Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 881 - файл
.pdf
10 Esophageal Cancer
171
Fig. 10.1 Treatment protocol for stage IA-IIB squammous cell carcinoma (a) and Adenocarcinoma
(b) tumors in Patients in poor clinical condition (ECOG>2) unfit for surgery
10.7.1 Intramucosal Tumor (Tis–T1a)
The intramucosal tumors have an extremely low nodal spread estimated at between
0 and 2%, unlike T1b tumors that can present a nodal involvement at more than 20%
[40]. Given the low propensity of lymph node involvement of the intramucosal cancer, endoscopic treatment can nd a potentially curative role.
Endoscopic treatment is mainly represented by the endoscopic resection that can
be made either by band ligation methods, cap-and-snare methods, or with endoscopic submucosal resection (ESR). Other endoscopic techniques are represented
by radiofrequency ablation (RFA), argon plasma coagulation (APC), and photodynamic therapy; nowadays, there are no reliable data on the real advantage of one
technique over the other [41].
172
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
D.M. Natale and M. Luigi
Fig. 10.2 Treatment protocol for stage IA-IIB squammous cell carcinoma (a) and Adenocarcinoma
(b) resectable tumors in Patients in good clinical condition (ECOG<2) fit for surgery
According to the most recent guidelines, in relation to the low sensitivity of EUS
to accurately discriminate between lesions T1a and T1b, submucosal endoscopic
resection appears to offer the greatest benets for these tumors, in particular in
elderly patients, and, in addition, offers a histological sample useful in accurately
assessing the margins of resection and the real depth of invasion of the esophageal
wall [42]. In case of high-grade dysplasia (HDG) in Barrett’s esophagus, ESD
should always be followed by a complete eradication of Barrett because it is shown
that patients with Barrett who developed adenocarcinoma, if not eradicated, will
develop a relapse in about 30% of cases [43, 44].
10 Esophageal Cancer
Fig. 10.3 Treatment protocol for locally Advanced disease, partially reswctable (stage IIIA-IIIC)
squammous cell carcinoma and Adenocarcinoma in Patients in good clinica condition (ECOG<2)
fit for CT/RT and surgery
173
Furthermore, according to recent guidelines, for patients t for surgery, in good
clinical condition, esophagectomy has an important role in the curative treatment of
these malignancies, particularly when associated with motor abnormalities [45, 46].
10.7.2 Invasive Cancer (T1b–T2)
Invasive tumors, meaning those tumors involving the submucosa (sm T1b 1–3) and
extending to the muscularis propria without exceeding it (T2) unlike intramucosal
lesions, have a signicantly higher percentage of lymph node involvement that can
vary from 20 to 50% [40–46].
T1b lesions sm1 G1 can nd a valid therapeutic option in ESD that can also be
applied in combination to adjuvant therapy in t-for-CRT patients but who are
unt for surgery [47–49]. In lesions sm 2–3, which may present even greater
lymph node involvement, the esophagectomy in patients t for surgery remains
indicated [40].
The invasion of the submucosal layer by the tumor is, therefore, to be considered
an indication for esophagectomy and should be addressed directly to surgery, even
in patients where the EMR was found to be incomplete or not executable. We must
also consider that patients with T2 tumors are upstaged in more than 60% of the
cases. For these patients and for patients properly staged, surgical therapy may be
considered as the denitive treatment, while understaged patients should be directed
to an adjuvant therapy [50].
174
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
D.M. Natale and M. Luigi
10.7.3 Locally Advanced Tumor (T3–T4)
Locally advanced tumors are considered tumors whose wall invasion is invasion of the
adventitia (T3) and up to tumors that exceed the adventitia and are inltrating the
pleura, pericardium, or diaphragm but are still resectable (T4a) or malignancies with
involvement of locoregional lymph nodes T1 with a wall involvement in T4a. These
malignancies still represent the majority of cancers in patients who seek treatment,
especially elderly patients who, very often, do not fall into public screening programs.
