Stomach Cancer
`
`What is
`stomach cancer?
`
`Let us explain
`it to you.
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`www.anticancerfund.org
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`www.esmo.org
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`ESMO/ACF Patient Guide Series
`based on the ESMO Clinical Practice Guidelines
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`Ex. 1044-0001
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`STOMACH CANCER: A GUIDE FOR PATIENTS
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`PATIENT INFORMATION BASED ON ESMO CLINICAL PRACTICE GUIDELINES
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`This guide for patients has been prepared by the Anticancer Fund as a service to patients, to help
`patients and their relatives better understand the nature of stomach cancer and appreciate the best
`treatment choices available according to the subtype of stomach cancer. We recommend that
`patients ask their doctors about what tests or types of treatments are needed for their type and
`stage of disease. The medical information described in this document is based on the clinical practice
`guidelines of the European Society for Medical Oncology (ESMO) for the management of stomach
`cancer. This guide for patients has been produced in collaboration with ESMO and is disseminated
`with the permission of ESMO. It has been written by a medical doctor and reviewed by two
`oncologists from ESMO including the lead author of the clinical practice guidelines for professionals.
`It has also been reviewed by patients’ representatives from ESMO’s Cancer Patient Working Group.
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`More information about the Anticancer Fund: www.anticancerfund.org
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`More information about the European Society for Medical Oncology: www.esmo.org
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`For words marked with an asterisk, a definition is provided at the end of the document.
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`Stomach cancer: a guide for patients - Information based on ESMO Clinical Practice Guidelines - v.2012.1
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`Page 1
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`This document is provided by the Anticancer Fund with the permission of ESMO.
`The information in this document does not replace a medical consultation. It is for personal use only and cannot be modified,
`reproduced or disseminated in any way without written permission from ESMO and the Anticancer Fund.
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`Ex. 1044-0002
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`Table of contents
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`Definition of stomach cancer ..................................................................................................... 3
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`Is stomach cancer frequent? ...................................................................................................... 5
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`What causes stomach cancer? ................................................................................................... 6
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`How is stomach cancer diagnosed? ........................................................................................... 9
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`What it is important to know to get the optimal treatment? ................................................. 11
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`What are the treatment options? ............................................................................................ 14
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`What happens after treatment? .............................................................................................. 21
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`Definitions of difficult words .................................................................................................... 23
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`This text was written by Dr Annemie Michiels (Anticancer Fund) and reviewed by Dr. Gauthier Bouche (Anticancer Fund), Dr.
`Svetlana Jezdic (ESMO), Dr. Alicia Okines (ESMO), Prof. David Cunningham (ESMO), Dr. William Allum (ESMO) and Pr. Lorenz
`Jost (ESMO’s Cancer Patient Working Group).
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`Stomach cancer: a guide for patients - Information based on ESMO Clinical Practice Guidelines - v.2012.1
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`Page 2
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`This document is provided by the Anticancer Fund with the permission of ESMO.
`The information in this document does not replace a medical consultation. It is for personal use only and cannot be modified,
`reproduced or disseminated in any way without written permission from ESMO and the Anticancer Fund.
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`Ex. 1044-0003
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`DEFINITION OF STOMACH CANCER
`This definition is adapted from and is used with the permission of the National Cancer Institute (NCI) of the United States of America.
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`Stomach cancer is a cancer that forms in tissues lining the stomach. Most stomach cancers start from
`cells in the inner layer of the stomach (the mucosa) which normally make and release mucus* and
`other fluids. These cancers are called adenocarcinomas and represent about 90% of stomach
`cancers.
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`Anatomy of the digestive system and layers of the stomach wall.
`The mucosa* or inner layer of the stomach is made up of the epithelium* and the lamina propria*. Going deeper in the
`stomach wall we find the submucosa*, followed by the muscle layers, subserosa* (not shown in the picture) and the
`serosa*. The serosa* is the membrane* covering the outside of the stomach.
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`Stomach cancer: a guide for patients - Information based on ESMO Clinical Practice Guidelines - v.2012.1
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`Page 3
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`This document is provided by the Anticancer Fund with the permission of ESMO.
