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<p><strong>Gastric cancer</strong> can develop in any part of the <a title="Stomach" href="/wiki/Stomach"><font color="#002bb8">stomach</font></a> and may spread throughout the stomach and to other organs; particularly the <a title="Esophagus" href="/wiki/Esophagus"><font color="#002bb8">esophagus</font></a>, <a class="mw-redirect" title="Lungs" href="/wiki/Lungs"><font color="#002bb8">lungs</font></a> and the <a title="Liver" href="/wiki/Liver"><font color="#002bb8">liver</font></a>. Stomach cancer causes about 800,000 deaths worldwide per year.<sup id="cite_ref-WHO_0-0" class="reference"><a href="#cite_note-WHO-0"><font size="2"><font color="#002bb8"><span>[</span>1<span>]</span></font></font></a></sup></p>
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<h2>Contents</h2>
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<ul>
<li class="toclevel-1 tocsection-1"><a href="#Signs_and_symptoms"><font color="#002bb8"><span class="tocnumber">1</span> <span class="toctext">Signs and symptoms</span></font></a> </li>
<li class="toclevel-1 tocsection-2"><a href="#Causes"><font color="#002bb8"><span class="tocnumber">2</span> <span class="toctext">Causes</span></font></a> </li>
<li class="toclevel-1 tocsection-3"><a href="#Diagnosis"><font color="#002bb8"><span class="tocnumber">3</span> <span class="toctext">Diagnosis</span></font></a>
<ul>
<li class="toclevel-2 tocsection-4"><a href="#Histopathology"><font color="#002bb8"><span class="tocnumber">3.1</span> <span class="toctext">Histopathology</span></font></a> </li>
<li class="toclevel-2 tocsection-5"><a href="#Staging"><font color="#002bb8"><span class="tocnumber">3.2</span> <span class="toctext">Staging</span></font></a> </li>
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<li class="toclevel-1 tocsection-6"><a href="#Management"><font color="#002bb8"><span class="tocnumber">4</span> <span class="toctext">Management</span></font></a>
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<li class="toclevel-2 tocsection-7"><a href="#Surgery"><font color="#002bb8"><span class="tocnumber">4.1</span> <span class="toctext">Surgery</span></font></a> </li>
<li class="toclevel-2 tocsection-8"><a href="#Chemotherapy"><font color="#002bb8"><span class="tocnumber">4.2</span> <span class="toctext">Chemotherapy</span></font></a> </li>
<li class="toclevel-2 tocsection-9"><a href="#Radiation_therapy"><font color="#002bb8"><span class="tocnumber">4.3</span> <span class="toctext">Radiation therapy</span></font></a> </li>
<li class="toclevel-2 tocsection-10"><a href="#Multimodality_therapy"><font color="#002bb8"><span class="tocnumber">4.4</span> <span class="toctext">Multimodality therapy</span></font></a> </li>
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<li class="toclevel-1 tocsection-11"><a href="#Epidemiology"><font color="#002bb8"><span class="tocnumber">5</span> <span class="toctext">Epidemiology</span></font></a> </li>
<li class="toclevel-1 tocsection-12"><a href="#References"><font color="#002bb8"><span class="tocnumber">6</span> <span class="toctext">References</span></font></a> </li>
<li class="toclevel-1 tocsection-13"><a href="#External_links"><font color="#002bb8"><span class="tocnumber">7</span> <span class="toctext">External links</span></font></a> </li>
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<h2><span id="Signs_and_symptoms" class="mw-headline">Signs and symptoms</span></h2>
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<div style="WIDTH: 182px" class="thumbinner"><a class="image" href="/wiki/File:Linitis_plastica_2.jpg"><img class="thumbimage" alt="" src="http://upload.wikimedia.org/wikipedia/commons/thumb/9/94/Linitis_plastica_2.jpg/180px-Linitis_plastica_2.jpg" width="180" height="165" /></a>
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<div class="magnify"><a class="internal" title="Enlarge" href="/wiki/File:Linitis_plastica_2.jpg"><img alt="" src="http://bits.wikimedia.org/skins-1.5/common/images/magnify-clip.png" width="15" height="11" /></a></div>
Endoscopic image of <a title="Linitis plastica" href="/wiki/Linitis_plastica"><font color="#002bb8">linitis plastica</font></a>, a type of stomach cancer where the entire <a title="Stomach" href="/wiki/Stomach"><font color="#002bb8">stomach</font></a> is invaded, leading to a leather bottle-like appearance with <a title="Bleeding" href="/wiki/Bleeding"><font color="#002bb8">blood</font></a> coming out of it.</div>
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<p>Stomach cancer is often <a title="Asymptomatic" href="/wiki/Asymptomatic"><font color="#002bb8">asymptomatic</font></a> or causes only <a class="mw-redirect" title="Nonspecific symptoms" href="/wiki/Nonspecific_symptoms"><font color="#002bb8">nonspecific symptoms</font></a> in its early stages. By the time symptoms occur, the cancer has generally <a title="Metastasis" href="/wiki/Metastasis"><font color="#002bb8">metastasized</font></a> to other parts of the body, one of the main reasons for its poor prognosis. Stomach cancer can cause the following signs and symptoms:</p>
<p>Early</p>
<ul>
<li><a class="mw-redirect" title="Indigestion" href="/wiki/Indigestion"><font color="#002bb8">Indigestion</font></a> or a burning sensation (<a title="Heartburn" href="/wiki/Heartburn"><font color="#002bb8">heartburn</font></a>) </li>
<li><a class="mw-redirect" title="Loss of appetite" href="/wiki/Loss_of_appetite"><font color="#002bb8">Loss of appetite</font></a>, especially for meat </li>
</ul>
<p>Late</p>
<ul>
<li><a title="Abdominal pain" href="/wiki/Abdominal_pain"><font color="#002bb8">Abdominal pain</font></a> or discomfort in the upper abdomen </li>
<li><a title="Nausea" href="/wiki/Nausea"><font color="#002bb8">Nausea</font></a> and <a title="Vomiting" href="/wiki/Vomiting"><font color="#002bb8">vomiting</font></a> </li>
<li><a title="Diarrhea" href="/wiki/Diarrhea"><font color="#002bb8">Diarrhea</font></a> or <a title="Constipation" href="/wiki/Constipation"><font color="#002bb8">constipation</font></a> </li>
<li><a title="Bloating" href="/wiki/Bloating"><font color="#002bb8">Bloating</font></a> of the stomach after meals </li>
<li><a title="Weight loss" href="/wiki/Weight_loss"><font color="#002bb8">Weight loss</font></a> </li>
<li><a title="Weakness" href="/wiki/Weakness"><font color="#002bb8">Weakness</font></a> and <a class="mw-redirect" title="Fatigue (physical)" href="/wiki/Fatigue_(physical)"><font color="#002bb8">fatigue</font></a> </li>
