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Investigación Contemporánea 01 - 2025 Vol. 3 - No. 1 ISSN-e: 2960-8015
DOI: https://doi.org/10.58995/redlic.rmic.v3.n1.a78
Gastric Cancer, Update in management; clinical case presentation 17 - 52
Gastric Cancer, Update in management; clinical case presentation
Clinical case. Revista Multidisciplinaria Investigación Contemporánea.
Vol. 3 - No. 1, pp. 17- 52. January-June, 2025. e-ISSN: 2960-8015
Gastric Cancer, Update in
management; clinical case
presentation
Cáncer gástrico, avances recientes en su tratamiento;
presentación de un caso
Article information:
Received: 25-04-2024
Accepted: 04-09-2024
Published: 05-01-2025
Editor's note:
REDLIC remains neutral with respect to juris-
dictional claims in published messages and
institutional afliations.
Publisher:
Red Editorial Latinoamericana de Investigación
Contemporánea (REDLIC) www.editorialredlic.com
Sources of nancing:
The research was carried out with own resources.
Conicts of interest:
No conicts of interest.
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1 General and Laparoscopic Surgeon, Attending at San Juan Hospital Martin -
Azogues; marco.polo11@live.com Azogues, Ecuador.
2 Undergraduate student at the Catholic University of Cuenca, Azogues campus;
daysi.correa.00@est.ucacue.edu.ec. Azogues, Ecuador.
3 Undergraduate student at the Catholic University of Cuenca, Azogues campus;
stephany.penaloza.82@est.ucacue.edu.ec. Azogues, Ecuador.
4 Undergraduate student at the Catholic University of Cuenca, Azogues campus;
luis.mora.47@est.ucacue.edu.ec . Azogues, Ecuador.
5 Undergraduate student at the Catholic University of Cuenca, Azogues campus;
jennifer.rivera.28@est.ucacue.edu.ec. Azogues, Ecuador.
Marco Vinicio Urgilés Rivas 1*, Daysi Doménica Correa Coronel 2, Stephany Guadalupe Peñaloza
Minchala 3, Luis Fernando Mora Ochoa 4, Jennifer Maribel Rivera Ortiz 5
DOI: https://doi.org/10.58995/redlic.rmic.v3.n1.a78
How to cite:
Urgilés Rivas MV, Correa Coronel DD, Peñaloza Minchala SG, Mora Ochoa LF, Rivera Ortiz JM. Gastric Cancer,
Update in management; clinical case. REVMIC [Internet]. 2024 Oct. 22 [cited 2024 Oct. 22];3(1).
Available at: https://doi.org/10.58995/redlic.rmic.v3.n1.a78
Revista multidisciplinaria
Investigación Contemporánea 01 - 2025 Vol. 3 - No. 1 ISSN-e: 2960-8015
DOI: https://doi.org/10.58995/redlic.rmic.v3.n1.a78
Gastric Cancer, Update in management; clinical case presentation 18 - 52
Gastric Cancer, Update in management; clinical case presentation
Resumen
The current problem of advanced gastric cancer is its high morbidity and mortality,
it represents the fth most frequent tumor and the fourth cause of death, surgical
treatment determines a benet in the patient's survival, however; most tumors at the
time of diagnosis are in advanced stages, resulting in the surgical procedure being
ineffective, the case of an 82-year-old male patient is presented, who consults for
abdominal distension, unquantied weight loss and hyporexia. Endoscopically, a
tumor lesion was evidenced whose histological report was gastric adenocarcinoma,
therefore, a total gastrectomy and subsequent chemotherapy were performed, it
presents a torpid evolution and nally dies. Conclusion: multiple factors inuence
the genesis of the tumor, gastrectomy remains the standard of treatment in early
stages but most cases are in advanced stages.
Keywords: adenocarcinoma, gastrectomy, helicobacter pylori, digestive endoscopy.
Abstract
El problema actual del cáncer gástrico avanzado es su alta morbilidad y mortalidad,
representa el quinto tumor más frecuente y la cuarta causa de muerte, el tratamiento
quirúrgico determina un benecio en la sobrevida del paciente, sin embargo, la
mayoría de los tumores al momento del diagnóstico se encuentran en estadios
avanzados resultando un procedimiento quirúrgico efectivo, presentamos el caso
de un paciente masculino de 82 años, que consulta por distensión abdominal,
pérdida de peso no cuanticada e hiporexia. La endoscopia reveló una lesión
tumoral cuyo reporte histológico fue adenocarcinoma gástrico, por lo que se realizó
gastrectomía total y posterior quimioterapia, presentó una evolución tórpida y
nalmente falleció. Conclusión: múltiples factores inuyen en la génesis del tumor;
la gastrectomía sigue siendo el estándar de tratamiento en estadios tempranos pero
la mayoría de los casos se encuentran en estadios avanzados.
Palabras clave: adenocarcinoma, gastrectomía, helicobacter pylori, endoscopia
digestiva.
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Gastric Cancer, Update in management; clinical case presentation
1. Introduction
Gastric cancer is one of the most common malignancies, being the fourth
cause of death worldwide; according to statistical data, in East Asian countries
there is a higher mortality rate; in Japan, mortality occurs in 1.4% of men and
5.8% corresponds to women; in Ecuador, in 2018, around 2.3% of mortality
was recorded with an approximate of 9.8/100,000 inhabitants; despite this, its
incidence has decreased and the male sex is the most affected population (1, 3)(1)(2)(3).
It is considered a multifactorial condition; gastric adenocarcinoma is a
malignant neoplasm with high aggressiveness, so its early diagnosis is of vital
importance to reduce the number of incidences as well as modify the risk
factors. There are various classications of this disease, whether endoscopic or
histopathological , it is staged by the TNM system established by the American
Cancer Committee. Currently, the presence of certain risk factors has been
observed, including family history, alcohol consumption, diet, smoking,
infections by Helicobacter Pylori or the Epstein Barr virus (2).
Depending on the cell type, the location of the tumor, the degree of cellular
differentiation, and the presence or absence of metastasis, treatment is directed
either to a partial or total gastrectomy with lymphadenectomy.
