Gastric Cancer

Gastric adenocarcinoma is one of the most common human solid tumors worldwide. In the United States, approximately 25,000 people are diagnosed annually with gastric adenocarcinoma. We see approximately 300 patients with newly diagnosed gastric cancer yearly at M. D. Anderson.

The symptoms related to gastric cancer are typically vague and longstanding in many patients. Thus, advanced-stage disease is diagnosed in a significant proportion of patients. Esophagogastroduodenoscopy is considered the standard of care in the evaluation of patients with new or worsening symptoms of epigastric pain, gastroesophageal reflux, early satiety, or unremitting nausea and vomiting. A Clo test is performed on gastric aspirates to determine the presence of Helicobacter pylori infection. Any suspicious mass lesion, areas of inflammation, or edges of ulcers are biopsied to assess for the presence of malignant disease.

The history obtained from a new gastric cancer patient includes symptoms, risk factors, and family history. During the physical examination, evidence of advanced-stage disease can be found in the form of a palpable epigastric mass or a nodule located in the periumbilical region (Sister Mary Joseph's node) or supraclavicular region (Virchow's node) or on digital rectal examination (Blummer's shelf). Lymphatic regions in the neck, supraclavicular, and infraclavicular regions are thoroughly examined, and suspicious lymph nodes are biopsied by fine-needle aspiration.

At M. D. Anderson, the diagnostic evaluation includes initial laboratory tests, including a complete blood cell count (CBC), liver function studies, and measurement of serum electrolytes. Baseline serum tumor markers, carcinoembryonic antigen and carcinoma antigen 125, are measured and then followed serially during treatment and follow-up. Standard 2-view chest radiographs are evaluated for the presence of pulmonary metastasis. Chest computed tomography (CT) is performed only in patients with abnormal results on standard chest radiography or with gastroesophageal junction tumors to assess extent of disease. Helical

CT of the abdomen and pelvis is performed in all patients to evaluate the stomach, regional lymph nodes, liver, and peritoneal cavity.

Esophagogastroduodenoscopy with endoscopic ultrasonography (EUS) is now a routine component of our staging in new patients with gastric cancer. At M. D. Anderson, we follow the American Joint Committee on Cancer (AJCC) staging guidelines (Table 1-1). EUS is extremely useful in determining the T classification of the tumor and may be helpful in assessing the presence of regional lymph node metastases. State-of-the-art EUS endoscopes are equipped with biopsy channels that can be used to perform needle aspiration biopsies of the stomach wall or of lymph nodes adjacent to the stomach.

Subclinical peritoneal spread (carcinomatosis) of gastric adenocar-cinoma may not be diagnosed by high-quality CT or EUS. Because of this limitation, surgeons at M. D. Anderson routinely employ staging laparo-scopic evaluation in patients with potentially resectable gastric carcinoma. Staging laparoscopy is generally the final staging procedure in gastric cancer patients who are thought to be surgical candidates with stage II or III disease. A finding of peritoneal carcinomatosis diagnoses stage IV disease, and the patient is considered for systemic rather than surgical therapy.

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