<li><a title="Bleeding" href="/wiki/Bleeding"><font color="#002bb8">Bleeding</font></a> (<a class="mw-redirect" title="Vomiting blood" href="/wiki/Vomiting_blood"><font color="#002bb8">vomiting blood</font></a> or having <a class="mw-redirect" title="Blood in the stool" href="/wiki/Blood_in_the_stool"><font color="#002bb8">blood in the stool</font></a>) which will appear as black. This can lead to <a title="Anemia" href="/wiki/Anemia"><font color="#002bb8">anemia</font></a>. </li>
<li><a title="Dysphagia" href="/wiki/Dysphagia"><font color="#002bb8">Dysphagia</font></a>; this feature suggests a tumor in the cardia or extension of the gastric tumor in to the <a title="Esophagus" href="/wiki/Esophagus"><font color="#002bb8">esophagus</font></a>. </li>
</ul>
<p>These can be symptoms of other problems such as a <a class="mw-redirect" title="Stomach virus" href="/wiki/Stomach_virus"><font color="#002bb8">stomach virus</font></a>, <a class="mw-redirect" title="Gastric ulcer" href="/wiki/Gastric_ulcer"><font color="#002bb8">gastric ulcer</font></a> or <a title="Tropical sprue" href="/wiki/Tropical_sprue"><font color="#002bb8">tropical sprue</font></a> and diagnosis should be done by a <a class="mw-redirect" title="Gastroenterologist" href="/wiki/Gastroenterologist"><font color="#002bb8">gastroenterologist</font></a> or an <a class="mw-redirect" title="Oncologist" href="/wiki/Oncologist"><font color="#002bb8">oncologist</font></a>.</p>
<h2><span id="Causes" class="mw-headline">Causes</span></h2>
<p>Infection by <a title="Helicobacter pylori" href="/wiki/Helicobacter_pylori"><font color="#002bb8">Helicobacter pylori</font></a> is believed to be the cause of most stomach cancer while autoimmune atrophic <a title="Gastritis" href="/wiki/Gastritis"><font color="#002bb8">gastritis</font></a>, <a title="Intestinal metaplasia" href="/wiki/Intestinal_metaplasia"><font color="#002bb8">intestinal metaplasia</font></a> and various genetic factors are associated with increased risk levels. It is not currently believed that diet has any role to play.<sup id="cite_ref-Merck-1_1-0" class="reference"><a href="#cite_note-Merck-1-1"><font size="2"><font color="#002bb8"><span>[</span>2<span>]</span></font></font></a></sup></p>
<p>In more detail, <em>H. pylori</em> is the main risk factor in 65–80% of gastric cancers, but in only 2% of such infections.<sup id="cite_ref-GVRF-4_2-0" class="reference"><a href="#cite_note-GVRF-4-2"><font size="2"><font color="#002bb8"><span>[</span>3<span>]</span></font></font></a></sup> Approximately ten percent of cases show a genetic component.<sup id="cite_ref-3" class="reference"><a href="#cite_note-3"><font size="2"><font color="#002bb8"><span>[</span>4<span>]</span></font></font></a></sup> In Japan and other countries <a title="Bracken" href="/wiki/Bracken"><font color="#002bb8">bracken</font></a> consumption and spores are correlated with incidence of stomach cancer, though causality has yet to be established.<sup id="cite_ref-4" class="reference"><a href="#cite_note-4"><font size="2"><font color="#002bb8"><span>[</span>5<span>]</span></font></font></a></sup></p>
<p>Gastric cancer shows a male predominance in its incidence as up to three males are affected for every female. Estrogen may protect women against the development of this cancer form.<sup id="cite_ref-5" class="reference"><a href="#cite_note-5"><font size="2"><font color="#002bb8"><span>[</span>6<span>]</span></font></font></a></sup> A very small percentage of diffuse-type gastric cancers (see Histopathology below) are thought to be genetic. Hereditary Diffuse Gastric Cancer (HDGC) has recently been identified and research is ongoing. However, genetic testing and treatment options are already available for families at risk.<sup id="cite_ref-pmid15235021_6-0" class="reference"><a href="#cite_note-pmid15235021-6"><font size="2"><font color="#002bb8"><span>[</span>7<span>]</span></font></font></a></sup></p>
<p>Some researchers <sup id="cite_ref-7" class="reference"><a href="#cite_note-7"><font size="2"><font color="#002bb8"><span>[</span>8<span>]</span></font></font></a></sup> showed a correlation between <a title="Iodine" href="/wiki/Iodine"><font color="#002bb8">Iodine</font></a> deficiency or excess, iodine-deficient goitre and gastric cancer; a decrease of the incidence of death rate from stomach cancer after implementation of the effective I-prophylaxis was reported too.<sup id="cite_ref-8" class="reference"><a href="#cite_note-8"><font size="2"><font color="#002bb8"><span>[</span>9<span>]</span></font></font></a></sup> The proposed mechanism of action is that iodide ion can function in gastric mucosa as an antioxidant <a title="Redox" href="/wiki/Redox"><font color="#002bb8">reducing</font></a> species that can detoxify poisonous <a title="Reactive oxygen species" href="/wiki/Reactive_oxygen_species"><font color="#002bb8">reactive oxygen species</font></a>, such as <a title="Hydrogen peroxide" href="/wiki/Hydrogen_peroxide"><font color="#002bb8">hydrogen peroxide</font></a>. <a title="China" href="/wiki/China"><font color="#002bb8">China</font></a> being member of <a title="International Cancer Genome Consortium" href="/wiki/International_Cancer_Genome_Consortium"><font color="#002bb8">International Cancer Genome Consortium</font></a> is leading efforts to map stomach cancer's complete <a title="Genome" href="/wiki/Genome"><font color="#002bb8">genome</font></a>.</p>
<h2><span id="Diagnosis" class="mw-headline">Diagnosis</span></h2>
<p>To find the cause of symptoms, the doctor asks about the patient's medical history, does a physical exam, and may order laboratory studies. The patient may also have one or all of the following exams:</p>
<ul>
<li><a class="mw-redirect" title="Gastroscopic exam" href="/wiki/Gastroscopic_exam"><font color="#002bb8">Gastroscopic exam</font></a> is the diagnostic method of choice. This involves insertion of a <a class="mw-redirect" title="Fibre optics" href="/wiki/Fibre_optics"><font color="#002bb8">fibre optic</font></a> camera into the stomach to visualize it. </li>
<li><a class="mw-redirect" title="Upper GI series" href="/wiki/Upper_GI_series"><font color="#002bb8">Upper GI series</font></a> (may be called barium roentgenogram) </li>
<li><a class="mw-redirect" title="Computed tomography" href="/wiki/Computed_tomography"><font color="#002bb8">Computed tomography</font></a> or CT scanning of the abdomen may reveal gastric cancer, but is more useful to determine invasion into adjacent tissues, or the presence of spread to local lymph nodes. </li>
</ul>
<p>Abnormal tissue seen in a gastroscope examination will be <a title="Biopsy" href="/wiki/Biopsy"><font color="#002bb8">biopsied</font></a> by the <a title="Surgery" href="/wiki/Surgery"><font color="#002bb8">surgeon</font></a> or <a class="mw-redirect" title="Gastroenterologist" href="/wiki/Gastroenterologist"><font color="#002bb8">gastroenterologist</font></a>. This tissue is then sent to a <a title="Pathology" href="/wiki/Pathology"><font color="#002bb8">pathologist</font></a> for <a title="Histology" href="/wiki/Histology"><font color="#002bb8">histological</font></a> examination under a microscope to check for the presence of cancerous cells. A biopsy, with subsequent histological analysis, is the only sure way to confirm the presence of cancer cells.</p>
