Tumors of the stomach

Gastroscopy is a diagnostic technique that allows the gastroenterologist to visually explore the esophagus, stomach, and duodenum and to identify exactly the site of the tumor.

It consists of inserting, through the mouth or nose down the esophagus to the stomach, the gastroscope, a long, flexible probe equipped with a light source and a camera that transmits images to a computer screen.

The gastroscope also allows the gastroenterologist, using miniaturized surgical forceps inserted into the probe, to take one or more fragments of the suspected lesion and then perform a biopsy.

The procedure does not cause pain but can be uncomfortable, so it may be necessary to administer mild anesthesia to the patient, either by spraying it directly into the throat or injecting it intravenously. The examination takes about 5 to 10 minutes.

Echoendoscopy is based on the use of a probe similar to the gastroscope but which additionally allows, through the use of ultrasound (like ultrasound), to analyze the walls of the stomach and other organs in the abdomen and chest and to detect even very small lesions that would not be visible with a normal ultrasound scan from the outside.

Also with this examination, using a fine needle that is inserted through the endoscopic probe, cell and/or tissue sampling (biopsies) can be performed.

The procedure takes longer than traditional gastroscopy (30-40 minutes) and is performed with sedation administered intravenously.

CT scan, a diagnostic technique that uses X-rays to create very detailed, three-dimensional images of various areas of the body, is used to precisely locate the tumor in the stomach and check whether it has spread to the lymph nodes and other organs nearby in the abdomen, chest and neck.

The examination requires a contrast agent that is injected into the vein. It is performed on an empty stomach at the Division of Radiodiagnostics and lasts about a quarter of an hour, during which time the patient should remain as still as possible.

By microscopically analyzing the tissue and cells taken in biopsies, the anatomopathologist first defines the histotype of the tumor, that is, the type of cells of which it is made up. The most common type of stomach cancer (about 90-95% of all cases) is theadenocarcinoma: This tumor develops from the glandular cells that make up the inner mucosa of the stomach and whose function is to secrete substances necessary for the digestion of food.

The anatomo-pathologist also determines the grade of the tumor (1 to 3), that is, how much cancer cells differ from normal cells and how quickly they can grow. This difference is indicative of the aggressiveness of the disease: grade 1 cancer cells look similar to normal stomach cells, multiply slowly and are less likely to spread; grade 3 cancer cells look very abnormal and multiply rapidly.

The anatomo-pathologist also performs immunohistochemical analysis on the tumor to obtain information about the genes in its cells, particularly the HER2 gene which regulates the production of a protein involved in cell growth and migration processes. An alteration of this gene (called amplification) causes the overproduction of the HER2 protein and consequently the uncontrolled growth of cancer cells.

Stomach cancers that have elevated values of this protein on the cell surface are termed HER2-positive: these are aggressive tumors, however, which can be treated with a specific therapy, called “biologic” or “molecular-targeted” therapy.

Further immunohistochemical analysis involves assessment of expression on tumor cells of PDL1 protein and mismatch repair (MMR) proteins involved in DNA repair functions, the alteration of which confers susceptibility to immunotherapy treatments.

Based on the results of diagnostic tests, the stage of the tumor is also defined, that is, how far the disease has invaded the stomach lining, muscle wall, lymph nodes, or surrounding organs. Stage is calculated by a combination of the categories T (tumor size and invasion of adjacent tissues), N (lymph node involvement) and M (presence of metastasis or spread of the tumor to other organs of the body).

If the tumor is located only on the inner mucosa of the stomach, is small in size, and does not appear to have affected the lymph nodes, it can be removed by endoscopic resection: as is done during gastroscopy, the doctor moves a thin tube-shaped instrument down the patient’s throat and pushes it down to the stomach after which he removes the tumor.

Depending on the histological examination on the excised piece, such resection may be considered sufficient or instead require subsequent surgery.

This intervention is the main treatment option, especially in cases of early stage (0-III) cancer.

Surgery may be preceded by chemotherapy to reduce the size or extent of the disease. Chemotherapy can also be used after surgery, sometimes combined with radiation therapy, to eliminate any remaining cancer cells and reduce the risk of recurrence.

Surgery for stomach cancer–called gastrectomy–can be performed with different techniques, depending on the extent and aggressiveness of the disease, the age and health status of the patient:

• may be partial, and thus involve removal of only part of the stomach, if the tumor has developed in specific locations
• can be total, that is, of the entire organ, and possibly of other tissues if invaded by the tumor. Lymph nodes surrounding the stomach are always removed, however, as they are potential sites of metastasis.

The remaining part of the stomach or esophagus is connected directly to the intestines to allow the digestive system to continue functioning.

Minimally invasive surgery

At the Candiolo Institute, gastrectomy is performed, when made possible by the extent of the disease and the patient’s situation, withminimally invasive surgical techniques that reduce side effects and allow rapid patient recovery.