`The information in this document does not replace a medical consultation. It is for personal use only and cannot be modified,
`reproduced or disseminated in any way without written permission from ESMO and the Anticancer Fund.
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`Ex. 1044-0004
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`Important note regarding other types of stomach cancer
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`The information provided in this Guide for Patients does not apply to other types of stomach cancers.
`The main other types of stomach cancer include:
` Gastric lymphomas, which are cancers originating from cells of the immune system found in
`the wall of the stomach. Most gastric lymphomas are non-Hodgkin lymphomas. More
`information on non-Hodgkin lymphoma can be found here.
` Gastro-intestinal stromal tumors or GIST, which are rare tumors that are believed to
`originate from cells in the wall of the stomach called interstitial cells of Cajal. Information on
`gastro-intestinal stromal tumor can be found here.
` Neuroendocrine tumors which are tumors originating from nervous or endocrine cells of the
`stomach. Information on gastric neuroendocrine tumors can be found here.
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`Diagnosis and treatment of these types of cancer are different from those for gastric
`adenocarcinoma.
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`Stomach cancer: a guide for patients - Information based on ESMO Clinical Practice Guidelines - v.2012.1
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`Page 4
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`This document is provided by the Anticancer Fund with the permission of ESMO.
`The information in this document does not replace a medical consultation. It is for personal use only and cannot be modified,
`reproduced or disseminated in any way without written permission from ESMO and the Anticancer Fund.
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`Ex. 1044-0005
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`IS STOMACH CANCER FREQUENT?
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`Worldwide, stomach cancer is most common in East Asia, South America and Eastern Europe. It is
`less common in Western Europe even though stomach cancer is the fifth most frequent cancer in
`Europe. It is approximately twice as frequent in men as it is in women. It is most often diagnosed
`between the age of 60 and 80. In Europe, about 150,000 people developed stomach cancer in 2008.
`The marked variation in the frequency of stomach cancer between continents and countries is mainly
`due to differences in diet and to genetic factors.
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`In Europe, an average of 1 or 2 in every 100 men and 0.5 to 1 in every 100 women will develop
`stomach cancer at some point in their lifetime. There are marked geographic variations between
`countries worldwide but also within Europe. Stomach cancer is more frequent in countries of Eastern
`Europe and in Portugal where up to 4 in every 100 men and 2 in every 100 women will develop the
`disease at some point in their lifetime.
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`Stomach cancer: a guide for patients - Information based on ESMO Clinical Practice Guidelines - v.2012.1
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`Page 5
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`This document is provided by the Anticancer Fund with the permission of ESMO.
`The information in this document does not replace a medical consultation. It is for personal use only and cannot be modified,
`reproduced or disseminated in any way without written permission from ESMO and the Anticancer Fund.
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`Ex. 1044-0006
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`WHAT CAUSES STOMACH CANCER?
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`Today, it is not clear why stomach cancer occurs. Some risk factors* have been identified. A risk
`factor* increases the risk of cancer occurring, but is neither sufficient nor necessary to cause cancer.
`It is not a cause in itself. Most people with these risk factors* will never develop stomach cancer
`and some people without any of these risk factors will nonetheless develop stomach cancer.
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`The main risk factors* of stomach cancer are:
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` Environmental factors: Helicobacter pylori or H.
`pylori is a bacteria and can reside in the stomach and
`cause chronic inflammation or stomach ulcers*. If this
`situation persists for a few decades, it can evolve into
`cancer. However, the infection will first go through a
`number of pre-cancerous stages
`(like atrophic
`gastritis, metaplasia and dysplasia) that could, but do not systematically turn into cancer.
`These stages can already be detected and treated before they could evolve to cancer. If left
`untreated, 1% of all patients with H. pylori will eventually develop stomach cancer.
`About 50% of the world’s population is infected with H. pylori. Transmission occurs through
`stools and saliva and is strongly related to poor socio-economic status and poor living
`conditions. Treatment of this infection consists of a cure with antibiotics. Infection with H.
`pylori is the most important and at the same time, one of the most treatable risk factors for
`stomach cancer.