<p>Various gastroscopic modalities have been developed to increased yield of detect mucosa with a dye that accentuates the cell structure and can identify areas of dysplasia. <em>Endocytoscopy</em> involves ultra-high magnification to visualize cellular structure to better determine areas of dysplasia. Other gastroscopic modalities such as <a title="Optical coherence tomography" href="/wiki/Optical_coherence_tomography"><font color="#002bb8">optical coherence tomography</font></a> are also being tested investigationally for similar applications.<sup id="cite_ref-9" class="reference"><a href="#cite_note-9"><font size="2"><font color="#002bb8"><span>[</span>10<span>]</span></font></font></a></sup></p>
<p>A number of cutaneous conditions are associated with gastric cancer. A condition of darkened hyperplasia of the skin, frequently of the axilla and groin, known as <a title="Acanthosis nigricans" href="/wiki/Acanthosis_nigricans"><font color="#002bb8">acanthosis nigricans</font></a>, is associated with intra-abdominal cancers such as gastric cancer. Other cutaneous manifestations of gastric cancer include <em>tripe palms</em> (a similar darkening hyperplasia of the skin of the palms) and the sign of <a class="mw-redirect" title="Leser-Trelat sign" href="/wiki/Leser-Trelat_sign"><font color="#002bb8">Leser-Trelat</font></a>, which is the rapid development of skin lesions known as <a title="Seborrheic keratosis" href="/wiki/Seborrheic_keratosis"><font color="#002bb8">seborrheic keratoses</font></a>.<sup id="cite_ref-pmid15230897_10-0" class="reference"><a href="#cite_note-pmid15230897-10"><font size="2"><font color="#002bb8"><span>[</span>11<span>]</span></font></font></a></sup></p>
<h3><span id="Histopathology" class="mw-headline">Histopathology</span></h3>
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<div style="WIDTH: 182px" class="thumbinner"><a class="image" href="/wiki/File:Adenocarcinoma_low_differentiated_(stomach)_H%26E_magn_400x.jpg"><img class="thumbimage" alt="" src="http://upload.wikimedia.org/wikipedia/commons/thumb/8/85/Adenocarcinoma_low_differentiated_%28stomach%29_H%26E_magn_400x.jpg/180px-Adenocarcinoma_low_differentiated_%28stomach%29_H%26E_magn_400x.jpg" width="180" height="144" /></a>
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<div class="magnify"><a class="internal" title="Enlarge" href="/wiki/File:Adenocarcinoma_low_differentiated_(stomach)_H%26E_magn_400x.jpg"><img alt="" src="http://bits.wikimedia.org/skins-1.5/common/images/magnify-clip.png" width="15" height="11" /></a></div>
Poor to moderately differentiated adenocarcinoma of the stomach. <a title="H&E stain" href="/wiki/H%26E_stain"><font color="#002bb8">H&E stain</font></a>.</div>
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<div style="WIDTH: 182px" class="thumbinner"><a class="image" href="/wiki/File:Gastric_signet_ring_cell_carcinoma_histopatholgy_(1).jpg"><img class="thumbimage" alt="" src="http://upload.wikimedia.org/wikipedia/commons/thumb/1/11/Gastric_signet_ring_cell_carcinoma_histopatholgy_%281%29.jpg/180px-Gastric_signet_ring_cell_carcinoma_histopatholgy_%281%29.jpg" width="180" height="135" /></a>
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<div class="magnify"><a class="internal" title="Enlarge" href="/wiki/File:Gastric_signet_ring_cell_carcinoma_histopatholgy_(1).jpg"><img alt="" src="http://bits.wikimedia.org/skins-1.5/common/images/magnify-clip.png" width="15" height="11" /></a></div>
Gastric signet ring cell carcinoma. <a title="H&E stain" href="/wiki/H%26E_stain"><font color="#002bb8">H&E stain</font></a>.</div>
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<div style="WIDTH: 182px" class="thumbinner"><a class="image" href="/wiki/File:Gastric_adenocarcinoma.jpg"><img class="thumbimage" alt="" src="http://upload.wikimedia.org/wikipedia/commons/thumb/5/56/Gastric_adenocarcinoma.jpg/180px-Gastric_adenocarcinoma.jpg" width="180" height="135" /></a>
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<div class="magnify"><a class="internal" title="Enlarge" href="/wiki/File:Gastric_adenocarcinoma.jpg"><img alt="" src="http://bits.wikimedia.org/skins-1.5/common/images/magnify-clip.png" width="15" height="11" /></a></div>
Adenocarcinoma of the stomach and <a title="Intestinal metaplasia" href="/wiki/Intestinal_metaplasia"><font color="#002bb8">intestinal metaplasia</font></a>. <a title="H&E stain" href="/wiki/H%26E_stain"><font color="#002bb8">H&E stain</font></a>.</div>
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<ul>
<li><em>Gastric <a title="Adenocarcinoma" href="/wiki/Adenocarcinoma"><font color="#002bb8">adenocarcinoma</font></a></em> is a malignant epithelial tumor, originating from glandular epithelium of the gastric mucosa. It invades the gastric wall, infiltrating the <a title="Muscularis mucosae" href="/wiki/Muscularis_mucosae"><font color="#002bb8">muscularis mucosae</font></a>, the submucosa and thence the muscularis propria. Histologically, there are two major types of gastric cancer (Lauren classification): intestinal type and diffuse type. </li>
<li><em>Intestinal type adenocarcinoma</em>: tumor cells describe irregular tubular structures, harboring pluristratification, multiple lumens, reduced stroma ("back to back" aspect). Often, it associates intestinal metaplasia in neighboring mucosa. Depending on glandular architecture, cellular pleomorphism and mucosecretion, adenocarcinoma may present 3 degrees of differentiation: well, moderate and poorly differentiate. </li>
<li><em>Diffuse type adenocarcinoma (mucinous, colloid):</em> Tumor cells are discohesive and secrete mucus which is delivered in the interstitium producing large pools of mucus/colloid (optically "empty" spaces). It is poorly differentiated. If the mucus remains inside the tumor cell, it pushes the nucleus at the purpley- "<em><a class="mw-redirect" title="Signet-ring cell" href="/wiki/Signet-ring_cell"><font color="#002bb8">signet-ring cell</font></a></em>". </li>
</ul>
<h3><span id="Staging" class="mw-headline">Staging</span></h3>