The purpose of this work is to carry out a bibliographic review related to
gastric cancer based on the presentation of a clinical case that was managed in
a reference center in the country.
2. Clinical Case
Male patient, 82 years old, farmer, Catholic, mestizo, personal pathological
history: inguinal herniorrhaphy and knee osteosynthesis, no family history;
argues clinical picture of distension and abdominal pain at the epigastrium
level according to EVA 4/10, without radiation, six months of evolution, with
periods of remission and exacerbation, weight loss not quantied 3 months
ago for which reason he comes to the consultation, at the time of admission
presents: BP: 110/80 mm Hg, FR 20 rpm; Temperature of 35.8ºC, SAO2: 97%,
weight: 45 kg, height: 1.57. His general appearance is regular, the head and neck
normocephalic , at the level of the thorax the pulmonary elds are ventilated and
vesicular murmur normal; heart: R1 and R2 normophonetic synchronous with
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Gastric Cancer, Update in management; clinical case presentation
the pulse; At the abdominal level, palpation shows soft, depressible and painful
at the epigastrium level and auscultation shows increased RHA, oriented in
time, space and person. Since this is an elderly patient with weight loss without
history, blood tests are requested with the following results:
Table 1. Laboratory Results
Parameter Result Normal Values
Neutrophils 40% 45-70%
Hemoglobin 12 g/dl 13-17 g/dl
INR 1.08 Up to 1
Lactic dehydrogenase 236 U/L 250-450 U/L
Note . The rest of the laboratory tests were normal.
Source : Solca Cuenca Laboratory data (2022)
The low hemoglobin level was noted and tumor markers were also performed,
the results of which are shown in Table 2. After this, an Upper Digestive Endoscopy
(EDA) was performed, the report of which indicated: the esophagus had no
alterations ( Figure 1 ); the stomach did not show contraction or relaxation; in
the middle part of the gastric body, an ulcerated brotic neoplastic lesion was
observed that decreased the diameter of the gastric chamber, giving it the shape
of an hourglass, without affecting the antrum and fundus ( Figure 2a and b ); the
duodenum showed no alterations until the third portion ( Figure 3 ).
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Gastric Cancer, Update in management; clinical case presentation
Figure 1. Upper digestive endoscopy. Source: SOLCA Cancer Institute (2022).
Figure 2a and b. Upper digestive endoscopy. Source: SOLCA Cancer Institute (2022).
Figure 3. Upper digestive endoscopy. Source: SOLCA Cancer Institute (2022).
a b
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Gastric Cancer, Update in management; clinical case presentation
Table 2. Tumor Markers
Parameter Result Normal Values
Carcinoembryonic
Antigen (CEA) 3.00 ng/dl <4.70 ng/dl
CA 19-9 15.46 U/ml <39 U/ml
Source : Solca Cuenca Laboratory data (2022)
Samples were taken for pathology, the report indicates gastric mucosa
inltrated by a diffuse inltrating epithelial-type neoplastic proliferation,
with a predominantly solid pattern, made up of atypical, cohesive, large cells,
broad cytoplasm, eccentric and atypical nucleus, with marked pleomorphism,
hyperchromasia and focally cells with a "signet ring" appearance; lymphoid
neoplasia is ruled out and the examination for Helicobacter Pylori negative (see
figure 4). Subsequently, a CT scan of the abdomen with contrast was performed,
which showed thickening of the gastric wall of 16 mm thick with 56 mm in length
in the antrum and perigastric lymph nodes of approximately 6 mm and 5 mm
with no distant lesions suggesting metastasis.
Figure 4. Tissue samples for pathological anatomy.
The denitive diagnosis was Borrmann type IV diffuse gastric adenocarcinoma.
The patient underwent total gastrectomy plus Roux-en-Y esophagogastro
anastomosis; however, during this procedure, important ndings were
obtained, including: “peritoneal carcinomatosis and a 6 cm ulcerated tumor at the level
of the greater curvature in the middle third of the gastric body that infiltrated all layers.”
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Gastric Cancer, Update in management; clinical case presentation
The patient was discharged on the twelfth day and one month after surgery,
postoperative chemotherapy was started.
Three months after surgery, the patient presented dysphagia for solids
and liquids, developing gastroesophageal reux; based on this, it was decided
to perform new laboratory and imaging tests; the results of the blood count
and blood biochemistry are shown in table 3 and table 4. The CT scan showed
abundant free uid in the abdominal cavity (see figure 5). Then, an esophagogram
was performed, which showed a stenosis in the esophagoduodenojejunal
anastomosis (see figure 6). Having said this, an intervention was carried out
consisting of an esophageal balloon dilation after prior informed consent.
Table 3. Post-Complications Blood Count
Parameter Result Normal Values
White Blood Cells 3.42 4.50 – 10 /mm3
Red Blood Cells 3.51 4.50 – 5.90 /mm3
Hemoglobin 11.20 11.60 – 16.30 g/dl
Hematocrit 31.90 42 – 54%
Red blood cell distribution
width 19.20 11.50 – 14.50 %
Note . The rest of the blood count parameters were normal.
Source : Solca Cuenca Laboratory data (2022)
Figure 5. Abdomino-pelvic CT scan showing the presence of free uid.
Source : SOLCA Cancer Institute (2022).
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Gastric Cancer, Update in management; clinical case presentation
Figure 6. Esophagogram with evidence of esophagoduodenojejunal stenosis.
Source: SOLCA Cancer Institute (2022).
Table 4. Post-Complication Blood Biochemistry
Parameter Result Normal Values
Urea 55.9 10-50 mg/dl
Creatinine 0.62 0.70-1.20 mg/dl
Note. The rest of the blood biochemistry parameters were normal.
Source: Solca Cuenca Laboratory data (2022)
The patient's condition deteriorated 6 months after surgery , and the
patient passed away.
3. Gastric cancer
3.1 Concept
Gastric cancer (GC) is dened as an affection of the cells that line and form
part of the gastric wall, in which apoptosis of malignant cells fails. It develops
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Gastric Cancer, Update in management; clinical case presentation
in any portion of the stomach and can spread via lymphatic, hematogenous or
continuous routes (4)(5). (4,5).
