Like many malignant tumors, gastric cancer does not have a pathognomonic clinical picture and can be secretive for a long time. A. I. Savitsky described “small signs of stomach cancer”. These include: change in appetite - choosiness in food, the need for more tender food, worsening after ingestion fatty foods and aversion to meat; the appearance of hiccups, nausea, a feeling of heaviness after eating; loss of appetite; gradual weight loss. Often, patients have a decrease in interest in the environment, apathy appears. The most common symptom of stomach cancer is pain associated with compression of nerve fibers, it is aching and constant. The germination of the tumor in the liver or pancreas leads to the appearance of irradiation of pain in the right hypochondrium and back.
Cancer of the outlet section of the stomach leads to its stenosis. Food stays in the stomach for a long time and, in the absence of hydrochloric acid, rots. At the same time, patients note a feeling of fullness in the stomach, sometimes increasing peristalsis, belching rotten, and then profuse vomiting of decomposed food. Vomiting, as a rule, brings relief and patients cause it artificially. If it is possible to determine the tumor, it is necessary to get an idea of its size and mobility. The restriction of tumor mobility is due to the transition of the process to other organs. A dense, bumpy surface of the liver is more common in the presence of metastases in it. Percussion of the abdomen can reveal the presence of free fluid in the abdominal cavity, the appearance of which in such patients indicates peritoneal carcinomatosis. Ascitic fluid may also appear in connection with metastasis of cancer into the portal of the liver or into the hepatoduodenal ligament, while icterus is observed. skin.
Clinical course this disease has its own characteristics, and this is primarily the so-called. “masks”: anemic, hepatic, cardiac, pulmonary, febrile, polyarthritic. This is the initial oncological intoxication. Enlarged lymph nodes in the appropriate clinic indicate the presence of metastases in them, an example of this is the lymph node in the left supraclavicular region (Virchow's lymph node).
Shown vaginal and rectal examination. In this case, enlarged tuberous ovaries, a dense infiltrate in the rectovesical space and pararectal tissue (Krukenberg and Schnitzler metastases) can be detected.
The diagnosis of gastric cancer is confirmed by the data of an additional study of the patient. The leading role belongs to the X-ray method of research and fibrogastroscopy. To determine the prevalence of the process, the presence of distant metastases, laparoscopy is used. Changes in the blood in gastric cancer are not of a special nature. With stomach cancer, ESR and a decrease in hemoglobin can be accelerated.
Treatment
Surgical treatment of gastric cancer. Contraindications: oncological and general: high prevalence of the process (metastases of Virchow, Krukenberg, Schnitzler, in the bones, liver and cancerous ascites - IV stage); severe concomitant diseases of the cardiovascular system, lungs, liver, kidneys, etc., in which it is necessary to refrain from surgery. Pain relief is general.
Operation types:
1. Diagnostic laparotomy - to clarify the diagnosis.
2. Radical operations:
a) subtotal resection (distal and proximal);
b) gastroectomy;
c) combined resections - along with the affected stomach, other organs are removed. 3. Palliative operations:
a) palliative resection of the stomach;
b) bypass gastroenteroanastomosis;
c) gastrostomy with cardiac localization of the tumor.
4. Exploratory (trial) laparotomy - when it is not possible to perform any of the above operations.
The extent of the operation depends on the location and type of tumor. Gastric cancer usually does not progress to duodenum and therefore the lower border of the resection is 1-2 cm distal to the pyloric sphincter. With an exophytic tumor of the antrum in the proximal direction, it is necessary to deviate from a clearly defined tumor by 5-7 cm. Together with the stomach, they are resected. the greater and lesser omentums and the gastrocolic ligament, which contain the regional lymph nodes. The operation ends with the imposition of an anastomosis according to the Billroth-II method in the Hofmeister-Finsterer modification. During gastrectomy, an anastomosis is formed between the esophagus and a long loop of the jejunum with an additional Brownian fistula between the efferent and afferent loops. Severe complications of cancer - profuse bleeding, perforation, penetration - serve as an indication for palliative resection of the stomach.
If the surgeon detects a cancerous tumor that does not go beyond the limits of the stomach, but at the same time, unremovable metastases to the retroperitoneal lymph nodes are determined, a stomach resection should be done. Removal of the primary focus improves the patient's condition - reduces intoxication, eliminates pain and discomfort associated with eating. In addition, metastases are more sensitive to chemotherapy drugs than primary tumor. Such combined treatment allows prolonging the life of patients by 2-3 years. Currently, 5-fluorouracil is most often used at 0.5 intravenously per course up to
5 g or 1.0 IV for 7 days, 2 weeks off; ftorafur 1-2 g up to 50-40 g per course.
A malignant tumor of the stomach is the second most common cancer in the world. By using modern methods early diagnosis of stomach cancer is carried out, which is extremely important for maximum effectiveness medical measures.
How to diagnose stomach cancer?
Differential diagnosis of stomach cancer
The study of the differential diagnosis of gastric cancer is aimed at excluding diseases belonging to the category of precancerous, since their main symptoms are very similar to those of the development of a malignant tumor.