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`Lifestyle:
`o Nutrition:
` A high dietary intake of salt, including salt-
`preserved (e.g. smoked or pickled with salt)
`food, strongly increases the risk of developing
`stomach cancer. The presence of salt makes
`an infection with H. pylori more likely to occur
`and also seems to aggravate the effect of an
`infection. Besides that,
`it damages the
`mucosa* of the stomach and can in this way
`directly contribute to the development of
`stomach cancer.
` A high intake of food containing nitrates* or nitrites*, like preserved meat,
`can increase the risk of developing stomach cancer.
` Eating fruit and vegetables that contain vitamins A and C has proven to
`protect significantly against the development of stomach cancer.
`o Smoking: The rate of stomach cancer is about doubled in smokers.
`o Occupation: Workers in the coal, metal, and rubber industries seem to have a slightly
`higher risk of developing stomach cancer.
`o Some studies have shown that people who do a great deal of physical activity can
`reduce their risk of developing stomach cancer by up to a half.
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`Stomach cancer: a guide for patients - Information based on ESMO Clinical Practice Guidelines - v.2012.1
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`Page 6
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`This document is provided by the Anticancer Fund with the permission of ESMO.
`The information in this document does not replace a medical consultation. It is for personal use only and cannot be modified,
`reproduced or disseminated in any way without written permission from ESMO and the Anticancer Fund.
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`Ex. 1044-0007
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` Factors that cannot be modified:
`o Some inherited conditions may increase the risk of developing stomach cancer
` A rare hereditary mutation* in the gene that codes for a protein* called E-
`cadherin, leads to a very high risk of developing stomach cancer. The type of
`stomach cancer due to this mutation* is called hereditary diffuse stomach
`cancer and has a bad prognosis*. Individuals with this mutation* might
`therefore consider close surveillance, or discuss a preventative removal of
`the stomach.
` Some hereditary mutations which are predisposed to cancer in other parts of
`the body seem to slightly increase the risk of developing stomach cancer.
`Examples of these are mutations* in the BRCA1 and BRCA2-gene, which are
`known to increase the risk of developing breast and ovarian cancer, and two
`conditions increasing the risk for colorectal cancer, called Hereditary non-
`polyposis colorectal cancer or Lynch Syndrome and Familial Adenomatous
`Polyposis.
` A history of stomach cancer in first-degree relatives (parents, siblings or
`children) increases one’s own risk of developing the disease.
` For unknown reasons, people with type A blood are at a greater risk of
`developing stomach cancer.
`o Gender: Stomach cancer is more frequent in men than in women. Reasons for this
`difference are unclear, but the female sex hormone estrogen may have a protective
`effect.
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` Medical conditions:
`o People who have been treated for another type of stomach cancer, known as
`mucosa-associated lymphoid tissue (MALT) lymphoma, are at an increased risk of
`getting adenocarcinoma of the stomach. This is probably because MALT lymphoma
`of the stomach is caused by infection with H pylori bacteria.
`o Gastro-esophageal reflux, a common condition where stomach acid comes up from
`the stomach into the esophagus increases the risk of cancer at the junction of the
`stomach and the gullet (the oesophago-gastric junction or OGJ).
`o Previous stomach surgery: when a part of the stomach has been removed, e.g.
`because of a stomach ulcer, there is a higher chance of developing cancer in the
`remaining part. This may be because less stomach acid is produced. The reduced acid
`level may allow more bacteria to grow and the bacteria may help to produce more
`chemicals that may increase stomach cancer risk.
`o Gastric polyps are benign growths on the inner lining of the stomach. One type of
`polyp, called adenoma, can sometimes develop into cancer. Adenomas can be
`detected and removed during a gastroscopy, an examination of the stomach in which
`the doctor passes a thin, flexible, light-emitting tube, called an endoscope, downthe
`patient’s throat and into the stomach.
`o Pernicious anemia is a condition in which patients fail to absorb enough vitamin B12
`from their food, which is needed to make new red blood cells. Along with anemia
`(low red blood cell counts), the risk of stomach cancer is also increased for these
`patients.