<p>If cancer cells are found in the tissue sample, the next step is to <a title="Cancer staging" href="/wiki/Cancer_staging"><font color="#002bb8">stage</font></a>, or find out the extent of the disease. Various tests determine whether the cancer has spread and, if so, what parts of the body are affected. Because stomach cancer can spread to the liver, the pancreas, and other organs near the stomach as well as to the lungs, the doctor may order a <a class="mw-redirect" title="CT scan" href="/wiki/CT_scan"><font color="#002bb8">CT scan</font></a>, a <a class="mw-redirect" title="PET scan" href="/wiki/PET_scan"><font color="#002bb8">PET scan</font></a>, an <a title="Endoscopic ultrasound" href="/wiki/Endoscopic_ultrasound"><font color="#002bb8">endoscopic ultrasound</font></a> exam, or other tests to check these areas. Blood tests for <a title="Tumor marker" href="/wiki/Tumor_marker"><font color="#002bb8">tumor markers</font></a>, such as <a title="Carcinoembryonic antigen" href="/wiki/Carcinoembryonic_antigen"><font color="#002bb8">carcinoembryonic antigen</font></a> (CEA) and carbohydrate antigen (CA) may be ordered, as their levels correlate to extent of metastasis, especially to the liver, and the cure rate.</p>
<p>Staging may not be complete until after surgery. The surgeon removes nearby lymph nodes and possibly samples of tissue from other areas in the abdomen for examination by a pathologist.</p>
<p>TNM staging is used</p>
<h2><span id="Management" class="mw-headline">Management</span></h2>
<p>Like any cancer, treatment is adapted to fit each person's individual needs and depends on the size, location, and extent of the tumor, the stage of the disease, and general health. Cancer of the stomach is difficult to cure unless it is found in an early stage (before it has begun to spread). Unfortunately, because early stomach cancer causes few symptoms, the disease is usually advanced when the diagnosis is made. Treatment for stomach cancer may include surgery, <a title="Chemotherapy" href="/wiki/Chemotherapy"><font color="#002bb8">chemotherapy</font></a>, and/or <a title="Radiation therapy" href="/wiki/Radiation_therapy"><font color="#002bb8">radiation therapy</font></a>. New treatment approaches such as biological therapy and improved ways of using current methods are being studied in clinical trials.</p>
<h4><span id="Surgery" class="mw-headline">Surgery</span></h4>
<p>Surgery is the <strong>most common treatment</strong> and is the only hope of cure for stomach cancer. The surgeon removes part or all of the stomach, as well as the surrounding <a class="mw-redirect" title="Lymph nodes" href="/wiki/Lymph_nodes"><font color="#002bb8">lymph nodes</font></a>, with the basic goal of removing all cancer and a margin of normal tissue. Depending on the extent of invasion and the location of the tumor, surgery may also include removal of part of the intestine or pancreas. Tumors in the lower part of the stomach may call for a <a title="Billroth I" href="/wiki/Billroth_I"><font color="#002bb8">Billroth I</font></a> or <a title="Billroth II" href="/wiki/Billroth_II"><font color="#002bb8">Billroth II</font></a> procedure. Endoscopic mucosal resection (EMR) is a treatment for early gastric cancer (tumor only involves the mucosa) that has been pioneered in Japan, but is also available in the United States at some centers. In this procedure, the tumor, together with the inner lining of stomach (mucosa), is removed from the wall of the stomach using an electrical wire loop through the endoscope. The advantage is that it is a much smaller operation than removing the stomach. Endoscopic submucosal dissection (ESD) is a similar technique pioneered in Japan, used to resect a large area of mucosa in one piece. If the pathologic examination of the resected specimen shows incomplete resection or deep invasion by tumor, the patient would need a formal stomach resection.</p>
<p>Surgical interventions are currently curative in less than 40% of cases, and, in cases of metastasis, may only be <a class="mw-redirect" title="Palliative" href="/wiki/Palliative"><font color="#002bb8">palliative</font></a>.</p>
<h4><span id="Chemotherapy" class="mw-headline">Chemotherapy</span></h4>
<p>The use of <a title="Chemotherapy" href="/wiki/Chemotherapy"><font color="#002bb8">chemotherapy</font></a> to treat stomach cancer has no established <a title="Standard of care" href="/wiki/Standard_of_care"><font color="#002bb8">standard of care</font></a>. Unfortunately, stomach cancer has not been especially sensitive to these drugs until recently, and historically served to palliatively reduce the size of the tumor and increase survival time. Some drugs used in stomach cancer treatment include: <a class="mw-redirect" title="5-FU" href="/wiki/5-FU"><font color="#002bb8">5-FU</font></a> (fluorouracil), BCNU (carmustine), methyl-CCNU (Semustine), and <a title="Doxorubicin" href="/wiki/Doxorubicin"><font color="#002bb8">doxorubicin</font></a> (Adriamycin), as well as Mitomycin C, and more recently <a title="Cisplatin" href="/wiki/Cisplatin"><font color="#002bb8">cisplatin</font></a> and <a class="mw-redirect" title="Taxotere" href="/wiki/Taxotere"><font color="#002bb8">taxotere</font></a> in various combinations. The relative benefits of these drugs, alone and in combination, are unclear.<sup id="cite_ref-pmid17425475_11-0" class="reference"><a href="#cite_note-pmid17425475-11"><font size="2"><font color="#002bb8"><span>[</span>12<span>]</span></font></font></a></sup> Scientists are exploring the benefits of giving chemotherapy before surgery to shrink the tumor, or as adjuvant therapy after surgery to destroy remaining cancer cells. Combination treatment with chemotherapy and radiation therapy is also under study. Doctors are testing a treatment in which anticancer drugs are put directly into the abdomen (<a title="Intraperitoneal hyperthermic chemoperfusion" href="/wiki/Intraperitoneal_hyperthermic_chemoperfusion"><font color="#002bb8">intraperitoneal hyperthermic chemoperfusion</font></a>). Chemotherapy also is being studied as a treatment for cancer that has spread, and as a way to relieve symptoms of the disease. The side effects of chemotherapy depend mainly on the drugs the patient receives.</p>
<h4><span id="Radiation_therapy" class="mw-headline">Radiation therapy</span></h4>
<p><a title="Radiation therapy" href="/wiki/Radiation_therapy"><font color="#002bb8">Radiation therapy</font></a> (also called radiotherapy) is the use of high-energy rays to damage cancer cells and stop them from growing. When used, it is generally in combination with surgery and chemotherapy, or used only with chemotherapy in cases where the individual is unable to undergo surgery. Radiation therapy may be used to relieve pain or blockage by shrinking the tumor for <a class="mw-redirect" title="Palliation" href="/wiki/Palliation"><font color="#002bb8">palliation</font></a> of incurable disease</p>
<h4><span id="Multimodality_therapy" class="mw-headline">Multimodality therapy</span></h4>