These diseases include:
- Stomach ulcer.
- polyps of the stomach.
- Chronic gastritis of atrophic nature.
In particular, for differential diagnosis is used fecal analysis for occult blood . If this analysis shows a positive result, we can confidently speak about the absence peptic ulcer stomach, in which blood elements in the feces will not be observed.
Also differential diagnosis should be done for syphilis and tuberculosis.
Syphilis of the stomach, if it occurs (which happens infrequently), manifests itself as chronic syphilitic gastritis, or as gums characteristic of syphilis. Gummas are observed in the form of infiltrates, may be different sizes and forms, single or plural.
For syphilitic gastritis, ulcers are typical, as well as the transformation of the stomach into a narrow, short canal.
If a patient has pulmonary tuberculosis, he is at risk for stomach tuberculosis, because when the patient swallows his own sputum, the tubercle bacillus regularly enters the gastric environment. There is no pronounced clinical picture in stomach tuberculosis. Sometimes there may be allergic skin reactions. An accurate picture in this case will give only histological analysis .
Stomach cancer - aggressive disease which does not forgive errors in diagnosis and treatment. Doctors note: every year, malignant neoplasms in the stomach are detected in an increasing number of people, and often in young people. Hearing a frightening diagnosis, the patient may fall into prostration and recognize the situation as hopeless. But in no case should you despair: the prognosis largely depends on your activity and faith in a successful outcome of the disease.
Diagnosis - stomach cancer: treatment is urgently needed!
Gastric cancer is a malignant degeneration of the cells of the mucous membrane of this organ. In most cases, in such a situation, the human body is able to independently destroy the “error” in the early stages, but if for some reason the immune system does not respond to the pathological process, the tumor begins to grow in breadth and depth, capturing more and more organs, disrupting their work.
Only a few years can pass from the onset of the disease to its terminal stage - therefore it is so important to detect the disease in a timely manner and begin its treatment. 70% of patients in whom stomach cancer is detected at the first stage recover completely, and if the patient comes to the doctor with an already developed tumor, this figure drops to 1–5%.
Not all types of stomach cancer have the same prognosis. It is determined by the histological features of the tumor - some types of malignant cells grow slowly and rarely metastasize (new foci of the disease in other organs). For example, polypoid gastric cancer grows quite slowly and can be successfully treated. It is possible to clarify the type of disease only after a genetic analysis of the tumor.
Who is more likely to get stomach cancer? The development of this disease depends on many factors, and not all of them are known to doctors today. It has been established that gastric cancer is statistically more often diagnosed in people with a stomach ulcer (including those who underwent organ resection after bleeding). In addition, risk factors include dietary errors, alcohol abuse, smoking and hereditary predisposition: if one of your older relatives has already consulted an oncologist about tumors of the gastrointestinal tract, you should be on your guard.
In Russia, stomach cancer is the second most common (after lung cancer). At the same time, this circumstance cannot be explained by poor environmental conditions, the lack of quality medical care or the unfavorable living conditions of our fellow citizens: a similar situation is observed in such highly developed countries as Japan, Norway and Great Britain. Another thing is that the same Japanese are extremely responsible for timely diagnosis cancer, so they regularly undergo screening (preventive examination) of the stomach.
In our country, sadly, stomach cancer is almost always detected at stage 3 or 4, when sparing treatment is not enough. If the tumor has already affected the body for a long time, you can’t hesitate, because every missed day reduces the likelihood of a life-friendly prognosis. Therefore, with any suspicion of oncology, you should immediately go to the hospital.
Stomach cancer stages
From the very moment of its appearance, a stomach tumor can be classified into one of five stages, each of which is characterized by certain symptoms and prognosis. Doctors use this classification to select effective treatment, which will destroy cancer or at least improve the quality of life of the patient.
- Zero stage - the so-called "cancer in situ" (in situ). The tumor is a small, thin layer of altered cells on top of the gastric mucosa. The disease can only be detected through a thorough screening examination. At adequate treatment the survival rate of patients approaches 100%.
- 1 stage - tumor cells grow into the gastric mucosa at different depths. 1-2 nearest lymph nodes are involved in the pathological process (malignant cells get there with the blood flow and form a new colony). 80% of patients diagnosed with stage 1 stomach cancer live longer than 5 years.
- 2 stage counts from the moment when the tumor grows into muscle layer stomach or when cancer cells are found in 3 or more lymph nodes. During this period, the first symptoms appear: indigestion and abdominal pain, heartburn, etc. Approximately half of patients with stage 2 stomach cancer who start treatment on time recover.
- 3 stage gastric cancer means either an extensive growth of a tumor that has spread to neighboring organs and tissues of the abdominal cavity, or the detection of cancer cells in a large number of lymph nodes. A patient with such a diagnosis may show signs of advanced stomach cancer. The prognosis for stage 3 is unfavorable: even with the use of modern therapeutic methods, only every fourth patient recovers.