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`Other factors have been suspected to be associated with an increased risk of stomach cancer, like
`obesity, infection with the Epstein-Barr virus* (causing infectious mononucleosis) and a rare medical
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`Stomach cancer: a guide for patients - Information based on ESMO Clinical Practice Guidelines - v.2012.1
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`This document is provided by the Anticancer Fund with the permission of ESMO.
`The information in this document does not replace a medical consultation. It is for personal use only and cannot be modified,
`reproduced or disseminated in any way without written permission from ESMO and the Anticancer Fund.
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`Ex. 1044-0008
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`condition called Ménétrier’s disease*. However, the evidence is inconsistent and the mechanism
`remains unclear.
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`Stomach cancer: a guide for patients - Information based on ESMO Clinical Practice Guidelines - v.2012.1
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`This document is provided by the Anticancer Fund with the permission of ESMO.
`The information in this document does not replace a medical consultation. It is for personal use only and cannot be modified,
`reproduced or disseminated in any way without written permission from ESMO and the Anticancer Fund.
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`Ex. 1044-0009
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`HOW IS STOMACH CANCER DIAGNOSED?
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`Stomach cancer can be suspected in different circumstances. Unfortunately, these signals are often
`vague and quite common, and they can also point to many other medical conditions. In the early
`phase, most stomach cancers do not even cause any symptoms. Therefore a stomach tumor is often
`not suspected. In case of a combination of the following complaints, and especially if persistent,
`further examinations should be considered:
` abdominal discomfort or pain
` a sense of fullness, even after eating a small meal
` heartburn, indigestion, acidity and burping
` nausea and/or vomiting, especially including blood.
`swelling or fluid build-up in the abdomen
`
` poor appetite
` unexplained extreme weight loss
`Unnoticeable blood loss from the stomach may also cause anemia*, leading to tiredness and
`breathlessness in the long term.
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`In Japan and Korea, where there is a high number of new cases of stomach cancer, a screening is
`proposed to every individual at the age of 50 and with a follow-up according to the result of the
`screening exam.
`In Europe, no such screening is proposed because the number of new cases of stomach cancer is not
`considered to be sufficient for screening to be efficient1.
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`The diagnosis of stomach cancer is based on the following
`examinations.
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`1. Clinical examination. The doctor will examine the
`abdomen to identify any abnormal swelling or pain. He
`will also check for any abnormal swelling above the left
`collar bone, which may be caused by a spread of the
`cancer to the lymph nodes* that are situated there.
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`2. Endoscopic examination. During an endoscopic examination of the
`upper digestive tract or the gastroscopy, the doctor passes a thin,
`flexible, light-emitting tube called an endoscope down the patient’s
`throat and into the stomach. This allows the doctor to see the lining of
`the esophagus, stomach, and the first part of the small intestine. If
`abnormal areas are noted, biopsies* (tissue samples) can be taken
`using
`instruments passed through the endoscope. These tissue
`samples are examined by a specialist
`in the
`laboratory (see
`histopathological* examination).
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`1 Screening consists of performing an exam in order to detect cancer at an early stage, before any sign of the
`cancer appears. A screening is proposed if a safe and acceptable exam can be performed and if this exam is
`able to detect cancer in the majority of cases. It should also be proved that treating screened cancers is more
`effective than treating cancers diagnosed because signs of cancer were present.
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`Stomach cancer: a guide for patients - Information based on ESMO Clinical Practice Guidelines - v.2012.1
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`This document is provided by the Anticancer Fund with the permission of ESMO.
`The information in this document does not replace a medical consultation. It is for personal use only and cannot be modified,
`reproduced or disseminated in any way without written permission from ESMO and the Anticancer Fund.
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`Ex. 1044-0010
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`During the gastroscopy, an endoscopic ultrasound can be performed at the same time. An
`ultrasound probe is introduced down the throat and into the stomach. It provides images of
`the different layers of the stomach wall, as well as the nearby lymph nodes* and other
`structures. This technique is used to see how far a cancer has spread in the stomach wall,
`into nearby tissues or to nearby lymph nodes*. It can also guide the doctor in removing a
`small sample (biopsy*) of a suspicious lesion during the gastroscopy.