These malignancies, either squamous or adenocarcinoma tumors, still present
margins for resectability and nd the best treatment in esophagectomy with radical
lymphadenectomy in order to get local control of the disease. Unfortunately, performed in the rst instance, this is still burdened by a poor long-term survival and
signicant local recurrence. In addition, elderly patients are especially burdened by
high perioperative morbidity and mortality [51].
Numerous studies in the literature have evaluated the disease-free survival time and
long-term survival, comparing patients treated with surgery alone and patients treated with
surgery preceded by neoadjuvant therapy whether CT or RT.Patients undergoing neoadjuvant treatment present a long-term survival and a rate of R0 resections signicantly
greater than in patients treated with surgery alone. In particular, numerous studies have
shown that long-term survival is signicantly increased in patients treated with CRT followed by surgery and that the complete pathologic response highlighted in the histological
examination was found to be the most important positive prognostic factor [52, 53].
In SCC, in the evidence of a pCR, CRT treatment could be considered as denitive therapy in elderly subjects. As reported in a recent retrospective study conducted in China on patients with esophageal squamous cell carcinoma of
age>70years undergoing chemoradiotherapy, an average survival of 22.3months
with toxicity gr. 3–4 only in 17% of cases was observed [34].
10.7.4 Metastatic Disease or Unresectable Cancer
In patients that cannot be treated in a curative manner with surgery or cannot undergo
surgery, CRT or CT is the denitive therapy. In these patients, it was observed that
the combination of chemotherapy and radiotherapy offers, compared to the standard
chemotherapy, survival rates of approximately 15% at 5years [34–54].
Endoscopic treatment in these patients takes on a purely palliative intent and may
consist of expansion (with balloon or bougie) to improve dysphagia or, when possible, endoscopic resection which in addition to improving dysphagia can allow the
placement of stents [55, 56].
Conclusion
Esophageal cancer is still a leading cause of cancer-related death in the world,
and, in recent decades, the increase in life expectancy has led to a signicant
increase of elderly patients with cancer of the esophagus or cardia being referred
for treatment.
10 Esophageal Cancer
Even today, however, most of the patients, especially the elderly, who are rst
observed, present metastatic or locally advanced malignancies, and this gure
has emphasized the need for a multimodal approach to this pathology for a signicant improvement of survival, although, at present, it still amounts to approximately 20% at 5years [33].
For the therapeutic schedule, appropriate timing for the patient and a correct
preoperative staging are fundamental to predict long-term survival.
Endoscopic techniques, which represent the gold standard in the diagnosis of
esophageal lesions (EGD and EUS), are also useful in pure palliation particularly
to improve dysphagia (balloon, bougie, stent). With therapeutic intent, however,
endoscopic methods are indicated, represented mainly by endoscopic mucosectomy, in intramucose or in HGD lesions of Barrett with good results in terms of
survival and excellent results on quality of life.
Surgery is still the treatment of choice for patients with cancer of the esophagus or esophagogastric junction and, despite being one of the most challenging
in cancer surgery, when performed by experienced surgeons and centers with
large volumes, with proper indication and in selected patients, offers denite
advantages in the local control of the disease and quality of life of patients with
an acceptable morbidity and mortality.
In addition, with the improvement of anesthetic techniques and postoperative
pain control and, especially, the introduction into clinical practice of assessing
the “fragility” of the elderly patient, it has allowed the enlistment, even in aggressive treatment protocols, of a growing number of elderly patients with results in
terms of morbidity (especially pulmonary complications) and mortality, similar
to those of younger patients [5–57].
In the literature, there is no evidence of benets in terms of long-term survival of any
particular surgical technique compared one with the other, but certainly in the last few
years, a minimally invasive approach, in particular, the Ivor-Lewis, can offer advantages in terms of recovery and postoperative morbidity while respecting the fundamental surgical radicality parameter in improving the long-term survival of these patients.