- 4 stage does not necessarily mean significant tumor size or severe lymph node involvement. It is automatically set to all patients who have at least one metastasis during the diagnosis. For example, it may be a small secondary tumor in the liver, ovary, or lung. Only 5% of such patients have a chance to live longer than 5 years.
Diagnosis of the disease
To determine the stage of stomach cancer and prescribe the most effective combination of therapeutic measures, the patient successively undergoes several diagnostic examinations and passes lab tests. In this sense, the technical equipment of the oncology clinic where the patient applied plays a key role: modern techniques radiodiagnosis(such as positron emission tomography) allow much more accurate than conventional x-ray, ultrasound or CT to determine the spread of the tumor, as well as evaluate the effect of the treatment.
The most common methods for diagnosing stomach cancer include:
- Fibrogastroduodenoscopy (FGDS) is a study of the gastric mucosa using a video camera at the end of a flexible probe, which is inserted into the patient through the mouth. This - The best way get screened for stomach cancer.
- X-ray contrast examination - the patient drinks a special diagnostic solution, after which he is given X-ray stomach. The solution fills the organ, indicating abnormal constrictions or niches in the contour, characteristic of tumor pathology.
- Ultrasound is used to detect tumor metastases and assess the condition of the lymph nodes closest to the stomach.
- A study on tumor markers in the blood - in the presence of cancer in the patient's blood, specific substances are found that confirm the presence of a pathological process.
- A biopsy is the removal of a small area of altered tissue for subsequent examination under a microscope. This is the most reliable way to confirm or refute the diagnosis.
- CT, MRI, PET are high-tech methods of radiation diagnostics that help to assess the extent of tumor spread, find distant metastases in the body and plan an optimal treatment strategy.
Treatment of stomach cancer
Surgery
It is an important step in the fight against stomach cancer. During the operation, surgeons remove a section of the stomach or the entire organ (depending on the spread of the tumor) and cut out the nearest lymph nodes. Such a radical approach helps to prevent re-growth of the tumor. If the stomach is removed entirely, surgeons create something like an artificial stomach by connecting the esophagus to the intestines.
The operation is performed only after a complete diagnosis of all parts of the body using PET or CT (which is less informative). The results of the research allow the oncologist to assess the degree of spread of the disease in the body (including the presence of metastases), and therefore make an informed decision on the appropriateness of the operation.
Chemotherapy
It is used as an adjunct in the treatment of stomach cancer. Drugs that are detrimental to the tumor are sometimes prescribed shortly before surgery, which makes it possible to reduce the size of the tumor and, therefore, reduce the amount of intervention. Chemotherapy is also carried out after the surgeons have done their job - to kill cancer cells that could remain in the lymph nodes. Unfortunately, this method is quite aggressive in relation to the human body: many patients experience marked weakness, nausea, hair loss and other health problems.
Radiotherapy
essence this method- destruction of tumor cells by radiation. Radiotherapy is also an addition to the above methods. Oncologists use focused X-ray beams to minimize the effects of ionizing radiation on healthy organs and tissues, however side effects treatments that sometimes make themselves felt in the long term. For example, radiation heart disease.
hormone therapy
It is used for tumors that are sensitive to the effects of certain biological active substances. Is helper method care for patients with stomach cancer.
Targeted Therapy
The use of unique drugs that target cancer without affecting other body tissues (as is the case with chemotherapy). Currently underway clinical trials aimed at improving the effectiveness of targeted drugs in gastric cancer.
Palliative care
It is prescribed in situations where there is no hope for the complete destruction of the tumor. Remember that with the right medical strategy, a person with end-stage stomach cancer can live for several years, and these years can be the happiest of his life. Therefore, doctors do everything possible to avoid digestive disorders, pain, exhaustion and other manifestations of the disease. In some cases, tumor growth can be slowed down so much that the life expectancy of the patient (especially the elderly) exceeds all expected periods.
Stomach cancer is a difficult test in the life of a patient and his family members. But put your hands down big mistake. Medicine is rapidly developing in the direction of helping cancer patients, and with the proper degree of perseverance and fortitude, many patients cope with terrible diagnosis regaining the status of a healthy person.
flowing in different forms.
In the event that the pathology is diagnosed at the first stage, then the chance of recovery is more than 80%. Therefore, it is important to determine in time initial signs suspected to indicate cancer and undergo a comprehensive examination conducted by in modern ways diagnostics.
How to identify the disease by the first symptoms
Almost any growth of cancer cells, regardless of the location of the tumor in the initial stages, does not cause obvious changes in well-being. This fully applies to cancerous lesions of the walls of the stomach.
There are also painless forms of a malignant neoplasm, in which pain occurs only when metastases appear. But, despite the meager clinical picture in the first or second stage of gastric cancer, you can still fix a number of certain signs indicating that something in the body is not changing for the better.
The very first manifestations indicating the possible formation of a cancerous tumor in the stomach include:
- Disturbances in the process of digestion. With the development of a tumor, a person begins to periodically feel nausea, bloating, heartburn, or belching with air. A cancerous process in the stomach causes a decrease in appetite, which can be manifested by intolerance to a certain product, and most often it is meat. Patients are concerned about constipation, followed by diarrhea.