According to a study carried out in 2022 by the Calixto García Hospital,
the most frequent anatomical location of this type of cancer is in the antrum,
followed by tumors of the gastric body. Regarding the histological classication
of GC, there is a predominance of adenocarcinoma around 95% (4,5).
3.2 Etiopathogenesis
Some conditions have been identied that have a great impact on the
development of CG, such as those observed in Figure 7, on exogenous or
environmental factors.
Figure 7. Most frequent exogenous factors associated with gastric cancer.
Gastric cancer is multifactorial, however, Helicobacter pylori infection is
the main cause, being considered a type 1 carcinogen. The infection progresses
from a duodenal ulcer , gastric ulcer to the development of GC. This bacteria
alkalizes the gastric pH , allowing it to live there and thus proliferate and cause
a chronic inammatory response (6).
H. pylori comes into contact with the cell through adhesins, then
produces a type IV secretion system (CagL), certain toxins (VacA) and the
cytotoxin associated with gene A (CagA) that alter the normal functioning
of the epithelium. The host generates an inammatory response due to the
inltration of polymorphonuclear cells and consequently the patient suffers
from gastritis. The bacteria protects itself from reactive oxygen species (ROS)
Radiación
Obesidad
Alcohol
Tabaco
Dieta
H. Pilory
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Gastric Cancer, Update in management; clinical case presentation
through enzymes that reduce the production of nitric oxide (NO) by the cells
of the immune system. ROS leads to damage to cellular DNA, which decreases
apoptosis and thus prevents complete DNA repair(6, 7).
From another perspective, studies have shown that a diet high in salt
content is the most prevalent for the appearance of gastric neoplasias. This is
because salt produces an increase in the inammatory response and an increase
in DNA synthesis and cell proliferation. Among other epidemiological studies,
GC is also associated with smoked foods due to their content of polycyclic
aromatic hydrocarbons. On the other hand, fruits and vegetables (rich in vitamin
C or beta-carotene) have been considered as means of protection against the
appearance of GC; however, there are convictions against it that have not yet
been dened (6, 7).
Tobacco is a type 1 carcinogen that increases with the intensity and
duration of smoking. Since cigarettes contain a number of chemical substances,
including polycyclic aromatic hydrocarbons, benzopyrenes, heterocyclic
amines and nitrosamines, which could trigger GC. The smoke generated
by tobacco contains NO, which when combined with nicotine produces
nitrosamines and promotes oxidative DNA damage. Another factor involved is
alcohol consumption, although it is not well catalogued, there are some studies
that reveal that beer increases the risk, unlike wine, which is considered a
protective factor (6, 7).
According to Buján (7) ), obese populations (body mass index between 30-
35) are more prone to suffer from GC, mainly in the region of the cardia and the
gastroesophageal junction. The theories propose that it is due to an increase
in gastroesophageal reux, given the accumulation of abdominal fat, which in
turn releases excess insulin and insulin-like growth factor (IGF-1), which in a
certain way alters cell proliferation and apoptosis. In another sense, radiation
is less frequent but no less important, since gamma radiation predisposes to
GC, as does chemotherapeutic agents such as procarbazine. Figure 8 shows the
endogenous factors that increase the risk of GC.
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Gastric Cancer, Update in management; clinical case presentation
Figure 8. Most frequent endogenous factors associated with gastric cancer.
Recently, studies from 2019 have revealed that the cancer rate is more
prevalent in men as opposed to women. Approximately 0.8% of the population
will be diagnosed with GC at some point in their life, but the risk increases with
age. The average diagnosis of GC occurs in people between 65-74 years old,
despite this, today cancer is not limited and also affects young people. On the
other hand, race is inuenced by environmental factors more than genetic ones
for the presence of GC (6,7).
As mentioned by Cala and García (6,8),(8) genetic bases have also inuenced
this pathology, since having rst-degree relatives with the neoplasia increases
the risk, as well as individuals with an affected mother as opposed to a father.
Thus, we have the mutation of the E-Cadherin gene, responsible for the coding
of proteins that have the function of adhesion and intercellular communication.
Likewise, GC is attributed to hereditary syndromes in 5-10% as observed in table
5.
Lesiones premalignas
Gastritis autoinmune
Sindromes hereditarios
Agregación familiar
Sexo y raza
Edad
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Table 5. Hereditary syndromes responsible for the development of GC.
Syndrome Phenotype Gene involved Risk
Hereditary
diffuse gastric
cancer
Diffuse CDH1>80%
Lynch syndrome Intestinal MLH1
10%
MSH2
MSH6
Familial
adenomatous
polyposis
Intestinal APC 4-7%
Li-Fraumeni
Syndrome
Intestinal or
diffuse TP53 2-5%
Hamartomatous
polyposis
Intestinal or
diffuse SMAD429%
STK11
Source: Cala T, Estepa A, Martínez A (2021)
Autoimmune gastritis is due to a chronic inammatory process, affecting
the parietal cells of the stomach, leading to progressive atrophy of the mucosa.
This behavior reduces the iron content, and nally vitamin B12 deciency
at the cellular level, triggering what is known as pernicious anemia. Some
premalignant lesions such as chronic gastritis, intestinal metaplasia, gastric
polyps, previous gastrectomy and peptic ulcer; are also triggering factors of
gastric neoplasia (6,7).
3.3 Epidemiology
Gastric carcinoma has spread throughout the world, generating a higher
prevalence in Asian countries, which is why, based on the latest WHO incidence
and mortality estimates for 2019, about 5.7% of new cases of gastric cancer were
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Gastric Cancer, Update in management; clinical case presentation
reported worldwide, placing GC in fth place in the incidence of neoplasias and
the fourth cause of mortality (7).
At the Ecuadorian level, according to data obtained from the National
Institute of Statistics and Census (INEC), in 2018, 1,687 deaths were reported,
representing 2.3% of the total mortality of 9.8 cases. It has been shown that
the most outstanding risk factors are age (mean age 61 years) and it prevails
in the male sex. Approximately 37% of patients have been diagnosed already
in stage IV or regionally advanced, followed by stage III in 35% of cases. In
turn, the tumor in the majority has been located at the level of the middle
third of the stomach; as well, the metastasis presents a predominance at the
hepatic level, close to 18.6 of the patients diagnosed with GC (see figure 9) (9).