Certainly, an R0 resection and lymphadenectomy with removal of at least 18
negative nodes would seem to offer better survival than in patients with fewer
blocks of lymph nodes [58].
Neoadjuvant chemotherapy is the main cornerstone in improving the outcome
of patients with SCC and AEC, locally advanced and especially in metastatic
cancer or in patients unt for surgery. In the latter, it is the denitive therapy
allowing, in the case of disease recurrence, the possibility to make a salvage
esophagectomy however, this is also burdened by a signicantly greater morbidity and mortality than elective surgery.
Latest chemoradiotherapeutic protocols represented by the combination of cisplatin or its derivatives in combination with uorouracil represent the reference
regimen for both histologies, squamous and adenocarcinoma. Their use in neoadjuvant treatments has certainly resulted in improved survival rate not only helping
to understage disease and optimize surgery but, above all, increasing the rate of
complete pathological response that, at present, is the most important prognostic
factor in increasing disease-free survival and the overall survival rate [59, 60].
175
176
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
D.M. Natale and M. Luigi
Finally, the study of monoclonal antibodies might allow the planning of a
tailored therapy, in patients with genetically mutated receptors, and represent, as
it does now for colorectal and lung cancers, the future therapeutic strategy for
locally advanced esophageal cancer.
References
1. Fentiman IS, Tirelli U, Monfardini S, Schneider M, Festen J, Cognetti F, Aapro MS.Cancer in
the elderly: why so badly treated? Lancet. 1990;335(8696):1020–2.
2. O’Connel JB, Maggard MA, Ko CY. Cancer-direct surgery for localized disease: decreased
use in the elderly? Ann Surg Oncol. 2004 Nov;11(11):962–9.
3. Internullo E, Moons J, Nafteux P, Coosemans W, Decker G, De Leyn P, etal. Outcome after
esophagectomy for cancer of the esophagus and GEJ in patients aged over 75 years. Eur J
Cardiothorac Surg. 2008;33:1096–104.
4. Walter LC, etal. Cancer screening in elderly patients a framework for individualized decision
making. JAMA. 2001;285:2750–6.
5. Ruol A, Portale G, Zaninotto G, Cagol M, Cavallin F, Castoro C, et al. Results of esophagectomy for esophageal cancer in elderly patients: age has little inuence on outcome and
survival. J Thorac Cardiovasc Surg. 2007;133:1186–92.
6. Simard EP, Ward EM, Siegel R, Jemal A. Cancers with increasing incidence trends in the
United States: 1999 through 2008. CA Cancer J Clin. 2012;62:118–28.
7. Bosetti C, Levi F, Ferlay J, etal. Trends in oesophageal cancer incidence and mortality in
Europe. Int J Cancer. 2008;122:1118–29.
8. Falk GW. Risk factors for esophageal cancer development. Surg Oncol Clin N Am.
2009;18:469–85.
9. Pickens A, Orringer MB.Geographical distribution and racial disparity in esophageal cancer.
Ann Thorac Surg. 2003;76:S1367–9.
10. Pandeya N, Olsen CM, Whiteman DC.Sex differences in the proportion of esophageal squamous cell carcinoma cases attributable to tobacco smoking and alcohol consumption. Cancer
Epidemiol. 2013;37:579–84.
11. Pandeya N, Williams G, Green AC, Webb PM, Whiteman DC, Australian CS.Alcohol consumption and the risks of adenocarcinoma and squamous cell carcinoma of the esoph- agus.
Gastroenterology. 2009;136:1215–24. e1211ee1212
12. Lindkvist B, Johansen D, Stocks T, etal. Metabolic risk factors for esophageal squamous cell
carcinoma and adenocarcinoma: a prospective study of 580,000 subjects within the me-can
project. BMC Cancer. 2014;14:103.
13. Bosetti C, Levi F, Ferlay J, etal. Trends in oesophageal cancer incidence and mortality in
Europe. Int J Cancer. 2008;122:1118–29.