- Noticeable performance degradation, lethargy, depression, sleep problems.
- Periodic rise in body temperature.
- Weight loss.
- Discomfort in the upper abdomen, they are expressed by a feeling of heaviness, fullness.
- Pain. Soreness does not appear immediately and at first it quickly passes. The nature of the pain can be aching, pulling, cutting. There are pains in stomach cancer often regardless of food intake, and they can be localized not only in the epigastric region, but also in the projection of the pancreas, just above the navel. The pain often radiates to the back and upper chest.
The spread of the tumor to a large part of the organ leads to a narrowing of its cavity, and this, in turn, becomes the root cause of the rapid onset of saturation.
When a malignant neoplasm is located near the esophagus, it is possible to develop difficulties in swallowing food. A tumor that blocks the exit to the intestine prevents the passage of the food bolus and then the person is almost constantly worried about the feeling of heaviness. It is possible to get rid of it only by causing vomiting.
Digestive disorders change the functioning of all organs of the gastrointestinal tract, which leads to a deterioration in metabolism. In cancer patients, the tongue is coated with a grayish or yellowish coating, may appear bad smell from mouth. The development of a malignant tumor is evidenced by the appearance of tarry stools and vomiting with blood.
The above symptoms are also found in many other diseases. Therefore, you should not panic if you find even most of the signs of cancer in yourself. A reliable diagnosis can be made by specialists only on the basis of a number of diagnostic procedures performed, but it is not worth delaying the examination.
How to diagnose stomach cancer in the early stages?
Detection of the disease at the earliest stage allows oncologists to choose the most effective treatment.
When unusual symptoms appear and with a noticeable and unmotivated deterioration in well-being, you should always contact a medical institution.
The doctor must describe all his feelings, indicate the time of their appearance and increase.
Based on the examination and questioning, the doctor prescribes necessary tests and instrumental methods of examination, allowing with a greater degree of probability to confirm or exclude cancer.
Particular attention to their health and the appearance of unusual symptoms should be given to those people who already have or had stomach polyps, peptic ulcer, chronic gastritis.
Anemia is also considered a precancerous disease. Patients with these diagnoses need at least twice a year to engage in a control examination of the body.
Palpation
With a cancerous process in the stomach, it can be detected inflammatory process, ESR change, anemia. On final stages cancer, the parameters of the biochemical composition of the blood also change significantly.
Examination of feces and vomit for occult blood
Determines the violation of the integrity of the mucous membrane of the digestive tract. This method is used as additional examination confirming stomach disease.
Before collecting feces, the doctor should warn the patient about dieting, about refusing certain medications. credible positive test it is considered if the blood shows a two-time analysis.
The study of vomit is carried out when possible. A Guaiac test is usually carried out, showing even traces of blood.
Genetic examination
about hereditary predisposition to malignant neoplasms gastric cancer is evidenced by the determination in humans of an atypically altered (mutated) CDH1 gene. A similar study is recommended for those people in whose family there have already been cases of stomach cancer.
Magnetic resonance imaging
Diagnosis is carried out on a special tomograph. The principle of receiving data from the device is based on the interaction of radio frequency pulses and magnetic fields.
Photo of diagnosis of stomach cancer using MRI
The patient must first drink a contrast agent. After preparation, it is placed in a tomograph and several pictures are taken, the procedure takes about 30 minutes in time. Clear images obtained in three projections allow you to identify all changes in the organ.
In addition to the stomach itself, the nearest lymph nodes and nearby organs are examined.
Ultrasound and CT
Diagnostics is assigned to assess the spread of the cancer process in internal organs. When examining women, it is necessary to conduct gynecological ultrasound, since cancer in the stomach can lead to ovarian damage.
CT examination is an x-ray computed tomography. If gastric cancer is suspected, it is performed to examine the organs in the abdominal cavity and the entire retroperitoneal space.
The CT method reveals neoplasms, secondary foci located near the stomach and remotely.
Differential Diagnosis
Gastric cancer does not have the symptoms that are characteristic only for this type of disease. The same type of manifestations can accompany cancer and gastric ulcer, cancer and benign neoplasms.
Similar symptoms have some forms chronic gastritis into the acute stage. Therefore, modern diagnostic procedures are extremely necessary in order to correctly and quickly identify cancer at the zero and first stages of its development.
Video about preparing for the diagnosis of stomach cancer:
Causes of stomach cancer
The etiology and pathogenesis of gastric cancer, as well as cancer in general, still remain unclear, although a number of factors have been identified that predispose to a more frequent occurrence of this disease. So, it is noticed that in men the incidence of stomach cancer is 10-50% higher than in women.
This can be explained by more common smoking among men than among women and more frequent use of strong alcoholic beverages.
A significantly higher frequency of gastric cancer among the elderly (over 50 years) has long been noted, but it can occur in younger people, and in some cases even in children.
Gastric cancer may have a hereditary predisposition to occur. A number of families where all suffered from this disease are described.
