Stomach cancer natural history, complications and prognosis: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
No edit summary
No edit summary
Line 5: Line 5:


==Overview==
==Overview==
If left untreated, the five-year [[survival rate]]<nowiki/>s of gastric cancer range from almost no survival for patients with disseminated disease to almost 50% survival for patients with localized distal gastric cancers confined to resectable regions. Higher recurrence rates are seen in those who have piecemeal or incomplete resections. Depending on the extent of the [[tumor]] at the time of [[diagnosis]], the [[prognosis]] may vary. However, the [[prognosis]] is generally regarded as poor. Complications of gastric cancer are [[ascites]], [[gastrointestinal bleeding]], [[Metastasis|distant metastasis]] to other organs, [[weight loss]], recurrence of [[cancer]], and treatment complications. The [[prognosis]] of patients with gastric cancer is related to [[tumor]] extent that includes direct [[tumor]] extension and [[lymph nodes]] involvement. The five-year [[survival rate]] for treated early gastric cancer is over 90 percent; nearly 100 percent for [[mucosal]] [[tumors]], and 80 to 90 percent for [[Submucosa|submucosal]] [[tumors]].
If left untreated, the five-year [[survival rate]]<nowiki/>s of [[gastric cancer]] range from almost no survival for [[patients]] with [[disseminated disease]] to almost 50% survival for [[patients]] with localized distal [[Gastric cancer|gastric cancers]] confined to resectable regions. Higher recurrence rates are seen in those who have piecemeal or incomplete resections. Depending on the extent of the [[tumor]] at the time of [[diagnosis]], the [[prognosis]] may vary. However, the [[prognosis]] is generally regarded as poor. [[Complications]] of [[gastric cancer]] are [[ascites]], [[gastrointestinal bleeding]], [[Metastasis|distant metastasis]] to other [[organs]], [[weight loss]], recurrence of [[cancer]], and treatment [[complications]]. The [[prognosis]] of patients with [[gastric cancer]] is related to [[tumor]] extent that includes direct [[tumor]] extension and [[lymph nodes]] involvement. The five-year [[survival rate]] for treated early [[gastric cancer]] is over 90 percent; nearly 100 percent for [[mucosal]] [[tumors]], and 80 to 90 percent for [[Submucosa|submucosal]] [[tumors]].
 


==Natural History==
==Natural History==
The [[symptoms]] of gastric cancer usually develop in the fifth decade of life, and start with [[loss of appetite]] and [[loss of weight]]. The [[symptoms]] of gastric cancer typically progress to [[dysphagia]], [[abdominal pain]], and [[vomiting]]. Without treatment, 63 percent of patients with early gastric cancer will progress to advanced disease within five years. [[Metastasis]] occurs in 80-90% of individuals with stomach cancer.<ref name="pmid11034575">{{cite journal| author=Tsukuma H, Oshima A, Narahara H, Morii T| title=Natural history of early gastric cancer: a non-concurrent, long term, follow up study. | journal=Gut | year= 2000 | volume= 47 | issue= 5 | pages= 618-21 | pmid=11034575 | doi= | pmc=1728114 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11034575  }}</ref>  
The [[symptoms]] of [[gastric cancer]] usually develop in the fifth decade of [[life]], and start with [[loss of appetite]] and [[loss of weight]]. The [[symptoms]] of [[gastric cancer]] typically progress to [[dysphagia]], [[abdominal pain]], and [[vomiting]]. Without treatment, 63 percent of [[patients]] with early [[gastric cancer]] will progress to advanced [[disease]] within five years. [[Metastasis]] occurs in 80-90% of individuals with [[stomach cancer]].<ref name="pmid11034575">{{cite journal| author=Tsukuma H, Oshima A, Narahara H, Morii T| title=Natural history of early gastric cancer: a non-concurrent, long term, follow up study. | journal=Gut | year= 2000 | volume= 47 | issue= 5 | pages= 618-21 | pmid=11034575 | doi= | pmc=1728114 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11034575  }}</ref>  


==Complications==
==Complications==
Complications of gastric cancer include the following:
[[Complications]] of [[gastric cancer]] include the following:
* [[Ascites]]
* [[Ascites]]


Line 19: Line 20:


==== Recurrence: ====
==== Recurrence: ====
*Recurrence following curative resection was local or regional in 40 % and systemic in 60%.  
*Recurrence following curative [[resection]] was local or regional in 40 % and systemic in 60%.  