14. Monaco L, Brillantino A, Torelli F, Schettino M, Izzo G, Cosenza A, Di Martino N.Prevalence
of bile reux in gastroesophageal reux disease patients not responsive to proton pump inhibitors. World J Gastroenterol. 2009;15(3):334–8.
15. Nason KS, Wichienkuer PP, Awais O, et al. Gastro- esophageal reux disease symptom
severity, proton pump inhibitor use, and esophageal carcinogenesis. Arch Surg. 2011;146:
851–8.
16. Corley DA, Kubo A, Zhao W.Abdominal obesity and the risk of esophageal and gastric cardia
carcinomas. Cancer Epidemiol Biomark Prev. 2008;17:352–8.
17. Brillantino A, Monaco L, Schettino M, Torelli F, Izzo G, Cosenza A, Marano L, Di Martino
N.Prevalence of pathological duodenogastric reux and the relationship between duodenogastric and duodenogastrooesophageal reux in chronic gastrooesophageal reux disease. Eur J
Gastroenterol Hepatol. 2008;20(12):1136–43.
18. Hoyo C, Cook MB, Kamangar F, et al. Body mass index in relation to oesophageal and
oesophagogastric junction adenocarcinomas: a pooled analysis from the international BEACON consortium. Int J Epidemiol. 2012;41:1706–18.
10 Esophageal Cancer
19. Cook MB, Kamangar F, Whiteman DC, etal. Cigarette smoking and adenocarcinomas of the
esophagus and esophagogastric junction: a pooled analysis from the international BEACON
consortium. J Natl Cancer Inst. 2010;102:1344–53.
20. Ma J-Y, Wu Z, Wang Y, Zhao Y-F, Liu L-X, Kou Y-L, Zhou Q-H.Clinicopathologic characteristics of esophagectomy for esophageal carcinoma in elderly patients. World J Gastroenterol.
2006;12(8):1296–9.
21. Monson K, etal. Surgery in the aged population. Arch Surg. 2003;138(10):1061–7.
22. Feder G, Cryer C, Donovan S, Carter Y.Guidelines for the prevention of falls in people over
65. The Guidelines’ development group. BMJ. 2000;321:1007–11.
23. Robinson TN, etal. Simple frailty score predicts post-operative complications across surgicall
specialties. Am J Surg. 2013;206(4):544–50.
24. Young PE, Gentry AB, Acosta RD, et al. Endoscopic ultrasound does not accurately stage
early adenocarcinoma or high-grade dysplasia of the esophagus. Clin Gastroenterol Hepatol.
2010;8:1037–41.
25. Smith BR, Chang KJ, Lee JG, et al. Staging accuracy of endoscopic ultrasound based on
pathologic analysis after minimally invasive esophagectomy. Am Surg. 2010;76:1228–31.
26. Rebollo Aguirre AC, Ramos-Font C, Villegas Portero R, etal. 18F- uorodeoxiglucose positron emission tomography for the evaluation of neoadjuvant therapy response in esophageal
cancer: systematic review of the literature. Ann Surg. 2009;250:247–54.
27. Sjoquist KM, Burmeister BH, Smithers BM, etal. Survival after neoadjuvant chemotherapy or
chemoradiotherapy for resectable oesophageal carcinoma: an updated meta- analysis. Lancet
Oncol. 2011;12:681–92.
28. Bonavina L, Bona D, Binyom P, Peracchia A. A laparoscopy-assisted surgical approach to
esophageal carcinoma. J Surg Res. 2004;117:52–7.
29. Luketich JD, Meehan M, Nguyen NT, etal. Minimally invasive surgical staging for esophageal
cancer. Surg Endosc. 2000;4:700.
30. Baisi A, Bonavina L, Peracchia A.Bronchoscopic staging of squamous cell carcinoma of the
upper thoracic esophagus. Arch Surg. 1999;132:140–3.
