastasized, the chances of survival decrease. For the therapy of gastric cancer nowadays with surgical procedures are available. Modern cytostatic chemotherapies as well as checkpoint inhibitors provide effective treatment methods. Both the tumor diseases in the upper digestive tract and the necessary therapies that have taken place often leave behind considerable functional sequelae. These lead to necessary changes in lifestyle, diet and behavior in everyday life. After removal of the stomach, there is no longer a nutritional reservoir available for storing meals.
The altered anatomical conditions can also lead to abdominal discomfort, for example gas formation with flatulence, pain, diarrhea, etc. Three daily main meals are no longer sufficient to supply the necessary amount of energy. The number of meals per day must be increased to 5-7, and the amount of food consumed must be reduced (smaller meals, more frequent meals). The worsened energy utilization is reflected in an impediment of fat digestion with corresponding energy losses (and fatty stools). The drug administration of enzymes can be helpful here, especially to support fat digestion. It is not uncommon for patients to lose a significant portion of their initial weight after surgery. The change in diet usually lasts for several months and therefore requires extensive nutritional medical support and specialist advice during this period.
If an outpatient or inpatient rehabilitation program follows the hospital stay, the rehabilitation program will show the patient how best to cope with his or her disease.
The therapeutic measures, which are determined by the attending physicians at the beginning of rehabilitation and in consultation with patients, take into account both physical and psychological impairments. Because each person reacts in a very different way to the therapies they have undergone, with corresponding secondary disorders, individual treatments and consultations are of outstanding importance. These treatments are offered in specialized clinics for oncological rehabilitation. It is important to emphasize the presence of medical expertise after operations in the upper digestive tract, such as after removal of the entire stomach (gastrectomy after gastric pull-up) or after gastric Partial removal.
At the beginning of the rehabilitation stay, the doctor will obtain a comprehensive overview of the patient's medical history, taking into account the findings he or she has brought with him or her, and a detailed examination will be carried out. Subsequently, together Personal rehabilitation goals and a Therapy plan set. If necessary, modern diagnostic procedures are available. Thus, in addition to necessary laboratory tests. Endoscopic procedures if necessary. Additional diagnostic measures such as cardiovascular Functional diagnostics incl. electrocardiogram (ECG) or a lung function measurement can be arranged.
The primary goal of rehabilitation is always to overcome the consequences of the disease during and after gastric tumor treatment and at the same time to achieve the highest possible quality of life. A team of specialized doctors, nutritionists, physiotherapists, occupational therapists and social workers should accompany the patient during the stay. Physiotherapeutic training such as exercise therapy and equipment-supported training are aimed at improving physical performance, taking particular account of previous surgical interventions and thus the current scar condition. Intensive and individual Nutritional consultations are being used to improve situation-adapted nutritional intake. In Group and individual consultations with psychooncologists, the often stressful life situation is dealt with in individual discussions; in addition, special relaxation methods are used for further psychological stabilization (yoga, mindfulness meditation, autogenic training and progressive muscle relaxation according to Jacobson). Occupational therapy are offered for questions of independent coping with everyday life, but also especially for sensory disturbances, which can occur after certain chemotherapies. Go to Pain relief pain therapy methods are used, for the treatment of nausea possibly. alternative healing methods such as acupuncture are also used. The task of Social counseling is mainly focused on advisory support with regard to the current social situation, in particular with regard to questions about incapacity for work, severe disability law, reintegration into working life and support options in everyday life at home.
The success of rehabilitation treatment after operations and therapies in the upper gastrointestinal tract is therefore based on a differentiated, holistic treatment concept to help people regain their strength and cope with the changed life situation.
How to continue after the rehabilitation stay?
Oncological rehabilitation is always practice-oriented and suitable for everyday life. It shows the described important steps in dealing with the gastric tumor disease and the therapies that have taken place in such a way that the recommendations can be followed up consistently and concretely at home after rehabilitation. The rehabilitation doctor prepares for patients. your doctors who will continue your treatment a detailed medical report. The report contains recommendations on medically necessary follow-up examinations and therapies, on psychological and social care, on the work situation and, if necessary, on how to cope with the new situation.