The dependence of the frequency of gastric cancer on the nutritional habits of the population was noted. It has been established that the predominance of smoked meats, spices, bread, cheese, rice, very hot, especially fatty foods in the diet, frequent use of strong alcoholic beverages contribute to a more frequent occurrence of stomach cancer, while among population groups that mainly eat citrus fruits , vegetables, milk, beef, sterilized canned foods, stomach cancer is somewhat less common.
Among people who eat irregular meals, stomach cancer is also slightly more common than among people who follow a rational diet.
The undoubted carcinogenicity of such substances as methylcholanthrene, 3,4-benzpyrene contained in coal tar, and some others has been proven.
The most common background for the development of gastric cancer is chronic atrophic gastritis with secretory insufficiency of the stomach (especially atrophic-hyperplastic gastritis). Patients with B12-deficiency anemia, in whom the phenomena of pronounced atrophy of the gastric mucosa are naturally observed, according to various authors, die from gastric cancer 3-20 times more often than those who do not. suffering from this disease. Numerous observations indicate the possibility of malignancy of gastric polyps in 12-50% of cases.
The degeneration of chronic stomach ulcers, especially long-term, callous ones, into cancer, according to various authors, is observed in 1.3-20% of cases.
pathological anatomy
According to the nature of tumor growth (macroscopically), the following forms of gastric cancer are distinguished: 1) polypoid or mushroom-shaped cancer with exophytic growth into the lumen of the stomach, resembling a pedunculated polyp; the tumor is characterized by slow growth, usually ulcerates late and metastasizes; 2) saucer-shaped with ulceration in the center ("ulcer-like", late metastasizing; 3) icfiltrative-ulcerative, the most frequent; 4) diffuse infiltrative cancer. The last two forms are different. rapid growth and early multiple metastasis.
According to the histological structure, adenosolid, colloid or mucous cancer, medullary (with a predominance of the parenchyma in the tumor mass) and fibrous cancer - skirr (with a predominance of the stroma in the tumor) are distinguished.
Most often, gastric cancer is localized in the pyloroanthral section of the stomach, less often on the lesser curvature and in the cardial section, even more rarely on the anterior and back wall, greater curvature and in the fundus of the stomach. Metastasis occurs in the lymphatic and blood vessels: in regional lymph nodes (retropyloric, lesser omentum, greater omentum), in the left supraclavicular lymph nodes (the so-called Virchow metastasis), in women - in the ovaries (Krukenberg metastasis), in pararectal tissue (Schindler's metastasis). ), in the liver, navel, retroperitoneal lymph nodes, lungs, rarely in bones and other organs.
Stomach cancer symptoms and periods
Conditionally allocate:
1) early (or initial) period of the disease
2) the period of obvious clinical manifestations of the disease
3) terminal period
In the early stages of the disease, patients report the following symptoms stomach cancer: unmotivated weakness, apathy, fatigue, loss of appetite, often - aversion to meat food, sometimes - bad taste in the mouth, frequent belching, often with rotten smell, a feeling of heaviness in the epigastric region and other mild symptoms of gastric discomfort, unreasonable weight loss - the so-called syndrome of small signs (A. I. Savitsky), which makes it possible to suspect this disease and purposefully conduct an examination of patients.
Gastric cancer in the period of obvious clinical manifestations, the main symptoms:
1) pain in the epigastric region of a sucking or aching nature, constant or without a definite connection with the time of eating, sometimes resembling ulcers;
2) anorexia, in rare cases, there is an excessive appetite (bulimia);
3) progressive weight loss;
4) progressive dysphagia (with cancer of the cardial part of the stomach, spreading into the esophagus), mainly with a delay in swallowing poorly chewed and dry food;
5) nausea and vomiting, often with an admixture of blood in the vomit (often with localization of cancer in the pyloroanthral section of the stomach); a feeling of rapid satiety and fullness of the stomach - due to pyloric stenosis and impaired passage of gastric contents into the duodenum;
6) chronic gastric bleeding (with periodic stools such as melena or occult bleeding), leading to anemia;
7) causeless prolonged fever (at first, usually subfebrile condition). The listed symptoms with a predominance of one or another of them, depending on the location of the size, the morphological structure of the tumor, are observed at a certain stage of the disease in most patients.
Stomach cancer shape. Depending on the features clinical course The following types of stomach cancer are distinguished:
1) dyspeptic (manifested by a decrease and perversion of appetite, feelings of rapid satiety during meals, heaviness and pressure in the epigastric region, nausea);
2) pain (the leading symptom is pain);
3) febrile (with fever up to 38-40 ° C without pronounced other symptoms;
4) anemic;
5) hemorrhagic (manifested by gastric bleeding due to early ulceration and decay of the tumor).
However, the most unfavorable due to the difficulty of early recognition are latent (in which all the symptoms of the disease are absent for a rather long time) and painless (manifested for a long time only a syndrome of small signs) forms of stomach cancer.
When the tumor is localized in the cardial and fundal sections of the stomach, pain can simulate angina pectoris. Often, especially in cardioesophageal cancer, there is increased salivation, hiccups. In some cases, the first clinical manifestations of the tumor are due to metastases (to the lungs, liver, bones, etc.).