It is particularly developed the robotic surgery: The surgeon, from a computerized workstation, maneuvers the arms of a robot that terminate miniaturized surgical instruments-with which he makes incisions of a few millimeters-and a 3-D camera. The robot provides the surgeon with high-definition images to facilitate him or her during the procedure, which, because it lacks the physiological tremor of the hand, allows very precise movements to be performed. With this technique, the main advantages are easier removal of lymph nodes and execution of reconstructive sutures with less blood loss and less pain for the patient.

After surgery the patient is taken care of by a nutritionist physician who provides him or her with guidance on proper nutrition and thus prevent weight loss and malnutrition, promote tissue healing and gastrointestinal function.

The treatment uses Drugs aimed at blocking or eliminating cancer cells Taking advantage of their faster reproduction rate than healthy ones. Because it interferes with the replication mechanisms of cells, chemotherapy also damages healthy cells in the body causing major side effects that in most cases disappear once the treatment is over.

There are many chemotherapy drugs and they are often used in combination with each other. Before therapy begins, the oncologist provides guidance on which drugs to use and what to do to alleviate side effects.

Method of administration and treatment cycles

• The way chemotherapy is administered varies depending on the type of tumor and the drugs: it can be taken orally, in tablet form, but more often it is administered intravenously. Intravenous administration is performed on an outpatient basis, and its duration can vary from minutes to hours depending on the drugs used;
• chemotherapy is given in cycles: each cycle lasts for a few days and is followed by a few weeks of rest. The number of cycles depends on the type of tumor and, of course, the response to the drugs, which can vary greatly from patient to patient.

In stomach cancer, chemotherapy, sometimes also combined with radiation therapy, can be given at different points in the course of treatment:

• before surgery (neoadjuvant chemotherapy) to shrink the tumor mass and facilitate its surgical removal,
• after surgery (adjuvant chemotherapy) to reduce the risk of disease relapse (recurrence),
• before and after surgery (perioperative chemotherapy): consists of a very short therapy of only 2-4 cycles before surgery and another 3-4 cycles after surgery,
• When the tumor has spread to other organs, so it is metastatic, to relieve disease symptoms, improve quality of life and prolong survival.

Radiation therapy consists of the use of high-energy radiation targeted at the tumor mass. It does not require hospitalization and is administered in consecutive daily sessions, Monday through Friday. For the treatment of stomach cancer, radiation therapy is often given in combination with chemotherapy to make it more effective.

The intent may be:

• adjuvant, in selected cases, that is, subsequent surgery to sterilize the area undergoing surgery so as to avoid local recurrence;
• palliative if the tumor is in an advanced stage to relieve algic symptoms or any bleeding.

Biological therapies, also called target therapies or molecularly targeted therapies, are targeted therapies, that is, their action is specific only to the target (typically a protein) against which they are directed. These targets, found primarily in cancer cells, are responsible for the uncontrolled growth and spread of cells, their resistance to traditional therapies, and the production of new blood vessels.

One of the targets of biological therapies for stomach cancer is the HER2 protein, which stimulates cell multiplication and is present in higher-than-normal amounts on the surface of cancer cells of certain types of stomach cancer, thus defined as “HER2 positive.” The drug Trastuzumab recognizes and binds to the HER2 protein, blocks its action and thus prevents cancer cell proliferation and disease growth. It is used for HER2-positive advanced or metastatic tumors and administered intravenously in combination with chemotherapy.

In tumors that develop resistance to this treatment, the drug-conjugated antibody Trastuzumab deruxtecan be used as monotherapy.

Another goal of biological therapies is to prevent the formation of new blood vessels (angiogenesis), by which the tumor grows and spreads.

The drug Ramucirumab blocks the action of the VEGF protein, which is essential for blood vessel growth, and thus prevents the flow of blood and nutrients to the tumor cells. It is a drug indicated for patients with inoperable or metastatic tumors and in combination with second-line chemotherapy.

Immunotherapy includes drugs that work by activating the response of the immune system blocked by the tumor.

Immunotherapy drugs used for the treatment of stomach cancer are Nivolumab and
Pembrolizumab: by blocking the action of the PD-1 protein, which hinders the action of the immune system, they allow the system to resume its control activities and react against cancer cells.

Immunotherapeutics are used in combination with chemotherapy in advanced cancers in that subset of patients who, by molecular analysis, are shown to be potentially susceptible to immunotherapy.

For selected patients whose tumor has peculiar characteristics or for whom standard therapies had not proved effective, there is also the possibility of receive experimental therapies within clinical trials conducted by the Institute’s researchers.

In case this option is considered feasible by the Interdisciplinary Group, it will be proposed and explained to the patient with whom a shared decision will be made.

All cancer treatments involve side effects thatimpact the patient’s quality of life more or less severely.

The physicians and nurses on the multidisciplinary team are available to provide the patient with all the support he or she needs to manage the various side effects he or she will face both in the course of treatment and in resuming normal activities.