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`3. Radiological examination. A CT-scan shows how far the cancer has spread, both locally and
`to other parts of the body. It can also be used to guide a biopsy*. Additional investigations
`such as a chest X-ray and a PETscan may be performed to exclude distant spread of the
`disease, called metastasis*.
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`4. Histopathological* examination. The biopsy* specimen
`(the tissue sample that has been taken during the
`gastroscopy) will be examined in the laboratory by a
`pathologist*.
`This
`is
`called
`a histopathological*
`examination. Using the microscope and several other
`tests, the pathologist* will confirm the diagnosis of cancer
`and will give more information on the characteristics of
`the cancer.
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`The histopathological* examination can also be performed
`on samples obtained during either a laparoscopy*, or on the liquid used for peritoneal
`washing*, or on the tumor removed during surgery.
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` A
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` laparoscopy* is usually performed when the stomach cancer has already been found and
`when an operation is foreseen. It helps to confirm that the cancer is still only in the stomach
`and thus can be completely removed by surgery. During this intervention a thin flexible tube
`is inserted through a small surgical opening in the patient's tummy. It has a small camera on
`its end, through which doctors can look closely at the surfaces of the organs and nearby
`lymph nodes*, and take small samples of tissue, to check for possible metastases*.
`Sometimes surgeons also pour liquid in the abdominal cavity, remove it by suction and send
`it to the laboratory to check for cancer cells. This is called peritoneal washing*.
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`When surgery is performed to remove a tumor, the tumor and the lymph nodes* will also be
`examined in the lab. This is very important to confirm the results of the biopsy* and to
`provide more information on the cancer.
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`Stomach cancer: a guide for patients - Information based on ESMO Clinical Practice Guidelines - v.2012.1
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`Page 10
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`This document is provided by the Anticancer Fund with the permission of ESMO.
`The information in this document does not replace a medical consultation. It is for personal use only and cannot be modified,
`reproduced or disseminated in any way without written permission from ESMO and the Anticancer Fund.
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`Ex. 1044-0011
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`WHAT IT IS IMPORTANT TO KNOW TO GET THE OPTIMAL
`TREATMENT?
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`Doctors will need to consider many aspects of both the patient and the
`cancer in order to decide on the best treatment.
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`Relevant information about the patient
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` personal medical history
`results of the physical examination
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` general well-being
`results of the blood examination performed, including a blood count to check for anemia*,
`
`and liver and renal function tests
`results of a CTscan of the chest, the abdomen and the pelvis
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`Relevant information about the cancer
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` Staging
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`Doctors use staging to assess the extent of the cancer and the prognosis* of the patient. The TNM
`staging system is commonly used. The combination of size of the tumor and invasion of nearby tissue
`(T), involvement of lymph nodes* (N), and metastasis* or spread of the cancer to other organs of the
`body (M), will classify the cancer as being at one of the following stages.
`The stage is fundamental in order to make the right decision about the treatment. The less advanced
`the stage, the better the prognosis*. Staging is usually performed twice: after clinical and radiological
`examination and after surgery. This is because if surgery is performed, staging may be influenced by
`the results of the laboratory examination of the removed tumor and lymph nodes*.
`The table below presents the different stages of stomach cancer. See the picture on page 3 for the
`different layers of the stomach wall.
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`The definitions are sometimes technical, so it is recommended that you ask your doctor for more
`detailed explanations.
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`Stage
`Stage 0
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`Definition
`The abnormal cells are only found in the inner layer of the mucosa* of the
`stomach, called the epithelium. This stage is also called carcinoma in situ.
`The tumor invades the complete mucosa with or without affecting lymph
`nodes*, or invades the muscle layer or the subserosa* without affecting any of
`the lymph nodes*. Stage I is divided into stages IA and IB.
`The abnormal cells are found in the deepest layer of the mucosa* (called lamina
`propria) or in the submucosa*, but no lymph nodes* are affected.
` The abnormal cells are found in the deepest layer of the mucosa* (called
`lamina propria) or in the submucosa* and in 1 to 6 lymph nodes* OR
` The abnormal cells are found in the muscle layer or the subserosa* of the
`stomach, but no lymph nodes* are affected.