<p>While previous studies of multimodality therapy (combinations of surgery, chemotherapy and radiation therapy) gave mixed results, the Intergroup 0116 (SWOG 9008) study<sup id="cite_ref-pmid11547741_12-0" class="reference"><a href="#cite_note-pmid11547741-12"><font size="2"><font color="#002bb8"><span>[</span>13<span>]</span></font></font></a></sup> showed a survival benefit to the combination of chemotherapy and radiation therapy in patients with nonmetastatic, completely resected gastric cancer. Patients were randomized after surgery to the standard group of observation alone, or the study arm of combination chemotherapy and radiation therapy. Those in the study arm receiving chemotherapy and radiation therapy survived on average 36 months; compared to 27 months with observation.</p>
<h2><span id="Epidemiology" class="mw-headline">Epidemiology</span></h2>
<div class="thumb tright">
<div style="WIDTH: 182px" class="thumbinner"><a class="image" href="/wiki/File:Stomach_cancer_world_map_-_Death_-_WHO2004.svg"><img class="thumbimage" alt="" src="http://upload.wikimedia.org/wikipedia/commons/thumb/a/a7/Stomach_cancer_world_map_-_Death_-_WHO2004.svg/180px-Stomach_cancer_world_map_-_Death_-_WHO2004.svg.png" width="180" height="79" /></a>
<div class="thumbcaption">
<div class="magnify"><a class="internal" title="Enlarge" href="/wiki/File:Stomach_cancer_world_map_-_Death_-_WHO2004.svg"><img alt="" src="http://bits.wikimedia.org/skins-1.5/common/images/magnify-clip.png" width="15" height="11" /></a></div>
<a title="Age adjustment" href="/wiki/Age_adjustment"><font color="#002bb8">Age-standardized</font></a> death from stomach cancer per 100,000 inhabitants in 2004.<sup id="cite_ref-13" class="reference"><a href="#cite_note-13"><font size="1"><font color="#002bb8"><span>[</span>14<span>]</span></font></font></a></sup>
<div style="-moz-column-count: 3; column-count: 3" class="references-small"><span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #b3b3b3 1px solid; BORDER-LEFT: #b3b3b3 1px solid; BACKGROUND-COLOR: #b3b3b3; COLOR: #b3b3b3; BORDER-TOP: #b3b3b3 1px solid; BORDER-RIGHT: #b3b3b3 1px solid"> </span> no data</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ffff65 1px solid; BORDER-LEFT: #ffff65 1px solid; BACKGROUND-COLOR: #ffff65; COLOR: #ffff65; BORDER-TOP: #ffff65 1px solid; BORDER-RIGHT: #ffff65 1px solid"> </span> less than 3.5</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #fff200 1px solid; BORDER-LEFT: #fff200 1px solid; BACKGROUND-COLOR: #fff200; COLOR: #fff200; BORDER-TOP: #fff200 1px solid; BORDER-RIGHT: #fff200 1px solid"> </span> 3.5-8</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ffdc00 1px solid; BORDER-LEFT: #ffdc00 1px solid; BACKGROUND-COLOR: #ffdc00; COLOR: #ffdc00; BORDER-TOP: #ffdc00 1px solid; BORDER-RIGHT: #ffdc00 1px solid"> </span> 8-12.5</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ffc600 1px solid; BORDER-LEFT: #ffc600 1px solid; BACKGROUND-COLOR: #ffc600; COLOR: #ffc600; BORDER-TOP: #ffc600 1px solid; BORDER-RIGHT: #ffc600 1px solid"> </span> 12.5-17</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ffb000 1px solid; BORDER-LEFT: #ffb000 1px solid; BACKGROUND-COLOR: #ffb000; COLOR: #ffb000; BORDER-TOP: #ffb000 1px solid; BORDER-RIGHT: #ffb000 1px solid"> </span> 17-21.5</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ff9a00 1px solid; BORDER-LEFT: #ff9a00 1px solid; BACKGROUND-COLOR: #ff9a00; COLOR: #ff9a00; BORDER-TOP: #ff9a00 1px solid; BORDER-RIGHT: #ff9a00 1px solid"> </span> 21.5-26</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ff8400 1px solid; BORDER-LEFT: #ff8400 1px solid; BACKGROUND-COLOR: #ff8400; COLOR: #ff8400; BORDER-TOP: #ff8400 1px solid; BORDER-RIGHT: #ff8400 1px solid"> </span> 26-30.5</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ff6e00 1px solid; BORDER-LEFT: #ff6e00 1px solid; BACKGROUND-COLOR: #ff6e00; COLOR: #ff6e00; BORDER-TOP: #ff6e00 1px solid; BORDER-RIGHT: #ff6e00 1px solid"> </span> 30.5-35</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ff5800 1px solid; BORDER-LEFT: #ff5800 1px solid; BACKGROUND-COLOR: #ff5800; COLOR: #ff5800; BORDER-TOP: #ff5800 1px solid; BORDER-RIGHT: #ff5800 1px solid"> </span> 35-40</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ff4200 1px solid; BORDER-LEFT: #ff4200 1px solid; BACKGROUND-COLOR: #ff4200; COLOR: #ff4200; BORDER-TOP: #ff4200 1px solid; BORDER-RIGHT: #ff4200 1px solid"> </span> 40-45</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ff2c00 1px solid; BORDER-LEFT: #ff2c00 1px solid; BACKGROUND-COLOR: #ff2c00; COLOR: #ff2c00; BORDER-TOP: #ff2c00 1px solid; BORDER-RIGHT: #ff2c00 1px solid"> </span> 45-50</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #cb0000 1px solid; BORDER-LEFT: #cb0000 1px solid; BACKGROUND-COLOR: #cb0000; COLOR: #cb0000; BORDER-TOP: #cb0000 1px solid; BORDER-RIGHT: #cb0000 1px solid"> </span> more than 50</span></div>
</div>
</div>
</div>
<p>Stomach cancer is the fourth most common cancer worldwide with 930,000 cases diagnosed in 2002.<sup id="cite_ref-Parkin_14-0" class="reference"><a href="#cite_note-Parkin-14"><font size="2"><font color="#002bb8"><span>[</span>15<span>]</span></font></font></a></sup> It is a disease with a high death rate (~800,000 per year) making it the second most common cause of cancer death worldwide after <a title="Lung cancer" href="/wiki/Lung_cancer"><font color="#002bb8">lung cancer</font></a>.<sup id="cite_ref-WHO_0-1" class="reference"><a href="#cite_note-WHO-0"><font size="2"><font color="#002bb8"><span>[</span>1<span>]</span></font></font></a></sup> It is more common in men and in developing countries.<sup id="cite_ref-Parkin_14-1" class="reference"><a href="#cite_note-Parkin-14"><font size="2"><font color="#002bb8"><span>[</span>15<span>]</span></font></font></a></sup><sup id="cite_ref-WHO-QA15_15-0" class="reference"><a href="#cite_note-WHO-QA15-15"><font size="2"><font color="#002bb8"><span>[</span>16<span>]</span></font></font></a></sup></p>
<p>It represents roughly 2% (25,500 cases) of all new cancer cases yearly in the United States, but it is more common in other countries. It is the leading cancer type in Korea, with 20.8% of malignant neoplasms.</p>
<p><a title="Metastasis" href="/wiki/Metastasis"><font color="#002bb8">Metastasis</font></a> occurs in 80-90% of individuals with stomach cancer, with a six month survival rate of 65% in those diagnosed in early stages and less than 15% of those diagnosed in late stages.</p>