* Regional recurrences may be more frequent in patients treated with [[surgery]] alone or [[surgery]] plus postoperative [[chemotherapy]] without [[Radiotherapy|radiotheapy]], and among those who have a fewer number of negative resected [[lymph nodes]].<ref name="pmid22949400">{{cite journal| author=Li F, Zhang R, Liang H, Liu H, Quan J| title=The pattern and risk factors of recurrence of proximal gastric cancer after curative resection. | journal=J Surg Oncol | year= 2013 | volume= 107 | issue= 2 | pages= 130-5 | pmid=22949400 | doi=10.1002/jso.23252 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22949400  }}</ref>
* Regional recurrences may be more frequent in [[patients]] treated with [[surgery]] alone or [[surgery]] plus postoperative [[chemotherapy]] without [[Radiotherapy|radiotheapy]], and among those who have a fewer number of negative resected [[lymph nodes]].<ref name="pmid22949400">{{cite journal| author=Li F, Zhang R, Liang H, Liu H, Quan J| title=The pattern and risk factors of recurrence of proximal gastric cancer after curative resection. | journal=J Surg Oncol | year= 2013 | volume= 107 | issue= 2 | pages= 130-5 | pmid=22949400 | doi=10.1002/jso.23252 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22949400  }}</ref>


* Sites of regional recurrence include the [[luminal]] margins, the resection bed, and the regional [[Lymph nodes|nodes]].<ref name="pmid10973386">{{cite journal| author=Karpeh MS, Leon L, Klimstra D, Brennan MF| title=Lymph node staging in gastric cancer: is location more important than Number? An analysis of 1,038 patients. | journal=Ann Surg | year= 2000 | volume= 232 | issue= 3 | pages= 362-71 | pmid=10973386 | doi= | pmc=1421150 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10973386  }}</ref>
* Sites of regional recurrence include the [[luminal]] margins, the resection bed, and the regional [[Lymph nodes|nodes]].<ref name="pmid10973386">{{cite journal| author=Karpeh MS, Leon L, Klimstra D, Brennan MF| title=Lymph node staging in gastric cancer: is location more important than Number? An analysis of 1,038 patients. | journal=Ann Surg | year= 2000 | volume= 232 | issue= 3 | pages= 362-71 | pmid=10973386 | doi= | pmc=1421150 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10973386  }}</ref>


* The predominant sites of systemic recurrence are the [[liver]] and [[peritoneum]].<ref name="pmid28332034">{{cite journal| author=Ikoma N, Chen HC, Wang X, Blum M, Estrella JS, Fournier K et al.| title=Patterns of Initial Recurrence in Gastric Adenocarcinoma in the Era of Preoperative Therapy. | journal=Ann Surg Oncol | year= 2017 | volume= 24 | issue= 9 | pages= 2679-2687 | pmid=28332034 | doi=10.1245/s10434-017-5838-y | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28332034  }}</ref>
* The predominant sites of systemic recurrence are the [[liver]] and [[peritoneum]].<ref name="pmid28332034">{{cite journal| author=Ikoma N, Chen HC, Wang X, Blum M, Estrella JS, Fournier K et al.| title=Patterns of Initial Recurrence in Gastric Adenocarcinoma in the Era of Preoperative Therapy. | journal=Ann Surg Oncol | year= 2017 | volume= 24 | issue= 9 | pages= 2679-2687 | pmid=28332034 | doi=10.1245/s10434-017-5838-y | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28332034  }}</ref>
* [[Metastasis|Metastatic]] disease beyond the [[abdomen]] is uncommonly the first site of recurrence aside from the [[Supraclavicular|supraclavicula]]<nowiki/>r nodes.<ref name="pmid23536054">{{cite journal| author=Bickenbach KA, Gonen M, Strong V, Brennan MF, Coit DG| title=Association of positive transection margins with gastric cancer survival and local recurrence. | journal=Ann Surg Oncol | year= 2013 | volume= 20 | issue= 8 | pages= 2663-8 | pmid=23536054 | doi=10.1245/s10434-013-2950-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23536054  }}</ref>
*<nowiki/>[[Metastasis|Metastatic]] disease beyond the [[abdomen]] is uncommonly the first site of recurrence aside from the [[Supraclavicular|supraclavicula]]<nowiki/>r nodes.<ref name="pmid23536054">{{cite journal| author=Bickenbach KA, Gonen M, Strong V, Brennan MF, Coit DG| title=Association of positive transection margins with gastric cancer survival and local recurrence. | journal=Ann Surg Oncol | year= 2013 | volume= 20 | issue= 8 | pages= 2663-8 | pmid=23536054 | doi=10.1245/s10434-013-2950-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23536054  }}</ref>
*In a Japanese series, 9.2 % with early gastric cancers had a second cancer within the first year after therapy.<ref name="pmid16767364">{{cite journal| author=Nakajima T, Oda I, Gotoda T, Hamanaka H, Eguchi T, Yokoi C et al.| title=Metachronous gastric cancers after endoscopic resection: how effective is annual endoscopic surveillance? | journal=Gastric Cancer | year= 2006 | volume= 9 | issue= 2 | pages= 93-8 | pmid=16767364 | doi=10.1007/s10120-006-0372-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16767364  }}</ref>
* In a Japanese series, 9.2 % with early gastric cancers had a second [[cancer]] within the first year after [[therapy]]<nowiki/>.<ref name="pmid16767364">{{cite journal| author=Nakajima T, Oda I, Gotoda T, Hamanaka H, Eguchi T, Yokoi C et al.| title=Metachronous gastric cancers after endoscopic resection: how effective is annual endoscopic surveillance? | journal=Gastric Cancer | year= 2006 | volume= 9 | issue= 2 | pages= 93-8 | pmid=16767364 | doi=10.1007/s10120-006-0372-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16767364  }}</ref>
*The overall [[incidence]] of recurrence is 9.5 %t at five years, 13.1 % at seven years, and 22.7 % at 10 years.<ref name="pmid26165734">{{cite journal| author=Abe S, Oda I, Suzuki H, Nonaka S, Yoshinaga S, Nakajima T et al.| title=Long-term surveillance and treatment outcomes of metachronous gastric cancer occurring after curative endoscopic submucosal dissection. | journal=Endoscopy | year= 2015 | volume= 47 | issue= 12 | pages= 1113-8 | pmid=26165734 | doi=10.1055/s-0034-1392484 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26165734  }}</ref>
*The overall [[incidence]] of recurrence is 9.5 %t at five years, 13.1 % at seven years, and 22.7 % at 10 years.<ref name="pmid26165734">{{cite journal| author=Abe S, Oda I, Suzuki H, Nonaka S, Yoshinaga S, Nakajima T et al.| title=Long-term surveillance and treatment outcomes of metachronous gastric cancer occurring after curative endoscopic submucosal dissection. | journal=Endoscopy | year= 2015 | volume= 47 | issue= 12 | pages= 1113-8 | pmid=26165734 | doi=10.1055/s-0034-1392484 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26165734  }}</ref>


