Initial Workup and Staging Strategy For Gastric Cancer

As part of the initial diagnosis, a thorough clinical evaluation is just as critical as the complementary exams. Key risk factors specific to gastrointestinal tumors will be meticulously assessed during the clinical examination.

These include factors such as:

• Prior history of gastric ulcer
• Helicobacter pylori infection
• Daily habits, including diet, tobacco use, and alcohol consumption
• Signals of digestive bleeding
• Family history of gastric cancer or genetic syndromes

After assessing your overall health and history, your doctor will move on with more medical exams.

“If a physician is suspecting stomach cancer or it could potentially be one of the reasons for the symptoms. One of the first simple tests to do is blood work,” Dr. Sofya Pintova, a gastrointestinal medical oncologist at Mount Sinai Cancer Center in New York City, tells SurvivorNet.

“In the blood work, we are looking for several specific things. We’re looking at the organ function such as liver function, kidney function, but we’re also looking at the level of the red blood cells in the blood. So if the level of red blood cells is low, that is called anemia. And when someone has a new anemia that cannot be explained for other reasons, obvious reasons like a recent bleeding from the nose for example or other type of bleeding, then that warrants an evaluation by a gastroenterologist,” she adds.

Patients may also present with signs or symptoms of distant metastatic (spread) disease. The most common sites of metastatic disease are the liver, the peritoneal surfaces, and the lymph nodes.

More rarely, patients with gastric cancer may present with complications that result from direct extension through the gastric wall or gastrointestinal obstruction.

Besides blood exams to evaluate anemia, nutritional status, and overall biochemistry, the most important exam is the upper gastrointestinal endoscopy.

Upper Gastrointestinal Endoscopy: What to Expect

Upper gastrointestinal endoscopy (UGE) is the initial diagnostic tool for evaluating suspected gastric lesions, offering a detailed examination and precise localization of the primary tumor.

During the procedure, the patient will be put under anesthesia and doctors will use a thin tube with a tiny camera attached to analyze the inner sides of the upper digestive tract (including the esophagus, stomach, and duodenum).

The procedure also enables tissue biopsy for histological confirmation. Early implementation of endoscopy in patients presenting with gastrointestinal symptoms significantly enhances the detection of early-stage gastric cancer, potentially improving prognosis and treatment outcomes.

“We will usually offer patients test called endoscopies. That’s when the gastroenterologist does a test where a patient is put to sleep and then they insert a camera directly into the stomach to evaluate it. And if they see any masses or any suspicion for cancer, they will take biopsies,” Dr. Pintova explains.

During the upper gastrointestinal endoscopy, gastric cancer typically presents as a mass.

How are Tumors Staged?

One of the goals of staging is to put patients into one of two groups: those with disease that is considered locoregional and potentially resectable (meaning it could be removed with surgery) and those with locally advanced, unresectable or metastatic disease (or disease that has spread).

“If a cancer is found in the stomach, the next step for us as oncologists or surgeons would be staging. And what staging means is we ask ourselves: is the tumor, the cancer still confined only to the stomach or has it spread to other organs,” Dr. Pintova explains. “So, several tests that we usually do to identify that are what’s called radiology tests or imaging that could take the form of computerized tomography scans, PET scans, sometimes MRIs.”

The suggested approach, which is generally consistent with international guidelines, including the National Comprehensive Cancer Network (NCCN) and the European Society for Medical Oncology (ESMO), might include:

• Computed tomography (CT) scans of the chest, abdomen, and pelvis to evaluate for metastatic disease (when the tumor is not restricted to the stomach but has spread to other organs). This exam needs an injection of intravenous contrast to allow a better evaluation. Also, CT is not the same as magnetic resonance as many people think. The CT is quicker, is not performed in a completely closed tube, and should not be a problem for those who suffer from claustrophobia.
• Endoscopic ultrasound (EUS) is recommended for patients with gastric cancer regardless of original staging.
• In some situations, other exams can be ordered for further evaluations, including integrated positron emission tomography (PET)/CT or laparoscopy — a minor surgical procedure to look for difficult to detect cancer that has spread within the abdomen.

Serum tumor markers (including carcinoembryonic antigen [CEA] and the glycoprotein cancer antigen 125 [CA 125]) are of limited utility and should not drive therapy.

This approach makes it possible to accurately establish the diagnosis, determine the histologic subtype, and assess the tumor’s stage. These critical first steps lay the foundation for defining subsequent treatment strategies and evaluating the potential interventions.

Questions to Ask Your Doctor

If you’re been diagnosed with gastric cancer, or your doctor has told you they suspect it, consider asking the below questions to get a better idea of the type of cancer you have and what treatment options are available to you.

• What is the type and stage of my gastric cancer?
• What treatments are most effective for patients with this type/stage?
• What are the potential side effects of these treatments?
• Does my family need to undergo any exams to assess their risk?

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