On examination, pallor (due to anemia) or a peculiar earthy color of the skin is often noted. Palpation in some cases can be noted soreness and some stiffness of the muscles of the anterior abdominal wall in the epigastric region, sometimes it is possible to palpate the tumor in the form of a rounded dense formation.
In some patients, distant metastases are detected: For example, an enlarged (1-1.5 cm in diameter) lymph node in the left supraclavicular region (vortex metastasis) can be palpated or an enlarged liver with an uneven surface is determined. In patients with tumor localization in the pylorus, protrusion of the anterior abdominal wall in the epigastric region can be noted and a peristaltic wave of contraction of the stomach slowly moving from left to right can be observed. During percussion, the zone of tympanitis above the stomach area expands and goes to the right of the midline.
In the terminal period diseases of patients are usually disturbed by severe debilitating pain in the epigastrium, right hypochondrium (metastases to the liver), back (germination of the tumor in the pancreas), sometimes in the bones (in the area of metastases), there is complete absence appetite, aversion to food, nausea.
Often, after almost every meal, vomiting occurs, there is a sharp weakness, weight loss, sometimes to the extent of cachexia, and fever. The skin of patients is usually a kind of earthy shade, dry, in some cases, the presence of ascites can be noted (due to metastases in the lymph nodes of the liver gate and cancerous seeding of the peritoneum).
X-ray examination in many cases already in the early stages of the disease allows you to confirm the diagnosis and establish the localization of the tumor. A pathognomic radiological sign of gastric cancer is the presence of a so-called filling defect, which is an area on the contour or relief of the stomach that is not filled with a contrast mass.
In the area of tumor localization, there is usually no peristalsis of the stomach wall (due to cancerous infiltration), “cliff” and destruction of the mucosal folds are observed. With ulceration of the tumor, a niche-like protrusion is determined, performed with a contrast mass and surrounded by a section of the gastric wall protruding into the lumen of the stomach due to cancerous infiltration in the form of a finger-shaped “shaft”. With early disintegration of the tumor (primary ulcerative form of cancer), the x-ray picture may very much resemble a normal peptic ulcer of the stomach.
In some cases, cancerous infiltration of the stomach wall leads to its deformation, sometimes to kinks (cascade stomach). Cancer of the antral and pyloric sections of the stomach early leads to stenosis of the latter, which is accompanied by a violation of the evacuation of the contrast mass into the duodenum, the expansion of the overlying sections of the stomach, which contain a large amount of liquid on an empty stomach (gastric juice, saliva) and the food taken the day before.
The absence of displacement of the stomach (spontaneous and during palpation of the epigastric region by a radiologist during the study) is one of the signs of tumor invasion into nearby organs. Great importance in the diagnosis of stomach cancer acquires gastrofibroscopy.
Gastroscopy should be performed in all patients who have a suspected tumor of the "stomach, with long-term non-scarring peptic ulcers of the stomach, as well as with a diagnosis of a tumor established on the basis of clinical data and confirmed by X-ray - for exact definition its nature, size and biopsy. With gastroscopy, the appearance of the tumor in many cases is quite characteristic.
This is either a polypoid tumor, often on a broad base, usually with an uneven, bumpy surface, often with areas of ulceration and necrosis on the surface, or a saucer-shaped cancerous formation with ulceration in the center, surrounded by a high tuberous shaft rising above the surrounding mucosa. The color of the tumor can be from intense red to grayish yellow. The bottom of ulcers and ulcers can be smooth, but more often it is uneven, covered with necrotic overlays, and often bleeds. The later stage of the process is a large infiltrative tumor with a significant decay in the center in the form of a large cancerous ulcer several centimeters in diameter.
The mucosal folds around the tumor become rigid due to significant cancerous infiltration and break off at the edge of the ulceration, do not straighten out when the stomach is inflated (using a special gastrofibroscope device). Diffuse infiltrative cancer has the appearance of a focal bulging of the stomach wall with an uneven grayish-white mucous membrane, often bleeding easily; the wall of the stomach in this area is not peristaltic.
When the stomach is inflated with air, this swelling does not disappear, the folds of the mucous membrane around do not straighten out. During gastroscopy, a targeted biopsy is performed. A special device of some gastrofibroscopes allows photographing areas of the gastric mucosa suspicious of tumor growth and comparing the data during subsequent gastroscopy. In all suspicious cases, when it is not immediately possible to establish a diagnosis of a stomach tumor, a second gastroscopy and biopsy is performed after 10-20 days.
A cytological examination is widely used for diagnostic purposes, the material for which is obtained by washing the stomach with an isotonic solution, a solution of chemotrypsin (“exfoliative method”), or using a two-channel probe with an abrasive balloon having a rough surface, which facilitates the exfoliation of cells from the surface of the stomach wall, which are then together with washing waters of the stomach are sucked off through the second channel of the probe ("abrasive method"). However, the most reliable is the targeted taking of material for cytological examination from suspicious areas using a gastrofibroscope (as well as for histological examination).