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`Stage I
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`Stage IA
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`Stage IB
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`Stomach cancer: a guide for patients - Information based on ESMO Clinical Practice Guidelines - v.2012.1
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`This document is provided by the Anticancer Fund with the permission of ESMO.
`The information in this document does not replace a medical consultation. It is for personal use only and cannot be modified,
`reproduced or disseminated in any way without written permission from ESMO and the Anticancer Fund.
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`Ex. 1044-0012
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`Stage II
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`Stage III
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`Stage IIIA
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`Stage IIIB
`Stage IV
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`Stage II groups various combinations of depth of tumor invasion and number of
`lymph nodes* involved.
` Either the abnormal cells are found in the deepest layer of the mucosa*
`(called lamina propria) or in the submucosa* and in 7 to 15 lymph nodes* OR
` the abnormal cells are found in the muscle layer or in the subserosa* of the
`stomach and in 1 to 6 lymph nodes* OR
` the abnormal cells are found in the serosa*, but no lymph nodes* are
`affected.
`The tumor has spread to the muscle layer, the subserosa*or the serosa* and to
`up to 15 lymph nodes*, or has invaded the structures that surround the stomach
`without affecting any lymph nodes*. The tumor has not spread to distant organs
`such as liver, lungs or lymph nodes* in other parts of the body. Stage III is
`divided in stage IIIA and IIIB.
` The abnormal cells are found in the muscle layer or the subserosa* of the
`stomach and in 7 to 15 lymph nodes* OR
` The abnormal cells are found in the serosa* and in 1 to 6 lymph nodes* OR
` The tumor has invaded the structures that surround the stomach, but no
`lymph nodes* are affected.
`The abnormal cells are found in the serosa* and in 7 to 15 lymph nodes*.
`More than 15 lymph nodes* are involved or the tumor has spread to structures
`surrounding the stomach or to other parts of the body:
`-
`The tumor has invaded the structures that surround the stomach and there
`are lymph nodes* involved OR
`The tumor has not invaded structures that surround the stomach but more
`than 15 lymph nodes* are affected OR
`- Distant metastasis* is to be found, meaning the cancer has spread to other
`parts of the body.
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`-
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` Results of the biopsy*
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`The biopsy* will be examined in the laboratory. This examination is called a histopathology*. The
`second histopathological* examination involves the examination of the tumor and the lymph nodes*
`after surgical removal. This is very important to confirm the results of the biopsy* and to provide
`more information on the cancer. Results of the examination of the biopsy* should include:
`
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`o Histological* type
`The histological type describes the characteristics of the cells that make up the
`tumor. Most stomach cancers are from the adenocarcinoma histological type,
`meaning that tumor cells resemble, to some extent, cells of the inner layer of the
`stomach (the mucosa). Adenocarcinomas can then be divided into so-called diffuse
`or undifferentiated, and intestinal or well-differentiated types. Differentiation is the
`biological process in which a less specialized cell turns into a more specialized cell
`type. Differentiated tumor cells look more like normal stomach cells and grow more
`slowly than undifferentiated or poorly differentiated cells that look completely
`different and grow quickly. The diffuse or undifferentiated type of stomach cancer
`may be harder to treat.
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`Stomach cancer: a guide for patients - Information based on ESMO Clinical Practice Guidelines - v.2012.1
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`Page 12
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`This document is provided by the Anticancer Fund with the permission of ESMO.
`The information in this document does not replace a medical consultation. It is for personal use only and cannot be modified,
`reproduced or disseminated in any way without written permission from ESMO and the Anticancer Fund.
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`Ex. 1044-0013
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`o Presence of ulceration*
`Ulceration* is a break in the inner lining of the stomach, caused by the inflammation
`and death of the cells in this layer. Cancer with ulceration* may be harder to treat
`than cancer without ulceration*.
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`Besides investigating the biopsy* under the microscope, the pathologist* will perform certain tests
`that provide information about the genes of the tumor cells. These tests include FISH* or
`immunohistochemistry*.