Figure 9. Comparison of the incidence and mortality of GC in Ecuador with other Latin American
countries in 2018. Note. Blue: incidence. Red: mortality.
Source: Taken from Globocan (2018)
Chile
Perú
Guatemala
Costa Rica
Colombia
Ecuador
Honduras
French Guiana
Panamá
0 0.40 0.80 1.2 1.6 2.0
France, Guadeloupe
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3.4 Gastric Anatomy and Physiology
The gastrointestinal tract (see figure 10) has a dilated portion such as the
stomach, which is located in the upper left quadrant of the abdomen, occupies
part of the epigastrium as well as the left hypochondrium due to its "J" shape,
which forms two unequal curvatures, the greater and lesser at the body level. It
has a length of 25 cm and a storage capacity of 1-1.5 L. It is entirely covered by
the visceral peritoneum, except for the areas of the curvatures and adhered to
other structures by means of the epiplons. Among other aspects, ve regions
are recognized : cardia, fundus, body, antrum and pylorus. At a microscopic
level, the stomach has four layers; from the inside to the outside is the mucosa
that is in contact with gastric acid and in which some gastric glands are found,
it continues with the submucosa covered by the muscular and nally the serosa
(10).
Figure 10. Parts of the stomach and important structures. Note . A) portions of the stomach and curva-
tures, B) layers of the stomach, C) glands present. Source: Cala T, Estepa A, Martínez A (2021)
The stomach is supplied by the celiac trunk , which comes from two
systems that anastomose along the curvatures and branch into several direct
branches. The anastomosis of the left and right gastric arteries are located
Célula de recubrimiento de la
supercie
Célula mucosa del cuello
Células parietales (oxínticas)
Células principales (cimógenas)
Células regenerativas
Células enteroendocrinas
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along the lesser curvature, which comes from the celiac trunk and the common
hepatic artery, respectively. On the other hand, the anastomosis of the greater
curvature is formed by the union of the right and left gastroepiploic arteries,
which originate from the gastroduodenal and splenic arteries, respectively (11).
In addition, the splenic artery is also responsible for branching into
short gastric arteries and the posterior gastric artery that go to the fundus and
upper part of the body of the stomach. Pyloric irrigation is provided by the
gastroduodenal artery. The venous system is parallel to the arterial system with
the exception that they ow into the gastrocolic trunk or Henle's trunk. As for
lymphatic drainage, the lymph follows a path from the stomach through the
lymphatic vessels and ows into the gastric and gastroepiploic lymph nodes,
located close to the arteries of the gastric curvatures. In turn, the pylorus is
drained by the upper and lower lymph nodes. All vessels ow into the celiac
lymph nodes (11).
Regarding gastric physiology, the stomach is involved in both mechanical
and chemical digestion of food. Once the ingested food reaches the stomach, it
remains stored for a few hours, while some substances interfere with its process
of size reduction and decomposition into basic metabolic elements. That said,
the stomach secretes gastric juices that are made up of proteolytic enzymes
(pepsin) and hydrochloric acid (HCL) secreted by parietal cells; which are
essential for the denaturation of proteins and the absorption of nutrients; it also
prevents certain infections by reducing the amount of ingested microorganisms,
this is due to a pH <2, which limits bacterial colonization and survival (12).
Once the food is mixed with gastric juices, the stomach produces a semi-
liquid substance called chyme, which then goes to the small intestine, the organ
in which most of the absorption of essential nutrients for the human body takes
place (12).
3.5 Pathophysiology
As Buele (13), points out , the main cause of this malignant disease is the
presence of Helicobacter Pylori, a bacteria that causes a series of pathologies
that end in cancer. Since it is an inammatory process, proinammatory
cytokines are released, which intensify the inammatory response and inhibit
acid secretion in the stomach. This leads to the synthesis and accumulation of
mutagenic compounds that in a certain way alter the cellular genomic level.
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Consequently, premalignant states are generated, which lead to gastric cancer,
as highlighted in Figure 11.
Figure 11. Algorithm of the pathophysiology of CG . Source: Arias M (2020)
It must be remembered that the process of cellular homeostasis involves
proliferation, differentiation and apoptosis. However, when carcinogenesis
occurs, these mechanisms are altered. Therefore, according to Correa's cascade,
malignant tissue progresses in several stages, from chronic gastritis that
progresses with multifocal atrophy, accompanied by the decrease of gastric
glands, due to the loss of parietal cells. Added to this is brosis of the lamina
propria that progresses from atrophy to intestinal metaplasia (IM). In turn, IM
is classied based on intestinal enzymes and the type of mucin secreted (13).
The penultimate stage of oncogenesis is dysplasia , characterized by
problems in the maturation of epithelial cells, resulting in growth. Finally, early
identication of this stage and the administration of timely treatment could
prevent the progression of GC. It should be noted that complete eradication of
Cáncer Gástrico, últimos avances en el manejo; presentación de caso
Volumen 1 | Número 1 | septiembre - diciembre| 2022 11
células parietales; que son fundamentales para la desnaturalización de las proteínas y la
absorción de nutrientes; además previene ciertas infecciones al reducir la cantidad de
microorganismos ingeridos, esto se debe a un pH <2, que limita la colonización y
supervivencia bacteriana (12).
Una vez que los alimentos se mezclan con los jugos gástricos, el estómago produce una
sustancia semilíquida denominada quimo, que luego se dirige al intestino delgado, órgano
en el cual se da la mayor parte de absorción de sustancias nutritivas esenciales para el
cuerpo humano. (12).
3.5 Fisiopatología
Como señala Buele(13), la principal causa de esta enfermedad maligna es la presencia de
la Helicobacter Pylori, dicha bacteria provoca una serie de patologías que termina en el
cáncer. Al tratarse de un proceso inflamatorio, se da la liberación de citoquinas
proinflamatorias, que intensifican la respuesta inflamatoria e inhiben la secreción del ácido
en el estómago. Lo que conlleva a síntesis y acumulación de compuestos mutagénicos que
de cierta forma alteran el nivel genómico celular. En consecuencia, se generan estados
premalignos lo que conduce al cáncer gástrico, como se resalta en la figura 11.
