What is gastric cancer?
Gastric cancer is a malignant tumour arising from the cells of the gastric wall. In approximately 95% of cases it is adenocarcinoma. Less commonly, lymphomas, gastrointestinal stromal tumours (GIST) or neuroendocrine tumours occur.
Treatment is multimodal, with radical surgery (total or subtotal gastrectomy with D2 lymphadenectomy) being the cornerstone of curative treatment, supplemented by perioperative chemotherapy. Modern minimally invasive techniques (laparoscopic, robotic) are applied in selected cases.
How common is it?
Gastric cancer is the 5th most common cancer worldwide and the 4th cause of cancer-related death. In Greece, approximately 1,500 new cases are diagnosed annually. Frequency varies significantly geographically — much more common in East Asia (Japan, Korea, China) than in Western countries.
Frequency increases with age — most cases appear after 55 years. Men are affected approximately twice as often as women. In recent decades, in the Western world, the incidence of distal stomach cancer has decreased, while that of the cardia and gastroesophageal junction has increased.
How does it present?
Symptoms of gastric cancer often appear late, contributing to the difficulty of early diagnosis:
- Persistent epigastric pain or dyspepsia, often resistant to treatment.
- Premature satiety, sense of fullness with small meals.
- Loss of appetite and unexplained weight loss.
- Nausea and vomiting, sometimes with blood (haematemesis).
- Dysphagia in tumours of the cardia.
- Iron deficiency anemia from chronic occult blood loss.
- Dark stools (melena).
- Fatigue, weakness.
- In advanced disease: palpable abdominal mass, ascites, supraclavicular lymphadenopathy (Virchow's node).
How is it diagnosed?
Diagnosis and staging include:
- Upper GI endoscopy with multiple biopsies — the gold standard. Allows direct visualisation and histological confirmation.
- Histopathology of the biopsy — confirms diagnosis, characterises type (Lauren classification: intestinal, diffuse).
- Abdominal-pelvic and chest CT with contrast — staging for local extension and distant metastases.
- Endoscopic ultrasound (EUS) — for accurate T (depth of invasion) and N (lymph nodes) staging.
- PET-CT in complex cases or for evaluation of suspected metastases.
- Diagnostic laparoscopy in locally advanced tumours — for exclusion of peritoneal carcinomatosis.
- Tumour markers (CEA, CA 19-9, CA 72-4).
- Molecular testing: HER2, MSI/MMR, PD-L1.
Which factors increase risk?
Approximately 1–3% of gastric cancers are clearly hereditary. Most arise from interaction of genetic predisposition with environmental factors.
- Helicobacter pylori infection (the strongest risk factor — Class I carcinogen by WHO).
- Family history of gastric cancer.
- Hereditary syndromes (Lynch syndrome, HDGC — hereditary diffuse gastric cancer with CDH1 mutation).
- Personal history of partial gastrectomy.
- Atrophic gastritis, pernicious anemia, intestinal metaplasia.
- Diet rich in salt, smoked or pickled foods.
- Diet low in fresh fruits and vegetables.
- Smoking, heavy alcohol consumption.
- Obesity (especially for tumours of the cardia).
- Male sex, age >55 years.
- Blood group A.
Modern therapeutic options
Treatment of gastric cancer is multidisciplinary and is decided in an oncology council. Choice of surgical technique depends on tumour location (proximal, middle, distal), stage of disease and patient condition. Lymphadenectomy must always be D2 (radical) for curative cases.
Subtotal Gastrectomy + D2
For tumours of the middle and distal stomach. Removes 75–80% of the stomach with the duodenum and complete D2 lymphadenectomy. Reconstruction usually with Roux-en-Y gastrojejunostomy. Preserves part of the stomach, with better postoperative nutrition.
Total Gastrectomy + D2
For tumours of the proximal stomach, diffuse-type tumours or large lesions. Complete removal of the stomach with D2 lymphadenectomy. Reconstruction with Roux-en-Y esophagojejunostomy. Requires nutritional adaptation and supplementation with vitamin B12.
Laparoscopic / Robotic Gastrectomy
Modern minimally invasive techniques for early stages. The robotic approach offers exceptional visualisation and precise lymph node dissection, especially in the splenic hilum area. Equivalent oncological outcomes with reduced postoperative pain and faster recovery.
ESD (Endoscopic Submucosal Dissection)
For very early lesions (T1a) without lymph node involvement, in selected patients. Performed endoscopically with no abdominal incisions. Excellent oncological outcomes in suitable cases. Mainly used in Japan and Korea, with increasing application in the West.
Frequently asked questions
Will I be able to eat normally after surgery?
Yes, but with adaptation. After subtotal gastrectomy, small frequent meals (5–6 daily) are required. After total gastrectomy, nutritional adaptation takes longer (3–6 months) and requires lifelong vitamin B12 supplementation. Most patients return to good quality of life.
Why must lymphadenectomy be D2?
D2 (radical) lymphadenectomy removes both perigastric and second-tier lymph nodes. International literature has demonstrated that D2 offers better overall and disease-free survival compared to limited D1, when performed by specialised teams with low complication rates.
Will I need chemotherapy?
Yes, in most cases of locally advanced disease (T3+ or N+). Modern standard is perioperative chemotherapy (FLOT regimen) — 4 cycles before and 4 cycles after surgery. Targeted treatments (trastuzumab for HER2+) and immunotherapy are added in selected cases.
What is 'dumping syndrome' and how is it managed?
It is a possible complication after gastrectomy, due to rapid passage of food into the small intestine. Early symptoms (15–30 min after eating): abdominal pain, diarrhea, weakness, palpitations. Managed with small frequent meals, separation of liquids from solids, avoidance of simple sugars. With proper adaptation, symptoms gradually resolve.