==== Surgery complications  ====
==== Surgery complications  ====
* [[Anastomotic]] leakage<ref name="pmid20632269">{{cite journal| author=Sierzega M, Kolodziejczyk P, Kulig J, Polish Gastric Cancer Study Group| title=Impact of anastomotic leakage on long-term survival after total gastrectomy for carcinoma of the stomach. | journal=Br J Surg | year= 2010 | volume= 97 | issue= 7 | pages= 1035-42 | pmid=20632269 | doi=10.1002/bjs.7038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20632269  }}</ref>
* [[Anastomotic]] leakage<ref name="pmid20632269">{{cite journal| author=Sierzega M, Kolodziejczyk P, Kulig J, Polish Gastric Cancer Study Group| title=Impact of anastomotic leakage on long-term survival after total gastrectomy for carcinoma of the stomach. | journal=Br J Surg | year= 2010 | volume= 97 | issue= 7 | pages= 1035-42 | pmid=20632269 | doi=10.1002/bjs.7038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20632269  }}</ref>
* [[Anastomotic]] strictures<ref name="pmid20458580">{{cite journal| author=Fukagawa T, Gotoda T, Oda I, Deguchi Y, Saka M, Morita S et al.| title=Stenosis of esophago-jejuno anastomosis after gastric surgery. | journal=World J Surg | year= 2010 | volume= 34 | issue= 8 | pages= 1859-63 | pmid=20458580 | doi=10.1007/s00268-010-0609-y | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20458580  }}</ref>
* [[Anastomotic]] [[strictures]]<ref name="pmid20458580">{{cite journal| author=Fukagawa T, Gotoda T, Oda I, Deguchi Y, Saka M, Morita S et al.| title=Stenosis of esophago-jejuno anastomosis after gastric surgery. | journal=World J Surg | year= 2010 | volume= 34 | issue= 8 | pages= 1859-63 | pmid=20458580 | doi=10.1007/s00268-010-0609-y | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20458580  }}</ref>
* [[Obstruction]]
* [[Obstruction]]
* [[Dumping syndrome]]: Dumping is a phenomenon caused by the destruction or bypass of the [[pyloric sphincter]]. [[Dumping syndrome|Dumping]] [[symptoms]] include [[gastrointestinal]] discomfort, [[abdominal pain]], [[flushing]], [[nausea]] and [[diarrhea]].<ref name="pmid25625992">{{cite journal| author=Mala T, Hewitt S, Høgestøl IK, Kjellevold K, Kristinsson JA, Risstad H| title=[Dumping syndrome following gastric surgery]. | journal=Tidsskr Nor Laegeforen | year= 2015 | volume= 135 | issue= 2 | pages= 137-41 | pmid=25625992 | doi=10.4045/tidsskr.14.0550 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25625992  }}</ref>
* [[Dumping syndrome]]: Dumping is a phenomenon caused by the destruction or [[bypass]] of the [[pyloric sphincter]]. [[Dumping syndrome|Dumping]] [[symptoms]] include [[gastrointestinal]] discomfort, [[abdominal pain]], [[flushing]], [[nausea]] and [[diarrhea]].<ref name="pmid25625992">{{cite journal| author=Mala T, Hewitt S, Høgestøl IK, Kjellevold K, Kristinsson JA, Risstad H| title=[Dumping syndrome following gastric surgery]. | journal=Tidsskr Nor Laegeforen | year= 2015 | volume= 135 | issue= 2 | pages= 137-41 | pmid=25625992 | doi=10.4045/tidsskr.14.0550 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25625992  }}</ref>
* [[Gastric stasis]] may develop as a result of post-surgical [[atony]], [[Vagus nerve|vagal]] denervation, or from a small gastric remnant following surgical resection.  
* [[Gastric stasis]] may develop as a result of post-surgical [[atony]], [[Vagus nerve|vagal]] denervation, or from a small gastric remnant following [[surgical resection]].  
* [[Symptoms]] consist of [[epigastric fullness]] with meals, often followed by [[emesis]] of undigested food, [[abdominal pain]], and [[weight loss]]<ref name="pmid25436381">{{cite journal| author=Paik HJ, Choi CI, Kim DH, Jeon TY, Kim DH, Son GM et al.| title=Risk factors for delayed gastric emptying caused by anastomosis edema after subtotal gastrectomy for gastric cancer. | journal=Hepatogastroenterology | year= 2014 | volume= 61 | issue= 134 | pages= 1794-800 | pmid=25436381 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25436381  }}</ref>
* [[Symptoms]] consist of [[epigastric fullness]] with meals, often followed by [[emesis]] of undigested food, [[abdominal pain]], and [[weight loss]]<ref name="pmid25436381">{{cite journal| author=Paik HJ, Choi CI, Kim DH, Jeon TY, Kim DH, Son GM et al.| title=Risk factors for delayed gastric emptying caused by anastomosis edema after subtotal gastrectomy for gastric cancer. | journal=Hepatogastroenterology | year= 2014 | volume= 61 | issue= 134 | pages= 1794-800 | pmid=25436381 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25436381  }}</ref>