<p>One in a million people under the age of 55 seeking medical attention for indigestion have stomach cancer <sup id="cite_ref-16" class="reference"><a href="#cite_note-16"><font size="2"><font color="#002bb8"><span>[</span>17<span>]</span></font></font></a></sup> and one in fifty of all ages seeking medical attention for burping and indigestion have stomach cancer.<sup id="cite_ref-17" class="reference"><a href="#cite_note-17"><font size="2"><font color="#002bb8"><span>[</span>18<span>]</span></font></font></a></sup> Out of 10 million people in the Czech Republic, only 3 new cases of stomach cancer in people under thirty years of age in 1999 were diagnosed.<sup id="cite_ref-18" class="reference"><a href="#cite_note-18"><font size="2"><font color="#002bb8"><span>[</span>19<span>]</span></font></font></a></sup> Other studies show that less than 5% of stomach cancers occur in people under 40 years of age with 81.1% of that 5% in the age-group of 30 to 39 and 18.9% in the age-group of 20 to 29.<sup id="cite_ref-19" class="reference"><a href="#cite_note-19"><font size="2"><font color="#002bb8"><span>[</span>20<span>]</span></font></font></a></sup></p>
<h2><span id="References" class="mw-headline">References</span></h2>
<div style="-moz-column-count: 2; column-count: 2" class="references-small references-column-count references-column-count-2">
<ol class="references">
<li id="cite_note-WHO-0">^ <a href="#cite_ref-WHO_0-0"><sup><em><strong><font color="#002bb8" size="2">a</font></strong></em></sup></a> <a href="#cite_ref-WHO_0-1"><sup><em><strong><font color="#002bb8" size="2">b</font></strong></em></sup></a> <span class="citation web"><a class="external text" href="http://www.who.int/mediacentre/factsheets/fs297/en/" rel="nofollow"><font color="#3366bb">"Cancer (Fact sheet N°297)"</font></a>. <a title="World Health Organization" href="/wiki/World_Health_Organization"><font color="#002bb8">World Health Organization</font></a>. February 2009<span class="printonly">. <a class="external free" href="http://www.who.int/mediacentre/factsheets/fs297/en/" rel="nofollow"><font color="#3366bb">http://www.who.int/mediacentre/factsheets/fs297/en/</font></a></span><span class="reference-accessdate">. Retrieved 2009-05-11</span>.</span><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=bookitem&rft.btitle=Cancer+%28Fact+sheet+N%C2%B0297%29&rft.atitle=&rft.date=February+2009&rft.pub=%5B%5BWorld+Health+Organization%5D%5D&rft_id=http%3A%2F%2Fwww.who.int%2Fmediacentre%2Ffactsheets%2Ffs297%2Fen%2F&rfr_id=info:sid/en.wikipedia.org:Stomach_cancer"><span style="DISPLAY: none"> </span></span> </li>
<li id="cite_note-Merck-1-1"><strong><a href="#cite_ref-Merck-1_1-0"><font color="#002bb8">^</font></a></strong> <span class="citation web"><a class="external text" href="http://www.merck.com/mmpe/sec02/ch021/ch021d.html" rel="nofollow"><font color="#3366bb">"Tumors of the GI Tract, Merck Manual (Professional)"</font></a>. Merck<span class="printonly">. <a class="external free" href="http://www.merck.com/mmpe/sec02/ch021/ch021d.html" rel="nofollow"><font color="#3366bb">http://www.merck.com/mmpe/sec02/ch021/ch021d.html</font></a></span><span class="reference-accessdate">. Retrieved 2009-06-06</span>.</span><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=bookitem&rft.btitle=Tumors+of+the+GI+Tract%2C+Merck+Manual+%28Professional%29&rft.atitle=&rft.pub=Merck&rft_id=http%3A%2F%2Fwww.merck.com%2Fmmpe%2Fsec02%2Fch021%2Fch021d.html&rfr_id=info:sid/en.wikipedia.org:Stomach_cancer"><span style="DISPLAY: none"> </span></span> </li>
<li id="cite_note-GVRF-4-2"><strong><a href="#cite_ref-GVRF-4_2-0"><font color="#002bb8">^</font></a></strong> <span class="citation web"><a class="external text" href="http://www.who.int/vaccine_research/documents/en/gvrf2003.pdf" rel="nofollow"><font color="#3366bb">"Proceedings of the fourth Global Vaccine Research Forum"</font></a>. <em>Initiative for Vaccine Research team of the Department of Immunization, Vaccines and Biologicals</em>. WHO. April 2004<span class="printonly">. <a class="external free" href="http://www.who.int/vaccine_research/documents/en/gvrf2003.pdf" rel="nofollow"><font color="#3366bb">http://www.who.int/vaccine_research/documents/en/gvrf2003.pdf</font></a></span><span class="reference-accessdate">. Retrieved 2009-05-11</span>. "Epidemiology of Helicobacter pylori and gastric cancer…"</span><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=bookitem&rft.btitle=Proceedings+of+the+fourth+Global+Vaccine+Research+Forum&rft.atitle=Initiative+for+Vaccine+Research+team+of+the+Department+of+Immunization%2C+Vaccines+and+Biologicals&rft.date=April+2004&rft.pub=WHO&rft_id=http%3A%2F%2Fwww.who.int%2Fvaccine_research%2Fdocuments%2Fen%2Fgvrf2003.pdf&rfr_id=info:sid/en.wikipedia.org:Stomach_cancer"><span style="DISPLAY: none"> </span></span> </li>
<li id="cite_note-3"><strong><a href="#cite_ref-3"><font color="#002bb8">^</font></a></strong> <span class="citation Journal">Lee HJ, Yang HK, Ahn YO (2002). "Gastric cancer in Korea". <em>Gastric Cancer : Official Journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association</em> <strong>5</strong> (3): 177–82. <a title="Digital object identifier" href="/wiki/Digital_object_identifier"><font color="#002bb8">doi</font></a>:<span class="neverexpand"><a class="external text" href="http://dx.doi.org/10.1007%2Fs101200200031" rel="nofollow"><font color="#3366bb">10.1007/s101200200031</font></a></span>. <a class="mw-redirect" title="PubMed Identifier" href="/wiki/PubMed_Identifier"><font color="#002bb8">PMID</font></a> <a class="external text" href="http://www.ncbi.nlm.nih.gov/pubmed/12378346" rel="nofollow"><font color="#3366bb">12378346</font></a>.</span><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.atitle=Gastric+cancer+in+Korea&rft.jtitle=Gastric+Cancer+%3A+Official+Journal+of+the+International+Gastric+Cancer+Association+and+the+Japanese+Gastric+Cancer+Association&rft.aulast=Lee+HJ%2C+Yang+HK%2C+Ahn+YO&rft.au=Lee+HJ%2C+Yang+HK%2C+Ahn+YO&rft.date=2002&rft.volume=5&rft.issue=3&rft.pages=177%E2%80%9382&rft_id=info:doi/10.1007%2Fs101200200031&rft_id=info:pmid/12378346&rfr_id=info:sid/en.wikipedia.org:Stomach_cancer"><span style="DISPLAY: none"> </span></span> </li>
<li id="cite_note-4"><strong><a href="#cite_ref-4"><font color="#002bb8">^</font></a></strong> <span class="citation Journal">Alonso-Amelot ME, Avendaño M (March 2002). <a class="external text" href="http://www.bentham-direct.org/pages/content.php?CMC/2002/00000009/00000006/0004C.SGM" rel="nofollow"><font color="#3366bb">"Human carcinogenesis and bracken fern: a review of the evidence"</font></a>. <em>Current Medicinal Chemistry</em> <strong>9</strong> (6): 675–86. <a class="mw-redirect" title="PubMed Identifier" href="/wiki/PubMed_Identifier"><font color="#002bb8">PMID</font></a> <a class="external text" href="http://www.ncbi.nlm.nih.gov/pubmed/11945131" rel="nofollow"><font color="#3366bb">11945131</font></a><span class="printonly">. <a class="external free" href="http://www.bentham-direct.org/pages/content.php?CMC/2002/00000009/00000006/0004C.SGM" rel="nofollow"><font color="#3366bb">http://www.bentham-direct.org/pages/content.php?CMC/2002/00000009/00000006/0004C.SGM</font></a></span><span class="reference-accessdate">. Retrieved 2009-06-20</span>.</span><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.atitle=Human+carcinogenesis+and+bracken+fern%3A+a+review+of+the+evidence&rft.jtitle=Current+Medicinal+Chemistry&rft.aulast=Alonso-Amelot+ME%2C+Avenda%C3%B1o+M&rft.au=Alonso-Amelot+ME%2C+Avenda%C3%B1o+M&rft.date=March+2002&rft.volume=9&rft.issue=6&rft.pages=675%E2%80%9386&rft_id=info:pmid/11945131&rft_id=http%3A%2F%2Fwww.bentham-direct.org%2Fpages%2Fcontent.php%3FCMC%2F2002%2F00000009%2F00000006%2F0004C.SGM&rfr_id=info:sid/en.wikipedia.org:Stomach_cancer"><span style="DISPLAY: none"> </span></span> </li>