31. Siewert JR, Stein HJ.Classication of adenocarcinoma of the oesophagogastric junction. Br J
Surg. 1998;85:1457–9.
32. Edge SB, American Joint Committee on Cancer, Amer- ican Cancer Society. AJCC cancer
staging handbook from the AJCC cancer staging manual. NewYork: Springer; 2010.
33. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2015. CA Cancer J Clin. 2015;65(1):
5–29.
34. Al-Sarraf M, Martz K, Herskovic A, etal. Progress report of combined chemoradiotherapy
versus radiotherapy alone in patients with esophageal cancer: an intergroup study. J Clin
Oncol. 1997;15:277–2.
35. Philip PA, Ajani JA.Has combined modality therapy improved the outlook in carcinoma of the
esophagus? Oncology. 1994;8:37–42.
36. Orditura M, Galizia G, Fabozzi A, Lieto E, Gambardella V, Morgillo F, Del Genio GM, Fei L,
Di Martino N, Renda A, Ciardiello F, De Vita F. Preoperative treatment of locally advanced
esophageal carcinoma (review). Int J Oncol. 2013;43(6):1745–53.
37. Van Hagen P, Hulshof MC, van Lanschot JJ, etal. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med. 2012;366:2074–84.
38. Ajani JA.Current status of new drugs and multidisciplinary approaches in patients with carcinoma of the esophagus. Chest. 1998;113(Suppl):S112–9.
39. Cools-Lartigue J, Spicer J, Ferri LE.Current status of management of malignant disease: current management of esophageal cancer. J Gastrointest Surg. 2015;19:964–72.
40. Leers JM, DeMeester SR, Oezcelik A, etal. The prevalence of lymph node metastases in
patients with T1 esophageal adenocarcinoma a retrospective review of esophagectomy specimens. Ann Surg. 2011;253:271–8.
41. Semlitsch T, Jeitler K, Schoe R, etal. A systematic review of the evidence for radiofrequency
ablation for Barrett’s esophagus. Surg Endosc. 2010;24:2935–43.
42. Chennat J, Waxman I. Endoscopic treatment of Barrett’s esophagus: from metaplasia to
intramucosal carcinoma. World J Gastroenterol. 2010;16:3780–5.
177
178
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
D.M. Natale and M. Luigi
43. Ell C, May A, Gossner L, etal. Endoscopic mucosal resection of early cancer and high-grade
dysplasia in Barrett’s esophagus. Gastroenterology. 2000;118:670–7.
44. May A, Gossner L, Pech O, etal. Local endoscopic therapy for intraepithelial high-grade neoplasia and early adenocarcinoma in Barrett’s oesophagus: acute-phase and intermediate results
of a new treatment approach. Eur J Gastroenterol Hepatol. 2002;14:1085–91.
45. Pech O, Bollschweiler E, Manner H, etal. Comparison between endoscopic and surgical resection of mucosal esophageal adenocarcinoma in Barrett’s esophagus at two high-volume centers. Ann Surg. 2011;254:67–72.
46. Sepesi B, Watson TJ, Zhou D, etal. Are endoscopic therapies appropriate for supercial submucosal esophageal adenocarcinoma? An analysis of esophagectomy specimens. J Am Coll
Surg. 2010;210:418–27.
47. Manner H, May A, Pech O, etal. Early Barrett’s carcinoma with “low-risk” submucosal invasion: long-term results of endoscopic resection with a curative intent. Am J Gastroenterol.
2008;103:2589–97.
48. Peters FP, Brakenhoff KP, Curvers WL, et al. Histologic evaluation of resection specimens obtained at 293 endoscopic resections in Barrett’s esophagus. Gastrointest Endosc.
2008;67:604–9.
49. Manner H, Pech O, Heldmann Y, et al. Efcacy, safety, and long-term results of endoscopic
treatment for early stage adenocarcinoma of the esophagus with low-risk sm1 invasion. Clin
Gastroenterol Hepatol. 2013;11:630–5. quiz e45
50. Rice TW, Mason DP, Murthy SC, etal. T2N0M0 esophageal cancer. J Thorac Cardiovasc Surg.
2007;133:317–24.