Line 51: Line 52:
==Prognosis==
==Prognosis==
===Five-year survival===
===Five-year survival===
* The [[prognosis]] of patients with gastric cancer is related to [[tumor]] extent that includes direct [[tumor]] extension and [[lymph node]] involvement.
* The [[prognosis]] of [[patients]] with [[gastric cancer]] is related to [[tumor]] extent that includes direct [[tumor]] extension and [[lymph node]] involvement.
* The five-year [[survival rate]] for treated early gastric cancer is over 90 percent; nearly 100 percent for [[mucosal]] [[tumors]], and 80 to 90 percent for [[Submucosa|submucosal]] [[tumors]].<ref name="pmid19904573">{{cite journal| author=Youn HG, An JY, Choi MG, Noh JH, Sohn TS, Kim S| title=Recurrence after curative resection of early gastric cancer. | journal=Ann Surg Oncol | year= 2010 | volume= 17 | issue= 2 | pages= 448-54 | pmid=19904573 | doi=10.1245/s10434-009-0772-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19904573  }}</ref>
* The five-year [[survival rate]] for treated early [[gastric cancer]] is over 90 percent; nearly 100 percent for [[mucosal]] [[tumors]], and 80 to 90 percent for [[Submucosa|submucosal]] [[tumors]].<ref name="pmid19904573">{{cite journal| author=Youn HG, An JY, Choi MG, Noh JH, Sohn TS, Kim S| title=Recurrence after curative resection of early gastric cancer. | journal=Ann Surg Oncol | year= 2010 | volume= 17 | issue= 2 | pages= 448-54 | pmid=19904573 | doi=10.1245/s10434-009-0772-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19904573  }}</ref>
* [[Survival rates]] are similar between patients who undergo [[Endoscopic surgery|endoscopic resection]] and those who undergo [[surgical resection]].<ref name="pmid25281498">{{cite journal| author=Choi IJ, Lee JH, Kim YI, Kim CG, Cho SJ, Lee JY et al.| title=Long-term outcome comparison of endoscopic resection and surgery in early gastric cancer meeting the absolute indication for endoscopic resection. | journal=Gastrointest Endosc | year= 2015 | volume= 81 | issue= 2 | pages= 333-41.e1 | pmid=25281498 | doi=10.1016/j.gie.2014.07.047 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25281498  }}</ref>
* [[Survival rates]] are similar between [[patients]] who undergo [[Endoscopic surgery|endoscopic resection]] and those who undergo [[surgical resection]].<ref name="pmid25281498">{{cite journal| author=Choi IJ, Lee JH, Kim YI, Kim CG, Cho SJ, Lee JY et al.| title=Long-term outcome comparison of endoscopic resection and surgery in early gastric cancer meeting the absolute indication for endoscopic resection. | journal=Gastrointest Endosc | year= 2015 | volume= 81 | issue= 2 | pages= 333-41.e1 | pmid=25281498 | doi=10.1016/j.gie.2014.07.047 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25281498  }}</ref>
* For advanced cases, the five-year [[survival rate]] ranges from almost no survival for patients with disseminated disease to almost 50% survival for patients with localized distal gastric cancers confined to resectable regions.
* For advanced cases, the five-year [[survival rate]] ranges from almost no survival for [[patients]] with [[disseminated disease]] to almost 50% survival for [[patients]] with localized [[distal]] [[Gastric cancer|gastric cancers]] confined to resectable regions.
* The 5-year survival rate of patients with proximal gastric cancer is only 10% to 15%.
* The 5-year survival rate of [[patients]] with proximal [[gastric cancer]] is only 10% to 15%.
* The recurrence rate after [[surgery]] is approximately 1 to 5 percent in reports from Korea and Japan and 5 to 15 percent in studies from Western centers.<ref name="pmid2792394">{{cite journal| author=Percivale P, Bertoglio S, Muggianu M, Aste H, Secco GB, Martines H et al.| title=Long-term postoperative results in 54 cases of early gastric cancer: the choice of surgical procedure. | journal=Eur J Surg Oncol | year= 1989 | volume= 15 | issue= 5 | pages= 436-40 | pmid=2792394 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2792394  }}</ref>
* The recurrence rate after [[surgery]] is approximately 1 to 5 percent in reports from Korea and Japan and 5 to 15 percent in studies from Western centers.<ref name="pmid2792394">{{cite journal| author=Percivale P, Bertoglio S, Muggianu M, Aste H, Secco GB, Martines H et al.| title=Long-term postoperative results in 54 cases of early gastric cancer: the choice of surgical procedure. | journal=Eur J Surg Oncol | year= 1989 | volume= 15 | issue= 5 | pages= 436-40 | pmid=2792394 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2792394  }}</ref>