It is believed that cytological examination allows confirming the diagnosis of a tumor in approximately 80% of cases, including at an early stage of the disease.
Methods laboratory diagnostics gastric cancers are unspecific. However, a growing increase in ESR, anemization (taking into account the corresponding clinical signs). Anemia may have a normochromic character and at first be mildly pronounced, however, with the collapse of the tumor due to chronic blood loss, and in some cases massive stomach bleeding anemia rapidly progresses and becomes hypochromic. Often there is a slight leukocytosis.
The presence of achlorhydria and achilia is often observed in cancer of the body of the stomach, but cancer of the pyloroanthral part of the stomach can occur against the background of normal and even increased acidity. gastric juice. In the presence of achlorhydria, attention is often paid to the relatively high (15-20-25 titer units) so-called bound acidity of gastric juice, which is explained by increased fermentation processes in the stomach with the formation of a large amount organic acids, in particular dairy. However, this symptom is also non-specific.
The study of feces for occult blood in the vast majority of cases gives positive results.
Laparoscopy is used already in the late diagnosis of gastric cancer, mainly to determine the operability of the case.
Gastric cancer course and complications
The course of the disease is progressive, the average life expectancy without treatment in most cases is 9-14 months after diagnosis. Complications are associated with the growth and decay of the tumor, as well as its metastasis.
Metastases of gastric cancer often affect the overall clinical picture of the disease, local symptoms occur due to the metastases themselves and their growth, so that in advanced cases with multiple metastases it is often difficult to confirm that the stomach is the primary source of the tumor. Sometimes a relatively large tumor of the stomach proceeds hidden, and metastasis or metastases to other organs determine the entire clinical picture of the disease.
In order to more clearly define medical tactics and prognosis distinguish 4 stages of stomach cancer:
Stage 1: a tumor no more than 2 cm in diameter, not growing beyond the mucous and submucosal membranes of the stomach and not metastasizing;
Stage 2: the tumor reaches a diameter of 4-5 cm, the submucosal and even the muscular layer of the stomach wall sprouts, there are single, mobile metastases in the nearest regional lymph nodes (lymph nodes of 1-2 collectors);
Stage 3: the tumor infiltrates the subserous and serous layers of the stomach wall; often grows into neighboring organs; there are multiple metastases in regional lymph nodes, various complications are often observed;
Stage 4: a cancerous tumor of any size and any nature in the presence of distant metastases.
In accordance with a more detailed international classification, the whole variety of development options tumor process is defined by the symbols T (tumor), N (nodules) and M (metastases). The classification takes into account the degree of germination of the stomach wall by the tumor (Ti_4), the absence or presence of regional (NX_, NX+) and. distant (M0, Mi) metastases.
Stomach cancer differential diagnosis
In some cases, rough, sharply thickened folds of the stomach (in some forms of chronic gastritis, the so-called Menetrier's gastritis, etc.), identified by X-ray or endoscopic studies, make us think about the possibility of cancerous infiltration of the stomach wall ("submucosal growth"). The use of special X-ray methods (double contrasting, parietography, angiography) and endoscopy (dosed filling of the stomach with air, leading to the straightening of the mucosal folds), transillumination, taking into account clinical data, a blood picture, makes it easier to establish the correct diagnosis.
Peptic ulcers of the stomach, especially long-term, "calleous" always present difficulties for differentiation from rapidly disintegrating cancerous tumor(the so-called primary ulcerative forms gastric cancer), in addition, in approximately 10% of cases over time they become malignant.
Often, ulcerative forms of gastric cancer occur with a clinical picture of peptic ulcer, while, which should always be remembered, when prescribing a sparing diet and intensive anti-ulcer therapy, cancerous ulcers can temporarily decrease in size (due to a decrease in dystrophic processes and tumor decay) and even disappear (cicatrize ). Of decisive importance in the differential diagnosis of cancerous and peptic ulcers of the stomach are histological and cytological studies of sighting (through a fiberscope) taken biopsy specimens from the edges of the ulcer.
A reliable establishment of persistent achlorhydria and achilia in the presence of an ulcer-like defect in the gastric mucosa is highly suspicious of cancer.
Syphilitic and tuberculous gastric ulcers are very rare, the latter - usually already against the background of generalized tuberculosis, which facilitates their differential diagnosis with cancerous ulcers.
The differential diagnosis of sarcoma and gastric cancer is based on tumor biopsy data and is not of fundamental importance for treatment tactics and prognosis.
Benign tumors of the stomach are much less common than cancer; on x-ray examination, they differ, as a rule, in the evenness of the contours of the "filling defect", the absence of rigidity of the stomach wall in the adjacent areas. Often a differential diagnosis is possible with gastrofibroscopy.
In rare cases, a combination of dyspeptic phenomena and a radiologically determined filling defect is a manifestation of a long-term presence in the stomach. foreign body(bezoar).
stomach cancer treatment
The only radical treatment for stomach cancer is surgery. Indications for surgical treatment are all cases of gastric cancer in stage I-II. IN Lately advances in surgery make it possible to successfully perform a radical operation with good long-term results in a number of patients with III stage stomach cancer.