<li id="cite_note-5"><strong><a href="#cite_ref-5"><font color="#002bb8">^</font></a></strong> <span class="citation Journal">Chandanos, Evangelos (December 2007) (PDF). <a class="external text" href="http://diss.kib.ki.se/2007/978-91-7357-370-2/thesis.pdf" rel="nofollow"><em><font color="#3366bb">Estrogen in the development of esophageal and gastric adenocarcinoma</font></em></a>. Karolinska Institutet. <a title="International Standard Book Number" href="/wiki/International_Standard_Book_Number"><font color="#002bb8">ISBN</font></a> <a title="Special:BookSources/978-91-7357-370-2" href="/wiki/Special:BookSources/978-91-7357-370-2"><font color="#002bb8">978-91-7357-370-2</font></a><span class="printonly">. <a class="external free" href="http://diss.kib.ki.se/2007/978-91-7357-370-2/thesis.pdf" rel="nofollow"><font color="#3366bb">http://diss.kib.ki.se/2007/978-91-7357-370-2/thesis.pdf</font></a></span><span class="reference-accessdate">. Retrieved 2009-06-20</span>.</span><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=book&rft.btitle=Estrogen+in+the+development+of+esophageal+and+gastric+adenocarcinoma&rft.aulast=Chandanos&rft.aufirst=Evangelos&rft.au=Chandanos%2C%26%2332%3BEvangelos&rft.date=December+2007&rft.pub=Karolinska+Institutet&rft.isbn=978-91-7357-370-2&rft_id=http%3A%2F%2Fdiss.kib.ki.se%2F2007%2F978-91-7357-370-2%2Fthesis.pdf&rfr_id=info:sid/en.wikipedia.org:Stomach_cancer"><span style="DISPLAY: none"> </span></span> </li>
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<li id="cite_note-Parkin-14">^ <a href="#cite_ref-Parkin_14-0"><sup><em><strong><font color="#002bb8" size="2">a</font></strong></em></sup></a> <a href="#cite_ref-Parkin_14-1"><sup><em><strong><font color="#002bb8" size="2">b</font></strong></em></sup></a> <span class="citation Journal">Parkin DM, Bray F, Ferlay J, Pisani P (2005). "Global cancer statistics, 2002". <em>CA: a Cancer Journal for Clinicians</em> <strong>55</strong> (2): 74–108. <a title="Digital object identifier" href="/wiki/Digital_object_identifier"><font color="#002bb8">doi</font></a>:<span class="neverexpand"><a class="external text" href="http://dx.doi.org/10.3322%2Fcanjclin.55.2.74" rel="nofollow"><font color="#3366bb">10.3322/canjclin.55.2.74</font></a></span>. <a class="mw-redirect" title="PubMed Identifier" href="/wiki/PubMed_Identifier"><font color="#002bb8">PMID</font></a> <a class="external text" href="http://www.ncbi.nlm.nih.gov/pubmed/15761078" rel="nofollow"><font color="#3366bb">15761078</font></a>.</span><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.atitle=Global+cancer+statistics%2C+2002&rft.jtitle=CA%3A+a+Cancer+Journal+for+Clinicians&rft.aulast=Parkin+DM%2C+Bray+F%2C+Ferlay+J%2C+Pisani+P&rft.au=Parkin+DM%2C+Bray+F%2C+Ferlay+J%2C+Pisani+P&rft.date=2005&rft.volume=55&rft.issue=2&rft.pages=74%E2%80%93108&rft_id=info:doi/10.3322%2Fcanjclin.55.2.74&rft_id=info:pmid/15761078&rfr_id=info:sid/en.wikipedia.org:Stomach_cancer"><span style="DISPLAY: none"> </span></span> </li>
<li id="cite_note-WHO-QA15-15"><strong><a href="#cite_ref-WHO-QA15_15-0"><font color="#002bb8">^</font></a></strong> <span class="citation web"><a class="external text" href="http://www.who.int/features/qa/15/en/index.html" rel="nofollow"><font color="#3366bb">"Are the number of cancer cases increasing or decreasing in the world?"</font></a>. <em>WHO Online Q&A</em>. WHO. 1 April 2008<span class="printonly">. <a class="external free" href="http://www.who.int/features/qa/15/en/index.html" rel="nofollow"><font color="#3366bb">http://www.who.int/features/qa/15/en/index.html</font></a></span><span class="reference-accessdate">. Retrieved 2009-05-11</span>.</span><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=bookitem&rft.btitle=Are+the+number+of+cancer+cases+increasing+or+decreasing+in+the+world%3F&rft.atitle=WHO+Online+Q%26A&rft.date=1+April+2008&rft.pub=WHO&rft_id=http%3A%2F%2Fwww.who.int%2Ffeatures%2Fqa%2F15%2Fen%2Findex.html&rfr_id=info:sid/en.wikipedia.org:Stomach_cancer"><span style="DISPLAY: none"> </span></span> </li>
<li id="cite_note-16"><strong><a href="#cite_ref-16"><font color="#002bb8">^</font></a></strong> <span class="citation web"><a class="external text" href="http://hcd2.bupa.co.uk/fact_sheets/html/stomach_cancer.html#3" rel="nofollow"><font color="#3366bb">"Stomach cancer - symptoms, causes and treatment"</font></a>. <a title="Bupa" href="/wiki/Bupa"><font color="#002bb8">Bupa</font></a>. 2007-05-02<span class="printonly">. <a class="external free" href="http://hcd2.bupa.co.uk/fact_sheets/html/stomach_cancer.html#3" rel="nofollow"><font color="#3366bb">http://hcd2.bupa.co.uk/fact_sheets/html/stomach_cancer.html#3</font></a></span><span class="reference-accessdate">. Retrieved 2009-05-11</span>.</span><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=bookitem&rft.btitle=Stomach+cancer+-+symptoms%2C+causes+and+treatment&rft.atitle=&rft.date=2007-05-02&rft.pub=%5B%5BBupa%5D%5D&rft_id=http%3A%2F%2Fhcd2.bupa.co.uk%2Ffact_sheets%2Fhtml%2Fstomach_cancer.html%233&rfr_id=info:sid/en.wikipedia.org:Stomach_cancer"><span style="DISPLAY: none"> </span></span> </li>
<li id="cite_note-17"><strong><a href="#cite_ref-17"><font color="#002bb8">^</font></a></strong> <span class="citation web"><a class="external text" href="http://www.cancerhelp.org.uk/help/default.asp?page=3897" rel="nofollow"><font color="#3366bb">"Stomach cancer symptoms: Cancer Research UK"</font></a>. CancerHelp UK. 2007-06-15<span class="printonly">. <a class="external free" href="http://www.cancerhelp.org.uk/help/default.asp?page=3897" rel="nofollow"><font color="#3366bb">http://www.cancerhelp.org.uk/help/default.asp?page=3897</font></a></span><span class="reference-accessdate">. Retrieved 2009-05-11</span>.</span><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=bookitem&rft.btitle=Stomach+cancer+symptoms%3A+Cancer+Research+UK&rft.atitle=&rft.date=2007-06-15&rft.pub=CancerHelp+UK&rft_id=http%3A%2F%2Fwww.cancerhelp.org.uk%2Fhelp%2Fdefault.asp%3Fpage%3D3897&rfr_id=info:sid/en.wikipedia.org:Stomach_cancer"><span style="DISPLAY: none"> </span></span> </li>