* These variable recurrence rates partially reflect differences in length of follow-up, but may also be due to differences in the [[Pathology|pathologic]] [[diagnosis]] of [[malignancy]].<ref name="pmid9193382">{{cite journal| author=Schlemper RJ, Itabashi M, Kato Y, Lewin KJ, Riddell RH, Shimoda T et al.| title=Differences in diagnostic criteria for gastric carcinoma between Japanese and western pathologists. | journal=Lancet | year= 1997 | volume= 349 | issue= 9067 | pages= 1725-9 | pmid=9193382 | doi=10.1016/S0140-6736(96)12249-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9193382  }}</ref>
* These variable recurrence rates partially reflect differences in length of follow-up, but may also be due to differences in the [[Pathology|pathologic]] [[diagnosis]] of [[malignancy]].<ref name="pmid9193382">{{cite journal| author=Schlemper RJ, Itabashi M, Kato Y, Lewin KJ, Riddell RH, Shimoda T et al.| title=Differences in diagnostic criteria for gastric carcinoma between Japanese and western pathologists. | journal=Lancet | year= 1997 | volume= 349 | issue= 9067 | pages= 1725-9 | pmid=9193382 | doi=10.1016/S0140-6736(96)12249-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9193382  }}</ref>
* Among patients undergoing [[Endoscopy|endoscopic resection]], recurrence rates have been reported to be between 0 and 30%.<ref name="pmid7676693">{{cite journal| author=Hiki Y, Shimao H, Mieno H, Sakakibara Y, Kobayashi N, Saigenji K| title=Modified treatment of early gastric cancer: evaluation of endoscopic treatment of early gastric cancers with respect to treatment indication groups. | journal=World J Surg | year= 1995 | volume= 19 | issue= 4 | pages= 517-22 | pmid=7676693 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7676693  }}</ref>
* Among [[patients]] undergoing [[Endoscopy|endoscopic resection]], recurrence rates have been reported to be between 0 and 30%.<ref name="pmid7676693">{{cite journal| author=Hiki Y, Shimao H, Mieno H, Sakakibara Y, Kobayashi N, Saigenji K| title=Modified treatment of early gastric cancer: evaluation of endoscopic treatment of early gastric cancers with respect to treatment indication groups. | journal=World J Surg | year= 1995 | volume= 19 | issue= 4 | pages= 517-22 | pmid=7676693 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7676693  }}</ref>
* Higher recurrence rates are seen with those who have piecemeal or incomplete resections.
* Higher recurrence rates are seen with those who have piecemeal or incomplete resections.
'''Prognosis with lymph node involvement'''
'''Prognosis with lymph node involvement'''
* Long-term survival was 95 percent in patients with no [[lymph node]] involvement, 88 percent in those with one to three [[Lymph node|nodes]] involved, and 77 percent in those with more than three [[Lymph nodes|nodes]] involved.<ref name="pmid7552619">{{cite journal| author=Kim JP, Hur YS, Yang HK| title=Lymph node metastasis as a significant prognostic factor in early gastric cancer: analysis of 1,136 early gastric cancers. | journal=Ann Surg Oncol | year= 1995 | volume= 2 | issue= 4 | pages= 308-13 | pmid=7552619 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7552619  }}</ref><ref name="pmid18095080">{{cite journal| author=Ohashi S, Okamura S, Urano F, Maeda M| title=Clinicopathological variables associated with lymph node metastasis in submucosal invasive gastric cancer. | journal=Gastric Cancer | year= 2007 | volume= 10 | issue= 4 | pages= 241-50 | pmid=18095080 | doi=10.1007/s10120-007-0442-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18095080  }}</ref>
* Long-term survival was 95 percent in patients with no [[lymph node]] involvement, 88 percent in those with one to three [[Lymph node|nodes]] involved, and 77 percent in those with more than three [[Lymph nodes|nodes]] involved.<ref name="pmid7552619">{{cite journal| author=Kim JP, Hur YS, Yang HK| title=Lymph node metastasis as a significant prognostic factor in early gastric cancer: analysis of 1,136 early gastric cancers. | journal=Ann Surg Oncol | year= 1995 | volume= 2 | issue= 4 | pages= 308-13 | pmid=7552619 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7552619  }}</ref><ref name="pmid18095080">{{cite journal| author=Ohashi S, Okamura S, Urano F, Maeda M| title=Clinicopathological variables associated with lymph node metastasis in submucosal invasive gastric cancer. | journal=Gastric Cancer | year= 2007 | volume= 10 | issue= 4 | pages= 241-50 | pmid=18095080 | doi=10.1007/s10120-007-0442-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18095080  }}</ref>