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`o HER2-status
`Some cells have an overexpression of a gene called HER2, meaning that there are too
`many copies of it in one of the cell’s chromosomes*. The HER2 gene is responsible
`for the production of a protein* that influences its growth and migration. Therefore
`it is an important element in defining the treatment options in patients with
`advanced, unresectable (inoperable) gastric cancer. When there are too many copies
`of HER2, we speak of a HER2-positive stomach cancer or HER2 overexpression.
`Otherwise, the HER2 status is negative.
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`Stomach cancer: a guide for patients - Information based on ESMO Clinical Practice Guidelines - v.2012.1
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`Page 13
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`This document is provided by the Anticancer Fund with the permission of ESMO.
`The information in this document does not replace a medical consultation. It is for personal use only and cannot be modified,
`reproduced or disseminated in any way without written permission from ESMO and the Anticancer Fund.
`
`Ex. 1044-0014
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`WHAT ARE THE TREATMENT OPTIONS?
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`Planning of the treatment involves an inter-disciplinary team of medical
`professionals. This usually implies a meeting of different specialists, called
`multidisciplinary opinion or tumor board review. In this meeting, the
`planning of treatment will be discussed according to the relevant information
`mentioned previously. A multidisciplinary opinion will preferably include that
`of a medical oncologist (who provides cancer treatment with drugs), a
`surgical oncologist (who provides cancer treatment with surgery), a radiation
`oncologist
`(who provides
`cancer
`treatment with
`radiation),
`a
`gastroenterologist (specialist in diseases of stomach and intestines), a
`radiologist* and a pathologist*.
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`They will, as a first step, judge the cancer as operable (or resectable), meaning that it is possible to
`remove the complete tumor in an operation, or as not operable (or unresectable), meaning that this
`is not possible. In a tumor judged operable, the tumor may also have invaded structures surrounding
`the stomach but these can be removed without complication. A tumor can be unresectable because
`it has grown too close to nearby organs or lymph nodes*, because it has grown too close to major
`blood vessels, or because it has spread to distant parts of the body. There is no distinct dividing line
`between resectable and unresectable in terms of the TNM stage of the cancer, but earlier stage
`cancers are more likely to be resectable.
`Surgery is the only treatment that is performed with the purpose of curing the cancer. If this is not
`possible, the other treatments are done with the purpose of relieving symptoms and prolonging the
`patient’s lifespan.
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`The treatments listed below have their benefits, their risks and their contraindications. It is
`recommended to ask oncologists about the expected benefits and risks of every treatment in order
`to be informed of all the possible consequences. For some treatments, several possibilities are
`available and the choice should be discussed based on weighing up their respective benefits and
`risks.
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`Treatment plan for localized disease (Stage 0 to III and resectable)
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`Endoscopic Treatment
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`Endoscopic Mucosal Resection or EMR can be done for cancers limited to the inner layer of the
`stomach or mucosa*, usually for small (<2cm) cancers without ulceration*. The doctor will pass a
`small tube down the throat and into the stomach (as is done during a gastroscopy) and remove the
`tumor. Recently, larger tumors could be removed by Endoscopic Submucosal Dissection (ESD).
`Endoscopic Submucosal Dissection also use a small tube passed down the throat and in the stomach,
`but the technique is different and allows for the removal of larger tumors. This technique should
`normally only be proposed to patients in a clinical trial*.
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`Stomach cancer: a guide for patients - Information based on ESMO Clinical Practice Guidelines - v.2012.1
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`Page 14
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`This document is provided by the Anticancer Fund with the permission of ESMO.
`The information in this document does not replace a medical consultation. It is for personal use only and cannot be modified,
`reproduced or disseminated in any way without written permission from ESMO and the Anticancer Fund.
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`Ex. 1044-0015
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`Surgery
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`During an operation surgeons will remove the tumor with part or all of the
`stomach. The amount of tissue to be removed depends on the stage. It is
`important to remove the tumor with a clear margin of healthy stomach and
`the lymph nodes* close to the stomach.
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`Removal of the Stomach
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` A part of the stomach, or the entire stomach, is surgically removed in cases of stage Ib to III
`stomach cancer. Th