Figura 11. Algoritmo de la fisiopatología del CG. Fuente: Arias M (2020)
Hay que recordar que el proceso de homeostasis celular implica la proliferación,
diferenciación y apoptosis. Pero al existir la carcinogénesis existe alteración de estos
mecanismos. Por lo cual según la cascada de Correa; el tejido maligno progresa en varias
etapas, desde la gastritis crónica que avanza con una atrofia multifocal, acompañado de la
disminución de glándulas gástricas, dado por la pérdida de células parietales. A esto se
suma la fibrosis de la lámina propia que progresa de una atrofia a la metaplasia intestinal
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H. pylori reduces the development of GC by 40%, which is a great benet as age
progresses (13).
3.6 Clinical Manifestations
Most patients with early-stage gastric cancer show no symptoms in
approximately 80% of cases. In the remaining 20%, symptoms are similar to
those of an ulcer syndrome or other gastric diseases, with epigastric pain
being characteristic. Medical attention is rarely sought, so early-stage cancer
is detected in only 10% of cases. On the other hand, advanced gastric cancer
presents intense symptoms and there may be dissemination or metastasis,
the most common sites being the liver and peritoneum. In liver involvement,
neoplastic hepatomegaly, ascites or masses on the right side of the abdomen
may be observed. On the other hand, when it affects the peritoneum, it is called
peritoneal carcinomatosis and manifests with constipation, ascites, and diffuse
abdominal pain (see table 6 ) (14).
Table 6. Comparison of the clinical picture of an asymptomatic and symptomatic patient
Patient Paciente Sintomático
Abdominal pain that responds to
antacids
Severe abdominal pain
Heartburn or acidity Cachexia
Indigestion Ascites
Nausea Hematochezia
Vomiting Hepatomegaly
Early satiety Hematemesis
Hypoorexia or lack of appetite Dysphagia
Anemia without apparent cause Upper gastrointestinal bleeding
Normal physical exam Physical exam, palpable mass
Source : Cárdenas Martínez, et al. (2021), Montoya & Montagnè (2019)
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Other sites of metastasis are the ovaries, local lymph nodes, bone structures,
central nervous system and lung level. It is also possible to nd paraneoplastic
syndromes, which refers to the release of substances by cancer cells that damage
nearby cells or tissues. However, it is important to note that this condition is
rare (15). As the disease progresses, mild symptoms may arise. It is important
to note that in senile patients who present a similar clinical picture, an upper
and lower digestive endoscopy is warranted to rule out or conrm the presence
of tumors in the digestive system (14).
3.7 Clinical Diagnosis
Diagnosing gastric cancer is difcult due to the absence of symptoms in the
early stages. To achieve an accurate diagnosis, it is necessary for the doctor
to perform an initial evaluation. In this case, he or she must consider the type
of cancer he or she suspects as a professional, the clinical signs, age, general
health of the patient and laboratory tests such as a blood test. In addition, a
series of complementary tests are added to the physical examination to conrm
the diagnosis (14).
Particularly effective tests for detecting gastric cancer and its spread are:
esophagogastroduodenal series (EGD), endoscopy, endoscopic ultrasound
(EUS) and computed tomography (CT). It is important to note that EGD is only
used in cases where endoscopy is not feasible or when dysphagia is the initial
symptom, since the use of double contrast improves its sensitivity. Endoscopy
or gastroscopy with biopsy is the most effective method, since it allows the
identication of the tumor, evaluation of its growth pattern, size and extension
in different segments of the organ, and obtaining histological conrmation by
taking samples. It is recommended to obtain a minimum of ve biopsies, which
guarantees a positive detection rate of 97% (16).
Endoscopic ultrasound (EUS) can determine tumor invasion in the
different layers of the gastric wall and the degree of involvement of perigastric
lymph nodes. Its effectiveness ranges from 60% to 90% in detecting tumor, and
from 50% to 95% in detecting lymph nodes. However, its usefulness is limited in
the evaluation of distant lymph nodes. Computed tomography (CT) is routinely
used for preoperative staging of gastric cancer and has an accuracy ranging
from 43% to 82% in determining tumor size and inltration into adjacent
organs. However, it is unreliable in assessing tumor depth and the presence of
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lymph node metastasis. The sensitivity and specicity of CT in detecting hepatic
dissemination are 72% and 85%, respectively (17).
On the other hand, it is important to carry out screening, which can be
carried out by two methods: screening of large populations or focusing on
patients at higher risk. This depends on the frequency of gastric cancer in the
region. In the case of gastroscopy, screening should begin at age 50 and be
repeated every 2 to 3 years, especially in high-risk populations, such as those
with gastric atrophy or intestinal metaplasia. In turn, there are hormones that
contribute to the diagnosis, such as serum ghrelin, in which reduced levels
may indicate a high risk of neoplasia, since its production decreases in cases of
atrophy and chronic inammation (7, 18)(18).
3.8 Cancer Classication
To differentiate the stages of GC, the Borrmann classication is used, a system
that consists of observing the macroscopic characteristics of the lesion through
endoscopy, each one is distinguished according to the affected gastric layers, as
seen in Figure 12 (19).
On the other hand, stage I : The tumor invades the deepest layer of the
mucosa (lamina propria) or the submucosa without affecting the lymph nodes
(stage IA), or with involvement of 1 to 6 nodes. It is also considered stage I
when the tumor invades the muscular layer or the subserosa without affecting
the lymph nodes. There is no presence of distant metastasis. After stage 0,
this is the stage with the best prognosis. Stage II and Stage III are considered
intermediate stages, considering that Stage II has a more favorable prognosis
compared to Stage III. The classication of these stages is based on both the
level of involvement of the stomach wall and the number of nodes affected by
the tumor (19).