* Between 2004 and 2010, the 5-year relative survival of patients with stomach cancer was 29%.<ref name="SEER">Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014.</ref>
* Between 2004 and 2010, the 5-year relative survival of [[patients]] with [[stomach cancer]] was 29%.<ref name="SEER">Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014.</ref>


* The 5-year relative survival of patients with stomach cancer was 31.4% and 26% for patients <65 years.<ref name="SEER">Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014.</ref>
* The 5-year relative survival of [[patients]] with [[stomach cancer]] was 31.4% and 26% for patients <65 years.<ref name="SEER">Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014.</ref>


* The survival of patients with stomach cancer varies with the stage of the disease.  Shown below is a table depicting the 5-year relative survival by the stage of stomach cancer:<ref name="SEER">Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014.</ref>
* The survival of [[patients]] with [[stomach cancer]] varies with the stage of the [[disease]].  Shown below is a table depicting the 5-year relative survival by the stage of [[stomach cancer]]:<ref name="SEER">Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014.</ref>


{| style="cellpadding=0; cellspacing= 0; width: 600px;"
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
Line 84: Line 85:
|}
|}


* Shown below is an image depicting the 5-year conditional relative survival (probability of surviving in the next 5-years given the cohort has already survived 0, 1, 3 years) between 1998 and 2010 of stomach cancer by stage at diagnosis according to [[SEER]]. These graphs are adapted from [[SEER]]: The Surveillance, Epidemiology, and End Results Program of the National Cancer Institute.<ref name="SEER">Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014.</ref>
* Shown below is an image depicting the 5-year conditional relative survival (probability of surviving in the next 5-years given the cohort has already survived 0, 1, 3 years) between 1998 and 2010 of [[stomach cancer]] by stage at [[diagnosis]] according to [[SEER]]. These graphs are adapted from [[SEER]]: The Surveillance, [[Epidemiology]], and End Results Program of the [[National Cancer Institute]].<ref name="SEER">Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014.</ref>


<figure-inline class="mw-default-size"><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline>[[Image:5-year survival of gastric cancer in USA.PNG|584x584px]]</figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline>
<figure-inline class="mw-default-size"><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline>[[Image:5-year survival of gastric cancer in USA.PNG|584x584px]]</figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline>