The operation is reduced to resection of a part of the stomach (distal or proximal subtotal resection) or total gastrectomy, removal of regional lymph nodes, and if the tumor grows in a limited area into neighboring organs, also to resection of the affected part of these organs (pancreas, liver, transverse colon) or the entire organ (spleen). A prerequisite is resection within healthy tissue 6-7 cm away from the visible edge of the tumor.
Conservative therapy for gastric cancer does not provide a cure for this disease, but it can alleviate the suffering of patients and, to a certain extent, prolong their lives. Conservative treatment is indicated for inoperable patients. It is carried out in 3 directions: 1) chemotherapy, 2) radiation therapy, 3) symptomatic therapy.
Currently, fluorouracil, ftorafur are used for chemotherapy of gastric cancer, which selectively inhibit the reproduction of tumor cells, however (though to a lesser extent) affect proliferating cells of normal tissue (especially hematopoietic tissue, the mucous membrane of the digestive tract).
Fluorouracil belongs to the group of antimetabolites, is 2,4-dioxo-5-fluoropyrimidine, in cancer cells it is converted to 5fluoro-2-deoxyuridine-5-monophosphate, which is a competitive inhibitor of the thymidine synthetase enzyme involved in DNA synthesis. Enter intravenously slowly (or drip in 500 ml of 5% glucose solution) at the rate of 10-15 mg / kg (0.5-1.0 g per day) daily or every other day.
Sometimes 15 mg per 1 kg of the patient's body weight is administered for 4 days in a row, and then treatment is continued at a half dose every other day. The drug is administered before the development of moderate toxic effects, which are most often hematopoiesis, anorexia, vomiting, diarrhea, dermatitis, etc.
Usually course dose 3-5 g of the drug, in rare cases of good tolerance - up to 7 g, then the treatment is interrupted, repeated courses with the effectiveness of the drug are carried out at intervals of 4-6 weeks. Treatment with fluorouracil is contraindicated in the terminal stages of the disease, with cachexia, severe parenchymal lesions of the liver and kidneys, leukopenia and thrombocytopenia. In order to reduce side effects, patients during treatment are prescribed large doses of vitamins (especially B6 and C), blood transfusions are performed.
Radiation therapy for gastric cancer is still ineffective, only about 10% of tumors under its influence temporarily decrease in size, mainly tumors of the cardial part of the stomach.
Symptomatic therapy for gastric cancer is carried out in inoperable cases. Its main goal is to relieve pain, maintain hemo- and homeostasis. Very strict adherence to a diet is usually not required, food should be complete, varied, easily digestible, rich in proteins and vitamins.
Creation in our country of a system of specialized cancer care and a wide network of specialized medical institutions (hospitals, dispensaries) makes it possible to improve early diagnosis and achieve better results in the treatment of this formidable disease.
Stomach cancer prognosis
The prognosis of a patient with stomach cancer is determined by the stage of the process, the possibility of performing a radical operation, and the histological structure of the tumor. With exophytically growing tumors, the prognosis is better than with endophytically growing ones, the presence of metastases in regional lymph nodes significantly worsens the prognosis.
Efficiency surgical treatment gastric cancer is primarily characterized by long-term results - the number of radically operated patients who lived more than 5 years after surgery. In this case, the risk of recurrence and the detection of metastases is significantly reduced.
Prevention of stomach cancer consists in the widespread promotion of rational regular nutrition, the fight against smoking, alcoholism, and the elimination of industrial hazards. Of great importance are the organization of dispensary observation of patients with so-called precancerous diseases, their timely treatment.
Recently, prerequisites have been created for the organization of a wide dispensary examination of the population in order to early detection stomach cancer.
Other malignant tumors of the stomach. Other malignant tumors of the stomach are much less common than gastric cancer. These are different types of gastric sarcomas: lymphosarcoma, spindle cell sarcoma (fibro-, neuro- or leiomyosarcoma; less often - round-cell or polymorphocellular sarcomas and its other varieties). Sarcoma occurs more often in more young age than cancer (up to 30-40 years), mainly in men. Very rarely, malignant gastric carcinoid is detected.
The clinical picture of gastric sarcomas is polymorphic, in some cases the disease is asymptomatic for a relatively long time and is detected by chance during palpation or x-ray examination of the stomach, in other cases the clinical and radiological picture is indistinguishable from gastric cancer and gastrofibroscopy and targeted biopsy of the tumor are necessary to establish the correct diagnosis.
The course of gastric sarcomas is progressive, the exhaustion of the patient gradually increases, there are gastrointestinal bleeding, immediate and distant metastases (in half of the cases); average life expectancy of a patient with gastric sarcomas without surgical treatment fluctuates in the range of 11-25 months.
A carcinoid tumor of the stomach is detected during an accidental prophylactic examination or during a targeted study of the digestive tract, undertaken in connection with the presence of characteristic features carcinoid syndrome.
Surgical treatment of sarcomas and malignant carcinoid of the stomach.
