Gastric (Stomach) Cancer

Frequently asked questions

What tests do I need once I am diagnosed with a Gastric Cancer?

You will need a CT Scan of your Chest/Abdomen and Pelvis to make sure the gastric cancer has not spread to the liver or lung.  You may require other tests, such as a Gastroscopy (camera into your stomach through your mouth) and/or Biopsy of the tumour.  This will be decided by your doctor at your initial consultation.

What is an Endoscopic Ultrasound?

An Endoscopic ultrasound is a special gastroscopy (camera through the mouth that goes into the stomach) that has a special ultrasound probe at its tip. This allows the gastroenterologist to see the layers of the stomach wall better and see how deep the gastric cancer has penetrated into the stomach. It can also see if there are surrounding suspicious lymph nodes. This helps give the T stage (how deep is the cancer) and the N (stage) to see if lymph nodes look involved with the gastric cancer. This is important as the stage of the gastric cancer helps us decide if you need a diagnostic laparoscopy and/or chemotherapy before surgery?

What is a Diagnostic Laparoscopy?

A diagnostic laparoscopy is a surgical procedure. It is day surgery where you go home the same day. Diagnostic Laparoscopies are offered to patients that have a T3 or T4 tumour on Endoscopic Ultrasound or if they have nodal disease on Endoscopic Ultrasound. On the day of surgery, a camera is inserted below the belly button and two other small incisions are made for working instruments. The purpose of this surgery is to look around inside your abdomen and make sure the gastric cancer hasn’t spread to the surfaces of the abdomen called the peritoneum. Sometimes these spots of cancer can be so small they cannot be seen by a CT Scan and that is why we would need to do the laparoscopy. If the gastric cancer has spread to the peritoneal surfaces then it is not beneficial to operate and remove your stomach. At this point the treatment would be chemotherapy. There are very few exceptions to this rule where, if there is very minimal disease, it may be considered to surgically remove all disease and put hot chemotherapy in the belly. This is decided on a case by case basis and is quite rare and specialized and only done in very specific circumstances.

What are lymph nodes?

Lymph nodes form a network throughout our body. They act as a filter for our body’s immune system. They are connected to one another by very small vein-like structures called lymphatic vessels. In general, in gastric cancer, these are found around the stomach and they are all removed at the time of your surgery for proper staging of your gastric cancer and for local control to remove all lymph nodes that may have gastric cancer that has spread to them.

What are the different stages of Gastric cancer?

All cancers are classified from stage 1 to stage 4. In the setting of gastric cancer, stage 1 and stage 2 disease are based on the depth (T stage) of the gastric cancer and are node negative. Stage 3 disease means that the gastric cancer has spread to your surrounding lymph nodes. Lastly, stage 4 disease indicates spreading of the gastric cancer to other organs in the body. The most common areas for gastric cancer to spread to are deeper lymph nodes, liver and lungs.

Can I live without a stomach?

Yes you can live without a stomach. The surgery often involves removal of almost all or all of the stomach and then the esophagus small remnant gastric pouch is reconnected to your small bowel to allow you to continue eating. You will, however have to alter your diet and how you eat. You will be seen by a nutritionist who will help you in this transition. After a gastrectomy you must learn to eat several small meals a day as opposed to three large meals a day. Also it is better to avoid mixing solids and fluids while you eat.

Will I need Chemotherapy?

Depending on the Stage of your Gastric Cancer you may require chemotherapy before and/or after surgery. If you have a T1a gastric cancer this is very early stage and can simply be removed with and endoscopic resection locally by gastroscopy not requiring surgery. In the cases of early gastric cancer T1b and node negative, surgery alone is curative not needing chemotherapy. In general, if you have a T2, T3, T4 or Node positive tumour on endoscopic ultrasound you will be considered for chemotherapy before and after surgery as this has shown to improve overall survival compared to surgery alone. Once again depending on your cancer and your situation you may only get chemotherapy after surgery. Moreover, if you have an MSI High Gastric Cancer, chemotherapy may not be effective and you may be treated with surgery alone. We can test the MSI Status on your gastric cancer tissue. This will be discussed further with your medical oncologist.

What is Chemotherapy?

Chemotherapy is a medication that acts upon rapidly dividing cells to kill them. Since cancer cells rapidly divide, most cancers will respond to varying degrees to chemotherapy. This is given as an IV injection every 2-3 weeks depending on the type of chemotherapy. Side effects often include, nausea, fatigue and more specific side effects occur depending on the type of chemotherapy. Gastric cancer can respond to chemotherapy. This is something you would discuss further with your medical oncologist.

What does MSI High Gastric Cancer mean?

We can test your gastric cancer tumour in pathology to see if it has microsattelite instability (MSI High). This is a genetic alteration that can be seen under the microscope. We know that MSI High gastric cancers do better than MSS (microsattelite stable) gastric cancers. We also know, however, that MSI high gastric cancer do not respond to Chemotherapy and therefore these patients at this time will only get surgery. We are currently studying if immunotherapy as an adjuvant treatment can be effective in MSI high gastric cancer as it is in MSI high colon cancer.

What is Immunotherapy?

Immunotherapy is a new innovative way of fighting off cancer cells. It works very differently than chemotherapy. It is a drug that is however also given IV every few weeks. The drug boosts your own immune system to fight off the cancer. This is currently being studied in clinical trials for several Gastrointestinal cancers and has shown promising results. This is something you would discuss further with your medical oncologist.

Will I need Radiation Therapy?

Depending on your particular situation and Gastric Cancer you may require Radiation either before or after surgery. This will be discussed with your surgeon and radiation oncologist. Radiation is mainly used if your gastric cancer recurs (comes back locally in the same place).

What does it mean to have metastatic disease?

Metastasis means the spread of disease. Regional metastasis refers to spread of the cancer to the surrounding lymph nodes. Distant metastasis refers to the spread of cancer to different organs throughout the body. In gastric cancer, these organs are most commonly the liver and the lungs. If you have metastases then the mainstay of treatment is chemotherapy. If you are metastatic your gastric cancer will be tested for a receptor called Her-2. If you have a Her-2 positive gastric cancer a treatment called Hercpetin may be added to your treatment as it can target against Her-2.

Can all Gastric cancers be removed?

Unfortunately, not all gastric cancers can be surgically removed. If they have spread to other organs or are too large for a safe removal, chemotherapy alone or in combination with radiation therapy are the mainstay of treatment.

In many cases a biopsy is required as this gives us the proper diagnosis to appropriately guide your treatment.  Given that there are more than 50 subtypes of Soft Tissue Sarcoma, the diagnosis is essential to help guide treatment, as the treatment may vary according to subtype. That being said, some sarcomas do not require biopsy.  It is best to wait and see a sarcoma specialist before a biopsy of your tumour is performed.