Revision as of 16:16, 18 January 2019


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Parminder Dhingra, M.D. [2] Mohammed Abdelwahed M.D[3]

Stomach cancer Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Stomach Cancer from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic study of choice

Staging

History and Symptoms

Physical Examination

Laboratory Findings

Endoscopy and Biopsy

Chest X Ray

CT

MRI

Echocardiography or Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Stomach cancer natural history, complications and prognosis On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Stomach cancer natural history, complications and prognosis

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Stomach cancer natural history, complications and prognosis

CDC on Stomach cancer natural history, complications and prognosis

Stomach cancer natural history, complications and prognosis in the news

Blogs on Stomach cancer natural history, complications and prognosis

Directions to Hospitals Treating Stomach cancer

Risk calculators and risk factors for Stomach cancer natural history, complications and prognosis

Overview

If left untreated, the five-year survival rates of gastric cancer range from almost no survival for patients with disseminated disease to almost 50% survival for patients with localized distal gastric cancers confined to resectable regions. Higher recurrence rates are seen in those who have piecemeal or incomplete resections. Depending on the extent of the tumor at the time of diagnosis, the prognosis may vary. However, the prognosis is generally regarded as poor. Complications of gastric cancer are ascites, gastrointestinal bleeding, distant metastasis to other organs, weight loss, recurrence of cancer, and treatment complications. The prognosis of patients with gastric cancer is related to tumor extent that includes direct tumor extension and lymph nodes involvement. The five-year survival rate for treated early gastric cancer is over 90 percent; nearly 100 percent for mucosal tumors, and 80 to 90 percent for submucosal tumors.


Natural History

The symptoms of gastric cancer usually develop in the fifth decade of life, and start with loss of appetite and loss of weight. The symptoms of gastric cancer typically progress to dysphagia, abdominal pain, and vomiting. Without treatment, 63 percent of patients with early gastric cancer will progress to advanced disease within five years. Metastasis occurs in 80-90% of individuals with stomach cancer.[1]

Complications

Complications of gastric cancer include the following:

Recurrence:

  • Recurrence following curative resection was local or regional in 40 % and systemic in 60%.
  • Sites of regional recurrence include the luminal margins, the resection bed, and the regional nodes.[3]
  • The predominant sites of systemic recurrence are the liver and peritoneum.[4]
  • Metastatic disease beyond the abdomen is uncommonly the first site of recurrence aside from the supraclavicular nodes.[5]
  • In a Japanese series, 9.2 % with early gastric cancers had a second cancer within the first year after therapy.[6]
  • The overall incidence of recurrence is 9.5 %t at five years, 13.1 % at seven years, and 22.7 % at 10 years.[7]

Surgery complications

Chemotherapy complications

Prognosis

Five-year survival

Prognosis with lymph node involvement

  • Long-term survival was 95 percent in patients with no lymph node involvement, 88 percent in those with one to three nodes involved, and 77 percent in those with more than three nodes involved.[17][18]
Stage 5-year relative survival (%), (2004-2010)
All stages 28.3%
Localized 64.1%
Regional 28.8%
Distant 4.2%
Unstaged 20.2%
  • Shown below is an image depicting the 5-year conditional relative survival (probability of surviving in the next 5-years given the cohort has already survived 0, 1, 3 years) between 1998 and 2010 of stomach cancer by stage at diagnosis according to SEER. These graphs are adapted from SEER: The Surveillance, Epidemiology, and End Results Program of the National Cancer Institute.[19]

<figure-inline class="mw-default-size"><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline>