51. Ronellentsch U, Schwarzbach M, Hofheinz R, etal. Preoperative chemo(radio)therapy versus
primary surgery for gastroesophageal adenocarcinoma: systematic review with meta- analysis
combining individual patient and aggregate data. Eur J Cancer. 2013;49:3149–58.
52. Markar SR, Karthikesalingam A, Penna M, etal. Assessment of short-term clinical outcomes
following salvage esophagectomy for the treatment of esophageal malignancy: systematic
review and pooled analysis. Ann Surg Oncol. 2014;21:922–31.
53. Teoh AY, Yan Chiu PW, Wong TC, etal. Functional performance and quality of life in patients
with squamous esophageal carcinoma receiving surgery or chemoradiation: results from a randomized trial. Ann Surg. 2011;253:1–5.
54. Herskovic A, Martz K, Al-Sarraf M, etal. Combined chemotherapy and radiotherapy compared with radio- therapy alone in patients with cancer of the esophagus. N Engl J Med.
1992;326:1593–8.
55. Manner H, May A, Rabenstein T, et al. Prospective evaluation of a new high-power argon
plasma coagulation system (hp-APC) in therapeutic gastrointestinal endoscopy. Scand J
Gastroenterol. 2007;42:397–405.
56. Abdel-Wahab M, Gad-Elhak N, Denewer A, et al. Endoscopic laser treatment of progressive dysphagia in patients with advanced esophageal carcinoma. Hepatogastroenterology.
1998;45:1509–15.
57. Alibakhshi A, Aminian A, Mirshari R, Jahangiri Y, Dashti H, Karimian F.The effect of age
on the outcome of esophageal cancer surgery. Ann Thorac Med. 2009;4(2):71–4.
58. Greenstein AJ, Litle VR, Swanson SJ, etal. Effect of the number of lymph nodes sampled on postoperative survival of lymph node-negative esophageal cancer. Cancer. 2008;112(6):1239–46.
59. Orditura M, Galizia G, Morgillo F, Martinelli E, Lieto E, Vitiello F, Di Martino N, Pacelli
R, Renda A, Ciardiello F, De Vita F.Complete response to preoperative chemoradiation and
survival in esophageal cancer: a pooled analysis of three single-institution phase II trials. Dis
Esophagus. 2012;25(2):130–6.
60. Orditura M, Galizia G, Di Martino N, Ancona E, Castoro C, Pacelli R, Morgillo F, Rossetti S,
Gambardella V, Farella A, Laterza MM, Ruol A, Fabozzi A, Napolitano V, Iovino F, Lieto E,
Fei L, Conzo G, Ciardiello F, De Vita F.Effect of preoperative chemoradiotherapy on outcome
of patients with locally advanced esophagogastric junction adenocarcinoma-a pilot study. Curr
Oncol. 2014;21(3):125–33.
Cancer oftheStomach
11
RobertoVergari, VanessaPolenta, andCristinaMarmorale
11.1 Epidemiology
In recent decades, socioeconomic habits and new medical knowledge have improved
average life expectancy and quality of life as well. As a direct consequence, the
geriatric population is progressively expanding, as is the risk of developing cancer.
Gastric tumour represents the fourth most common malignancy worldwide, after
cancers of the lung, breast and colorectum.
The worldwide incidence of gastric neoplasm has declined rapidly over the last
few decades [1]. Part of the decline may be due to the recognition of certain risk
factors such as Helicobacter pylori and other dietary and environmental risks.
Refrigerators have improved the storage of food, thereby reducing salt-based preservation of food and preventing bacterial and fungal contamination.
Despite the decrease in the global incidence of this disease, in endemic areas,
such as Japan and Latin American countries, gastric cancer is still a major cause of
mortality.