Physiotherapists for functional recovery, nutritionists for nutrition support, palliative physicians for pain control, and psychologists assist the patient in the course of treatment, rehabilitation, and follow-up.

The support of the nutritionist physician is especially necessary for the patient with stomach cancer because of both the location of the disease and the consequences of treatment.

At the Candiolo Institute, specialist evaluation by a clinical nutritionist is scheduled from the first oncology visit, to prevent inadequate nutritional status from interfering with the effectiveness of treatment. In addition, setting proper nutrition from the start can help counteract the side effects of medical and surgical therapies and improve the patient’s quality of life.

After surgery, which may have involved the removal of all or part of the stomach, the body necessarily undergoes an adjustment phase that may last several months. The operated patient has to deal with a number of complaints that may result in excessive weight loss, especially in the first few months after surgery, affecting quality of life and response to treatment. Also at this stage , nutritional counseling by the specialist helps the patient adjust to the new diet.

The impact of stomach cancer in a person’s life also affects the psychological sphere: in fact, getting cancer is always a traumatic event that affects all dimensions of a person and can generate anxiety, fear, anger, and depression.

In addition to this, the patient with stomach cancer, especially after undergoing partial or total stomach removal surgery, faces a period of physical fatigue that may persist for months after treatment has ended and may generate discouragement and loss of confidence in a possible recovery.

At the Candiolo Institute, alongside cutting-edge therapies, the treatment and care pathway for stomach cancer therefore always includes qualified psycho-oncological support that helps the patient cope positively not only with treatment but also with the delicate phase of physical and psychological recovery.

You can also participate in psychological support groups to compare yourself with others who have gone through or are going through the same experience.

The cancer patient is often a fragile patient, who needs help and support in his or her disease journey: when he or she experiences an ailment, whether related to the disease or a side effect of therapy, he or she should be able to receive a specialist’s opinion quickly, through a “fast track.”

For this reason, at the Candiolo Institute there is an assistance service every day, Monday through Friday from 8 a.m. to 5 p.m.: just call the secretary of the Oncology Day Hospital ( 011.993.3775 ) reporting the need for an urgent consultation, and the patient is quickly contacted by his or her specialist doctor.

The Social Service Department of the Candiolo Institute conducts information and orientation interviews for patients and their families on how to access services in the area and how to obtain welfare and social security benefits provided by law (disability, benefits for aids and prostheses, work leave, etc.).

The service operates on Wednesdays and Fridays from 9 a.m. to 1 p.m. – Phone: 011.993.3059

With the conclusion of the course of treatment, the follow-up period begins during which, through a series of examinations and visits, the side effects of the therapies performed and their effectiveness are monitored and the patient’s functional recovery is assessed. Follow-up examinations are especially important to intercept any recurrences early so that appropriate therapy can be intervened. For the patient, they are also a valuable opportunity for dialogue with their medical specialist.

It is the same specialist doctor who schedules follow-up visits, in which the patient’s health condition is assessed and the required test reports are viewed.

Checkups are carried out at scheduled intervals for the duration of 5-10 years.

They have a shorter cadence at first (three to six months), then gradually thin out over time. The frequency and type of examinations provided depend on the stage of the tumor and the treatments given.

Typically, follow-up checks for stomach cancer include:

• • for the first two years after the end of treatment, a clinical examination every 4 months with blood and instrumental tests to be performed on clinical necessity in the judgment of the physician;

• • over the next three years, a clinical examination every 6 months with any blood and instrumental tests.

Patients who have had a partial gastrectomy are usually prescribed a gastroscopy every 2-3 years in the first 5 years and then every 3-5 years.

Thehigh number of patients treated each year makes the Candiolo Institute a national benchmark in the management of gastric cancer.

The accumulated experience allows us to address even the most complex clinical pictures, building tailored treatment paths, calibrated to the clinical conditions and personal needs of each patient.

Every course of care begins with an accurate and timely assessment. Patients have access to advanced imaging techniques, such as high-definition CT and MRI scans, state-of-the-art endoscopy, and PET scans, for accurate mapping of the disease.

These are complemented by sophisticated laboratory investigations, including molecular and genomic analyses, which are essential for understanding the biological characteristics of the tumor and guiding therapeutic choice.

When surgery is indicated, minimally invasive techniques (such as laparoscopy) are adopted, which reduce surgical trauma, promote faster recovery, and improve postoperative comfort. Decisions are always shared within the GIC, ensuring a multidisciplinary and coordinated approach.

As an IRCCS, the Candiolo Institute combines clinical practice with intensive research activities. Patients may be candidates for national and international clinical trials, which provide opportunities to access promising experimental therapies, including those based on molecularly targeted drugs and immunotherapy.

The GIC follows each patient along the entire pathway: from diagnosis to treatment to follow-up. Nutritional support services, psychological counseling and assistance with reintegration into daily life are provided. The goal is to ensure not only the effectiveness of care, but also the overall well-being of the person, with human and ongoing caretaking.