Stage IV, which represents the most advanced phase, shows the poorest
prognosis, as the cancer has spread to organs such as the liver and lymph nodes
distant from the stomach. It is crucial to note that the survival of patients with
gastric cancer is closely linked to these stages. The survival rate exceeds 95% in
stage 0 and decreases as the stage increases. Stage IV exhibits the lowest survival
rate. Within gastric cancer, adenocarcinomas are predominantly common,
approximately 70% of cases, around the age of 70, however, 5% of malignant
tumors are gastric lymphomas (19).
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Figure 12. Borrmann classication. Source: Sabistón , 21st edition (2022).
As mentioned above, adenocarcinomas are predominantly common,
however, at least 5% of malignant neoplasms are considered gastric lymphomas.
Lauren's histological classication establishes that there are two types: diffuse
and intestinal. (20).
Table 7. Lauren's histological classication.
Guys Subtypes
Intestinal Tubular adenocarcinoma
Papillary adenocarcinoma
Diffuse
Signet ring cell adenocarcinoma
Undifferentiated carcinoma
Mucinous carcinoma
Source : Martínez, et al. (2021).
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3.9 Staging and risk assessment
The prediction of adenocarcinoma is related to the tumor stage determined
during diagnosis. To determine the staging of GC, the TNM classication is
used, which is based on the extent of tumor invasion (T), the involvement of
lymph nodes (N) and the presence of metastasis (M) ( see table 7) . In addition,
this disease is generally divided into two categories: early gastric cancer and
advanced gastric cancer (AGC). When we talk about early GC, we refer to
damage to the mucosa and also to the submucosa (T1), regardless of the size of
the tumor or the involvement at the lymph node level. Survival is higher than
90% in most cases. While, advanced GC directly affects the innermost layers (T2
and T4) and has a survival rate of 7-27% (21).
Table 7. TNM staging for gastric cancer.
Primary Tumor
TX The primary tumor cannot be assessed.
T0 There is no evidence of primary tumor in the stomach
TiS Carcinoma in situ: Found only in cells on the surface of the
stomach's inner lining.
T1 Large tumor in the lamina propria, muscularis mucosae, or
submucosa.
T2 The tumor has grown into the muscularis propria.
T3 The tumor has grown through all the muscle layers to the
connective tissue outside the stomach, without affecting the
serosa.
T4 The tumor invades the serosa and peritoneum.
Regional Lymph Nodes (N)
Nx Regional lymph nodes cannot be assessed.
N0 The cancer has not spread to regional lymph nodes.
N1 The cancer has spread to 1 to 2 regional lymph nodes.
N2 The cancer has spread to 3 to 6 regional lymph nodes.
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N3 The cancer has spread from 7 or more regional lymph nodes.
Metastasis Distance (M)
Mx Distant metastasis cannot be assessed.
M0 The cancer has not spread to other parts of the body.
M1 The cancer has spread to other parts of the body.
Source : Villagrán R, et al. (2021).
It is worth mentioning that in computed tomography (CT), the positivity of
lymph nodes is determined based on their size, shape and enhancement pattern.
Lymph nodes with a size between 8 and 10 mm in their shortest dimension,
a round shape, presence of central necrosis and marked or heterogeneous
enhancement will be considered positive (22).
3.10 Dissemination Patterns
Metastases to solid organs In early diagnosis they are rare, but it is crucial to
detect them in order to plan the appropriate treatment. The most common
hematogenous metastases occur in the liver, less common are the lungs, adrenal
glands, bones, ovaries or peritoneum due to continuity (23).
Computed tomography (CT) remains the technique of choice for the
preoperative diagnosis of peritoneal carcinomatosis. However, in many
cases, peritoneal carcinomatosis is only identied during surgery due to the
limitations of CT in its detection (23).
3.11 Treatment Plan
In summary, GC staging focuses on a neoplasm that may be localized, locally
advanced, or metastatic, which are a key point for treatment options as
visualized in Figure 13.
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Figure 13. Management algorithm for the diagnosis of gastric neoplasia.
Note. CT: computed tomography, MRI: nuclear magnetic resonance, PET: positron emission tomogra-
phy, Qt: chemotherapy , Qt Rt : concomitant chemo-radiotherapy . Source: Rojas V, Montagné N (2019)
.
In the case of metastatic disease, the patient is a non-surgical candidate,
who is only suitable for palliative care, since the cancer is in stage IV (24).
On the other hand, the neoadjuvant chemotherapy regimen has not
yet been established, however, it should be administered prior to surgery
in patients with resectable tumor T2 N0 or more and varies according to the
functional status and comorbidities. While, adjuvant treatment is given in cases
of T3 and T4 N0 after surgery, for those people who did not have an adequate
lymphadenectomy, otherwise radiotherapy is omitted. On the other hand,
patients with a good prognosis of localized pTis or pT1, N0 disease are not
recommended postoperative chemotherapy (24).
Cáncer Gástrico, últimos avances en el manejo; presentación de caso
Volumen 1 | Número 1 | septiembre - diciembre| 2022 16
Las metástasis a órganos sólidos en el diagnóstico temprano son poco frecuentes, pero es
crucial detectarlas para planificar el tratamiento adecuado. Las metástasis hematógenas
más habituales ocurren en el hígado, menos comunes son los pulmones, las glándulas
suprarrenales, huesos, ovarios o al peritoneo por continuidad. (23).
La tomografía computarizada (TC) sigue siendo la técnica de elección para el diagnóstico
preoperatorio de la carcinomatosis peritoneal. Sin embargo, en muchos casos, la
carcinomatosis peritoneal solo se identifica durante la cirugía debido a las limitaciones de
la TC en su detección (23).
3.11 Plan de Tratamiento
En resumen, la estadificación del CG se centra en una neoplasia que puede ser localizada,
localmente avanzada o metastásica, que son un punto clave para las opciones del
tratamiento como se visualiza en la figura 13.
Figura 13. Algoritmo de manejo ante el diagnóstico de neoplasia gástrica.
Nota. TC: tomografía computarizada, RMN: resonancia magnética nuclear, PET: tomografía por emisión
de positrones, Qt: quimioterapia, Qt Rt: quimio- radioterapia concomitante. Fuente: Rojas V, Montagné N
(2019).
En el caso de la enfermedad metastásica, el paciente es un candidato no quirúrgico, que
está apto solo para recibir cuidados paliativos, puesto que, el cáncer se encuentra en
estadio IV. (24).