According to the Italian Network of Cancer Registries [2], gastric cancer is currently in sixth place in order of incidence among both men and women (4% of all
cancers in males and 4% in females), and in 2016 new cases are expected to be
nearly 13,000. This distribution is almost entirely attributable to the incidence in
older age (over 70years). Gastric tumour is considered a disease of the old age with
a peak of incidence in the seventh decade of life. Although there is not a standard
R. Vergari • V. Polenta
Clinica Chirurgica—Ospedali Riuniti di Ancona, Ancona, Italy
C. Marmorale (
Formazione in Chirurgia Generale—Ospedali Riuniti di Ancona, Ancona, Italy
Direttrice della Scuola di Specialità in Chirurgia Generale—Università Politecnica delle
Marche, Ancona, Italy
e-mail: c.marmorale@univpm.it
© Springer International Publishing AG, part of Springer Nature 2018
A. Crucitti (ed.), Surgical Management of Elderly Patients,
https://doi.org/10.1007/978-3-319-60861-7_11
*)
179
180
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
R. Vergari et al.
denition of “elderly”, the most scientic papers x the age of 70 as the threshold.
The average human life expectancy is increasing worldwide and with it also the
proportion of elderly people. This is predicted to continue to increase in the coming
decades [3]. As a consequence, also the incidence of gastric carcinoma in elderly
patients is becoming more frequent. In Italy, the 5years overall survival is 32.4%,
higher than the European average (25.1%). The overall survival in elderly patients
is lower than in non-elderly ones: 22.1 versus 41.0% [2].
11.2 Risk Factors
The entire process of gastric carcinogenesis involves several factors, such as, gender, age, diet, tobacco and alcohol consumption, H. pylori infections, chronic gastritis, pernicious anaemia, some type of stomach polyps and previous gastric
surgery.
Stomach cancer is more common in men than in women, and, as already discussed, there is a sharp increase in people over the age of 70. An increased risk of
stomach cancer is seen in people with diets that have large amounts of smoked
foods, salted sh and meat and pickled vegetables. Nitrates and nitrites are substances commonly found in cured meats; they can be converted into compounds that
have been shown to cause stomach cancer in lab animals. A reduced consumption
of fresh fruit and vegetables is another dietary behaviour implicated in gastric carcinogenesis. The rate of stomach cancer is about doubled in smokers and is related
to the duration and intensity of smoking. Smoking increases stomach cancer risk,
particularly for cancers of the upper portion of the stomach, near the oesophagus
[4]. On the other hand, several studies suggest that alcohol consumption increases
the risk of cancer in the lower stomach.
It is demonstrated that H. pylori infection is frequent in areas of high gastric
cancer incidence. Infection with H. pylori bacteria seems to be a major cause of
stomach cancer, especially cancers located in the distal part of the stomach. On the
contrary, this infection seems not to be related with tumours of the gastroesophageal
junction. Chronic gastritis associated with pernicious anaemia is related with gastric
malignancy. Chronic gastritis is often associated with intestinal metaplasia and
mucosal dysplasia which are frequently observed in the mucosa adjacent to gastric
cancer. Pernicious anaemia is a disease characterized by fundic mucosal atrophy,
loss of parietal and chief cells, hypochlorhydria and hypergastrinemia, and it is
present in 3% of people over 60years. Polyps are growths on the lining of the stomach, and most types, such as hyperplastic polyps or inammatory polyps, do not
seem to increase the risk of gastric cancer. Endoscopic removal is a sufcient treatment; subsequent surveillance is also not necessary. In contrast, adenomatous polyps, also called adenomas, can sometimes develop into cancer; in fact dysplasia and
carcinoma in situ develop inside these growths. The carcinogenesis risk has been
estimated at 10–20%, and it is higher for polyps of more than 2cm in diameter.
Gastric cancer is more likely to develop in people who have undergone previous
partial gastrectomy, for example, due to a gastric ulcer. This condition is called
Соседние файлы в папке @xirurgi_2025