GASTROINTESTINAL CANCER PART-6

Welcome to the sixth part of educational series on GastroIntestinal Cancers. In last part, we had a very interesting discussion and guideline on how to make early diagnosis of GI tract cancers. We covered especially the evaluation of ANEMIA as an early sign.

Question: Dr. Chiragbhai, we have discussed risk factors for stomach cancer, and early signs. What evaluation is required for a patient who is diagnosed with stomach cancer?
Answer: Stomach cancer, as we have seen, is often diagnosed late. A good evaluation before starting treatment is important, since it can dramatically change therapy, as we will see.

Following tests are recommended:
CT scan
PET-CT, if available
EUS in few early cases
Laparoscopy

Out of above tests, most important tests in our scenario are a good quality CT scan, and laparoscopy. Both are widely available.

CT scan mainly helps to detect extent of local disease (along with endoscopy findings), lymphadenopathy-perigastric and distant, liver metastases. In one study, accuracy of PET-CT in preoperative staging was 68%, compared with 53% for CT scan alone. Newer MDCT scans, such as 64 slice CT scanners are likely to be better, however. Fortunately, PET-CT is now more widely available in India, including in Gujarat.

In one study, 657 patients with potentially resectable stomach cancer underwent laparoscopy before surgery. 31% of these patients were found to have metastatic disease. Thus laparoscopic staging helped to avoid a major surgery and related morbidity in these patients. Also, it allowed earlier initiation of palliative therapy.

Thus, at least a routine good CT scan and laparoscopy would help to avoid many “open and close” surgeries and palliative resections, and use patient’s limited resources for right treatment.

Que: Oh! Thank you for that clarity. Since laparoscopy is an invasive procedure, and rarely required in other cancers for staging, we never think of it for staging work up. This discussion was quite enlightening for me at least. What is your next step?
Ans: Now that we have completed staging the patient, patient will have either resectable OR non resectable tumor.
Non resectability could be secondary to distant spread/metastatic disease (which includes peritoneal spread) OR locally advanced disease.