Diagnóstico de cáncer gástrico:
Endoscopía+ biopsia
Estadiaje: ecoendoscopía, TC, RMN, PET-TC,
laparoscopía+ biopsia
Enfermedad
local
avanzada
(>T2, no M1)
Enfermedad
localizada
(<T2)
Enfermedad
metastásica
(M1)
Cirugía,
plantear
tratamiento
endoscópico
Cuidados
paliativos
Dos opciones:
Cirugía+ adyuvancia (QtRt)
Qt perioperatorio (Qt neoadyuvante+ cirugía+ Qt
adyuvante)
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In another instance, surgical resections are directed at early stage cancer
(stage II or less) with the goal of removing the malignancy. These procedures
include endoscopic mucosal resection, distal esophagectomy, subtotal
gastrectomy (distal tumors) or total (proximal or extensive tumors), the surgery
can be an open or laparoscopic approach, it will depend on the operator's ability
and the hospital's supplies (25).
3.12 Postoperative complications
Gastrectomy can cause several postoperative complications, either during or
after surgery. Among the immediate complications we can consider those related
to the procedure such as pneumonia, pulmonary thromboembolism, acute
coronary syndrome, among others. Meanwhile, those related to surgery include
anastomotic leakage, intestinal hemorrhage, duodenal stump dehiscence,
peritonitis, abscesses, and even sepsis and death; all of these contribute to an
important cause of morbidity and mortality in these patients. That is why the
treatment to be chosen should always be focused on appropriate palliative care,
trying to achieve low morbidity rates (11,26).(26)
In individuals with a short life expectancy, a limited resection should be
performed; in the case of localized disease, a more aggressive gastric resection
could be performed. Other complications may include the risk of contracting
surgical wound infections, in which case these are treated with antibiotics;
central line infections (venous catheter), and urinary tract infections (27).
3.13 Nutrition
The nutritional support requirement in patients undergoing gastrectomy is
divided into three stages: before surgery or pre-surgical, during the perioperative
period by implementing the ERAS (Enhanced Recovery After Surgery) protocol
and after surgery or postoperative. It is advisable to start nutritional support
immediately in patients who present malnutrition and in those who do not meet
their nutritional needs. The period of time required for nutritional support is
7-14 days in the pre-surgical stage. The use of oral food supplements in patients
with severe malnutrition in the perioperative period has been shown to reduce
the frequency, severity and permanence of post-surgical complications (28).
After gastrectomy and applying the ERAS protocol, it is suggested to start
oral intake early with clear liquids, after 6-8 hours after the operation, gradually
advancing and according to tolerance, on the rst postoperative day, a liquid
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diet is started and then a diet with soft foods is started. It has been proven
that early tolerance after gastric cancer surgery allows a rapid recovery of
intestinal function and reduces the length of hospitalization without increasing
complications (28).
3.14 Palliative Care
Palliative care focuses on improving well-being during treatment by managing
symptoms and providing support to patients and their loved ones. It is
important to note that anyone suffering from cancer, regardless of the type or
stage of cancer, can access this care, and favorable results are obtained when
it is started after the diagnosis is conrmed. It has been shown that patients
who receive this type of care accompanied by treatment to treat this disease
experience less severe symptoms and their lifestyle will improve (29).
4. Discussion
To date, cancer incidence has decreased worldwide; however, it remains among
the leading causes of death, given that most reports are diagnosed at a late stage,
once the patient shows the rst symptoms. It has been shown that the most
frequent risk factor for the development of GC is the presence of Helicobacter
pylori, which, if not treated properly, triggers a series of alterations in the gastric
epithelium, from simple atrophy to dysplasia, which evolves into a malignant
neoplasia.
Based on the case presented, it was an elderly patient who presented with
torpid symptoms of several months of evolution. The striking thing was his state
of malnutrition. The data that called attention from the physical examination
was the body mass index that indicates malnutrition, in addition to nding a
soft, depressible abdomen, painful in the epigastrium with increased RHA. For
this reason, laboratory tests were required, which did not show any alteration,
even the gastric tumor markers were negative. The EDA conrmed the clinical
suspicion of gastric neoplasia, once the sample was sent to pathology (18, 25),
data that are corroborated by Cárdenas M, et al. who indicate that in the initial
stages this pathology does not present symptoms until the advanced stages (14).
Once the diagnosis of Borrmann IV type diffuse gastric adenocarcinoma
was given, a total gastrectomy was performed. It should be noted that a CT scan
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was performed to identify the presence of metastasis, despite this, no other
alterations were evident other than the malignant tumor; however, during
the surgical procedure the important nding of peritoneal metastasis was
obtained, even so, the surgical procedure continued, the literature indicates
that patients with peritoneal metastasis survival is low at 6 months and zero at
5 years, this is the case of the patient who survived 6 months after and increased
the comorbidities typical of the surgery (32). Although the management of
imaging studies useful for the diagnosis of gastric cancer are abdominal, pelvic
and thoracic CT scans; there is another method such as positron emission
tomography that is advantageous in specic cases such as malignant tumors
that histologically present poorly differentiated signet ring cells (30).
According to Ajaní A, D'Amico T, Bentrem D, et al; (24), they express that,
in the Japanese guidelines this type of cancer is considered as an unresectable
condition, which should be treated only palliatively based on the classication
of the functional status (ECOG) as a way to decide whether to administer
monodrug or polychemotherapies (uoropyrimidines), without the possibility
of a complete recovery, since the objectives of the treatment are aimed at
controlling the symptoms, the disease and prolonging the quality of life of
the patient, in addition to this, supportive care and moral support should be
given. That said, the life expectancy with advanced GC is 6%. (30). Although a
treatment was chosen for the patient, other factors also inuenced, such as age
and alcoholism to which he was exposed for years; this could be the main factor
for the development of GC.
We consider some recommendations from the Japanese guidelines on the
management of gastric cancer in Japan (31):
• It is weakly recommended not to perform PET-CT scanning for staging
of gastric cancer (consensus rate 100%, 8/8, level of evidence C).
• Endoscopic management of differentiated adenocarcinoma without
ulceration (T1a) and diameter ≤2 cm.