References

  1. ↑ Tsukuma H, Oshima A, Narahara H, Morii T (2000). "Natural history of early gastric cancer: a non-concurrent, long term, follow up study". Gut. 47 (5): 618–21. PMC 1728114. PMID 11034575.
  2. ↑ Li F, Zhang R, Liang H, Liu H, Quan J (2013). "The pattern and risk factors of recurrence of proximal gastric cancer after curative resection". J Surg Oncol. 107 (2): 130–5. doi:10.1002/jso.23252. PMID 22949400.
  3. ↑ Karpeh MS, Leon L, Klimstra D, Brennan MF (2000). "Lymph node staging in gastric cancer: is location more important than Number? An analysis of 1,038 patients". Ann Surg. 232 (3): 362–71. PMC 1421150. PMID 10973386.
  4. ↑ Ikoma N, Chen HC, Wang X, Blum M, Estrella JS, Fournier K; et al. (2017). "Patterns of Initial Recurrence in Gastric Adenocarcinoma in the Era of Preoperative Therapy". Ann Surg Oncol. 24 (9): 2679–2687. doi:10.1245/s10434-017-5838-y. PMID 28332034.
  5. ↑ Bickenbach KA, Gonen M, Strong V, Brennan MF, Coit DG (2013). "Association of positive transection margins with gastric cancer survival and local recurrence". Ann Surg Oncol. 20 (8): 2663–8. doi:10.1245/s10434-013-2950-5. PMID 23536054.
  6. ↑ Nakajima T, Oda I, Gotoda T, Hamanaka H, Eguchi T, Yokoi C; et al. (2006). "Metachronous gastric cancers after endoscopic resection: how effective is annual endoscopic surveillance?". Gastric Cancer. 9 (2): 93–8. doi:10.1007/s10120-006-0372-9. PMID 16767364.
  7. ↑ Abe S, Oda I, Suzuki H, Nonaka S, Yoshinaga S, Nakajima T; et al. (2015). "Long-term surveillance and treatment outcomes of metachronous gastric cancer occurring after curative endoscopic submucosal dissection". Endoscopy. 47 (12): 1113–8. doi:10.1055/s-0034-1392484. PMID 26165734.
  8. ↑ Sierzega M, Kolodziejczyk P, Kulig J, Polish Gastric Cancer Study Group (2010). "Impact of anastomotic leakage on long-term survival after total gastrectomy for carcinoma of the stomach". Br J Surg. 97 (7): 1035–42. doi:10.1002/bjs.7038. PMID 20632269.
  9. ↑ Fukagawa T, Gotoda T, Oda I, Deguchi Y, Saka M, Morita S; et al. (2010). "Stenosis of esophago-jejuno anastomosis after gastric surgery". World J Surg. 34 (8): 1859–63. doi:10.1007/s00268-010-0609-y. PMID 20458580.
  10. ↑ Mala T, Hewitt S, Høgestøl IK, Kjellevold K, Kristinsson JA, Risstad H (2015). "[Dumping syndrome following gastric surgery]". Tidsskr Nor Laegeforen. 135 (2): 137–41. doi:10.4045/tidsskr.14.0550. PMID 25625992.
  11. ↑ Paik HJ, Choi CI, Kim DH, Jeon TY, Kim DH, Son GM; et al. (2014). "Risk factors for delayed gastric emptying caused by anastomosis edema after subtotal gastrectomy for gastric cancer". Hepatogastroenterology. 61 (134): 1794–800. PMID 25436381.
  12. ↑ Youn HG, An JY, Choi MG, Noh JH, Sohn TS, Kim S (2010). "Recurrence after curative resection of early gastric cancer". Ann Surg Oncol. 17 (2): 448–54. doi:10.1245/s10434-009-0772-2. PMID 19904573.
  13. ↑ Choi IJ, Lee JH, Kim YI, Kim CG, Cho SJ, Lee JY; et al. (2015). "Long-term outcome comparison of endoscopic resection and surgery in early gastric cancer meeting the absolute indication for endoscopic resection". Gastrointest Endosc. 81 (2): 333–41.e1. doi:10.1016/j.gie.2014.07.047. PMID 25281498.
  14. ↑ Percivale P, Bertoglio S, Muggianu M, Aste H, Secco GB, Martines H; et al. (1989). "Long-term postoperative results in 54 cases of early gastric cancer: the choice of surgical procedure". Eur J Surg Oncol. 15 (5): 436–40. PMID 2792394.
  15. ↑ Schlemper RJ, Itabashi M, Kato Y, Lewin KJ, Riddell RH, Shimoda T; et al. (1997). "Differences in diagnostic criteria for gastric carcinoma between Japanese and western pathologists". Lancet. 349 (9067): 1725–9. doi:10.1016/S0140-6736(96)12249-2. PMID 9193382.
  16. ↑ Hiki Y, Shimao H, Mieno H, Sakakibara Y, Kobayashi N, Saigenji K (1995). "Modified treatment of early gastric cancer: evaluation of endoscopic treatment of early gastric cancers with respect to treatment indication groups". World J Surg. 19 (4): 517–22. PMID 7676693.
  17. ↑ Kim JP, Hur YS, Yang HK (1995). "Lymph node metastasis as a significant prognostic factor in early gastric cancer: analysis of 1,136 early gastric cancers". Ann Surg Oncol. 2 (4): 308–13. PMID 7552619.
  18. ↑ Ohashi S, Okamura S, Urano F, Maeda M (2007). "Clinicopathological variables associated with lymph node metastasis in submucosal invasive gastric cancer". Gastric Cancer. 10 (4): 241–50. doi:10.1007/s10120-007-0442-7. PMID 18095080.
  19. ↑ 19.0 19.1 19.2 19.3 Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014.

Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=Stomach_cancer_natural_history,_complications_and_prognosis&oldid=1537371"