• Endoscopic management of differentiated adenocarcinoma with
ulceration, but the depth of invasion is T1a and the diameter is ≤3 cm.
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• Or if the adenocarcinoma is undifferentiated without ulcerative
ndings in el que la profundidad de la invasión se diagnostica
clínicamente como T1a y el diámetro es ≤ 2 cm.
• Following endoscopic resection, the following are recommended:
annual endoscopic check-ups or every 6 months, computed
tomography, to identify the presence of Helicobacter Pylori in order to
eradicate them.
• When there are lesions larger than 3 cm with invasion of the submucosa,
gastrectomy with lymphadenectomy should be recommended,
provided there is no distant metastasis.
• Laparoscopic distal gastrectomy is recommended for stage I as standard
treatment ( consensus rate 100%, 8/8, level of evidence A), laparoscopic
total gastrectomy or proximal gastrectomy is weakly recommended
(consensus rate 100%, 8/8, level of evidence C). The procedure should
be performed by a qualied surgeon.
• There are no precise recommendations for applying laparoscopic
surgery for stage II/III (consensus rate 71.4%, 5/7, strength of evidence
C).
• Splenectomy or splenic hilar lymph node dissection is strongly not
recommended for tumors without invasion of the greater curvature
(consensus rate 100%, 8/8, level of evidence A). Splenectomy or splenic
hilar lymph node dissection is weakly recommended for tumors with
invasion of the greater curvature (consensus rate 87.5%, 7/8, level of
evidence C).
• Diagnostic and staging laparoscopy is weakly recommended to evaluate
the treatment strategy for those with advanced gastric cancer likely
to have peritoneal metastasis (consensus rate 100%, 8/8, strength of
evidence C).
• The ERAS protocol is strongly recommended for perioperative
treatment of gastric cancer (100% consensus rate, 8/8, level of evidence
A) (30).
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5. Conclusions
In 80% of patients, gastric cancer presents in the nal stages, when the patient
already has metastasis and the therapeutic arsenal is very limited.
The symptoms in the early stages of gastric cancer are torpid, which is why
screening in these patients is very important for early detection.
When there is a gastric tumor in stage III , as well as stage IV, each of these
has a specic treatment, in the case of the rst, it is based on adjuvant therapies,
while, in the case of the one in stage IV, palliative care is applied, despite this,
the survival of patients at 5 years is less than 20 percent in stage III and zero in
stage IV.
Eliminating risk factors such as the presence of H. Pylori, a high-fat diet,
and smoked meats help prevent the onset of gastric cancer.
In patients with total gastrectomy for advanced gastric cancer, it negatively
affects clinical improvement and does not change patient survival .
6. Abbreviations
Adenocarcinoma: tumor of epithelial cells that internally cover a tissue
Gastrectomy: resection and removal of part or all of the stomach
Helicobacter Pylori: large negative helical bacillus type bacteria
7. Acknowledgements
We thank Dr. Marco Urgilés Rivas for providing us with his knowledge and being
our guide in the preparation of this work, with great skills to serve patients.
8. FINANCING
Self-nancing
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9. Ethical Approval And Consent To Participate
The data from the medical history for the preparation of this research were
obtained with the authorization of the relatives and are kept maintaining the
condentiality of the patient.
10. Conicts of interest
The authors report no conict of interest.
11. Authors' Information
• Marco Vinicio Urgilés Rivas: General and Laparoscopic Surgeon,
Attending Physician at San Martín Hospital - Azogues; marco.
polo11@live.com Azogues, Ecuador. Orcid: https://orcid.
org/0000-0002-2505-318X
• Daysi Domenica Correa Colonel: Undergraduate student at the
Catholic University of Cuenca, Azogues campus; daysi.correa.00
@est.ucacue.edu.ec. Azogues, Ecuador. Orcid: https://orcid.
org/0000-0001-7166-6115
• Stephany Guadalupe Peñaloza Minchala: Undergraduate student
at the Catholic University of Cuenca, Azogues campus; stephany.
penaloza.82@est.ucacue.edu.ec. Azogues, Ecuador. Orcid: https://
orcid.org/0000-0002-6913-8978
• Luis Fernando Mora Ochoa: Undergraduate student at the Catholic
University of Cuenca, Azogues campus; luis.mora.47@est.ucacue.edu.
ec . Azogues, Ecuador. Orcid: https://orcid.org/0000-0002-9032-2016
• Jennifer Maribel Rivera Ortiz: Undergraduate student at the
Catholic University of Cuenca, Azogues campus; jennifer.
rivera.28@est.ucacue.edu.ec. Azogues, Ecuador. Orcid https://orcid.
org/0000-0002-1806-3064
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Investigación Contemporánea 01 - 2025 Vol. 3 - No. 1 ISSN-e: 2960-8015
DOI: https://doi.org/10.58995/redlic.rmic.v3.n1.a78
Gastric Cancer, Update in management; clinical case presentation 46 - 52
Gastric Cancer, Update in management; clinical case presentation
12. Authors' contribution
DDCC: Selection of articles, research, writing of the review, discussion.
SGPM: Writing of the clinical case, research, writing of the review, discussion.
LFMO: Selection of articles, research, writing of the review, conclusions.
JMRO: Theoretical Framework, images, bibliography
MVUR: Review, correction of errors, contribution of ideas for writing
Revista multidisciplinaria
Investigación Contemporánea 01 - 2025 Vol. 3 - No. 1 ISSN-e: 2960-8015
DOI: https://doi.org/10.58995/redlic.rmic.v3.n1.a78
Gastric Cancer, Update in management; clinical case presentation 47 - 52
Gastric Cancer, Update in management; clinical case presentation
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Investigación Contemporánea 01 - 2025 Vol. 3 - No. 1 ISSN-e: 2960-8015
DOI: https://doi.org/10.58995/redlic.rmic.v3.n1.a78
Gastric Cancer, Update in management; clinical case presentation 52 - 52
Gastric Cancer, Update in management; clinical case presentation
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Stephany Guadalupe Peñaloza Minchala, Luis Fernando Mora Ochoa, Jennifer Maribel
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