<li id="cite_note-18"><strong><a href="#cite_ref-18"><font color="#002bb8">^</font></a></strong> <span class="citation Journal">Simsa J, Leffler J, Hoch J, Linke Z, Pádr R (2004). <a class="external text" href="http://www.belsurg.org/imgupload/RBSS/simsa.pdf" rel="nofollow"><font color="#3366bb">"Gastric cancer in young patients--is there any hope for them?"</font></a> (PDF). <em>Acta Chirurgica Belgica</em> <strong>104</strong> (6): 673–6. <a class="mw-redirect" title="PubMed Identifier" href="/wiki/PubMed_Identifier"><font color="#002bb8">PMID</font></a> <a class="external text" href="http://www.ncbi.nlm.nih.gov/pubmed/15663273" rel="nofollow"><font color="#3366bb">15663273</font></a><span class="printonly">. <a class="external free" href="http://www.belsurg.org/imgupload/RBSS/simsa.pdf" rel="nofollow"><font color="#3366bb">http://www.belsurg.org/imgupload/RBSS/simsa.pdf</font></a></span><span class="reference-accessdate">. Retrieved 2009-06-20</span>.</span><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.atitle=Gastric+cancer+in+young+patients--is+there+any+hope+for+them%3F&rft.jtitle=Acta+Chirurgica+Belgica&rft.aulast=Simsa+J%2C+Leffler+J%2C+Hoch+J%2C+Linke+Z%2C+P%C3%A1dr+R&rft.au=Simsa+J%2C+Leffler+J%2C+Hoch+J%2C+Linke+Z%2C+P%C3%A1dr+R&rft.date=2004&rft.volume=104&rft.issue=6&rft.pages=673%E2%80%936&rft_id=info:pmid/15663273&rft_id=http%3A%2F%2Fwww.belsurg.org%2Fimgupload%2FRBSS%2Fsimsa.pdf&rfr_id=info:sid/en.wikipedia.org:Stomach_cancer"><span style="DISPLAY: none"> </span></span> </li>
<li id="cite_note-19"><strong><a href="#cite_ref-19"><font color="#002bb8">^</font></a></strong> <span class="citation web"><a class="external text" href="http://www.inca.gov.br/rbc/n_46/v03/english/article6.html" rel="nofollow"><font color="#3366bb">"Gastric Cancer in Young Adults"</font></a>. <em>Revista Brasileira de Cancerologia - Volume 46 n°3 Jul/Ago/Set 2000</em>. Inca.gov.br. 2000<span class="printonly">. <a class="external free" href="http://www.inca.gov.br/rbc/n_46/v03/english/article6.html" rel="nofollow"><font color="#3366bb">http://www.inca.gov.br/rbc/n_46/v03/english/article6.html</font></a></span><span class="reference-accessdate">. Retrieved 2009-05-11</span>.</span><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=bookitem&rft.btitle=Gastric+Cancer+in+Young+Adults&rft.atitle=Revista+Brasileira+de+Cancerologia+-+Volume+46+n%C2%B03+Jul%2FAgo%2FSet+2000&rft.date=2000&rft.pub=Inca.gov.br&rft_id=http%3A%2F%2Fwww.inca.gov.br%2Frbc%2Fn_46%2Fv03%2Fenglish%2Farticle6.html&rfr_id=info:sid/en.wikipedia.org:Stomach_cancer"><span style="DISPLAY: none"> </span></span> </li>
</ol>
</div>
<h2><span id="External_links" class="mw-headline">External links</span></h2>
<ul>
<li><a title="National Cancer Institute" href="/wiki/National_Cancer_Institute"><font color="#002bb8">National Cancer Institute</font></a> <a class="external text" href="http://www.cancer.gov/cancertopics/pdq/treatment/gastric/HealthProfessional/page1" rel="nofollow"><font color="#3366bb">Gastric cancer treatment guidelines</font></a> </li>
<li><a class="external text" href="http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=gene&part=hgc" rel="nofollow"><font color="#3366bb">GeneReview/NIH/UW entry on Hereditary Diffuse Gastric Cancer</font></a> </li>
<li><a class="external text" href="http://www.nostomachforcancer.org" rel="nofollow"><font color="#3366bb">No Stomach For Cancer | Be Strong Hearted</font></a> is a source of information and support for Hereditary Diffuse Gastric Cancer and carriers of the CDH1 gene mutation and their families/friends. </li>
<li><span class="citation web"><a class="external text" href="http://web.tiscali.it/iodio/" rel="nofollow"><font color="#3366bb">"Stomach Cancer. In: Iodine Deficiency: studies by dr. Sebastiano Venturi (Italy)"</font></a><span class="printonly">. <a class="external free" href="http://web.tiscali.it/iodio/" rel="nofollow"><font color="#3366bb">http://web.tiscali.it/iodio/</font></a></span><span class="reference-accessdate">. Retrieved 2008-05-15</span>.</span><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=bookitem&rft.btitle=Stomach+Cancer.+In%3A+Iodine+Deficiency%3A+studies+by+dr.+Sebastiano+Venturi+%28Italy%29&rft.atitle=&rft_id=http%3A%2F%2Fweb.tiscali.it%2Fiodio%2F&rfr_id=info:sid/en.wikipedia.org:Stomach_cancer"><span style="DISPLAY: none"> </span></span> </li>
</ul>
<table id="toc" class="toc">
<tbody>
<tr>
<td>
<div id="toctitle">
<h2>Contents</h2>
<span class="toctoggle"><font size="2">[</font><a id="togglelink" class="internal" href="javascript:toggleToc()"><font color="#002bb8" size="2">hide</font></a><font size="2">]</font></span></div>
<ul>
<li class="toclevel-1 tocsection-1"><a href="#Signs_and_symptoms"><font color="#002bb8"><span class="tocnumber">1</span> <span class="toctext">Signs and symptoms</span></font></a> </li>
<li class="toclevel-1 tocsection-2"><a href="#Causes"><font color="#002bb8"><span class="tocnumber">2</span> <span class="toctext">Causes</span></font></a> </li>
<li class="toclevel-1 tocsection-3"><a href="#Diagnosis"><font color="#002bb8"><span class="tocnumber">3</span> <span class="toctext">Diagnosis</span></font></a>
<ul>
<li class="toclevel-2 tocsection-4"><a href="#Histopathology"><font color="#002bb8"><span class="tocnumber">3.1</span> <span class="toctext">Histopathology</span></font></a> </li>
<li class="toclevel-2 tocsection-5"><a href="#Staging"><font color="#002bb8"><span class="tocnumber">3.2</span> <span class="toctext">Staging</span></font></a> </li>
</ul>
</li>
<li class="toclevel-1 tocsection-6"><a href="#Management"><font color="#002bb8"><span class="tocnumber">4</span> <span class="toctext">Management</span></font></a>
<ul>
<li class="toclevel-2 tocsection-7"><a href="#Surgery"><font color="#002bb8"><span class="tocnumber">4.1</span> <span class="toctext">Surgery</span></font></a> </li>
<li class="toclevel-2 tocsection-8"><a href="#Chemotherapy"><font color="#002bb8"><span class="tocnumber">4.2</span> <span class="toctext">Chemotherapy</span></font></a> </li>
<li class="toclevel-2 tocsection-9"><a href="#Radiation_therapy"><font color="#002bb8"><span class="tocnumber">4.3</span> <span class="toctext">Radiation therapy</span></font></a> </li>
<li class="toclevel-2 tocsection-10"><a href="#Multimodality_therapy"><font color="#002bb8"><span class="tocnumber">4.4</span> <span class="toctext">Multimodality therapy</span></font></a> </li>
</ul>
</li>
<li class="toclevel-1 tocsection-11"><a href="#Epidemiology"><font color="#002bb8"><span class="tocnumber">5</span> <span class="toctext">Epidemiology</span></font></a> </li>
<li class="toclevel-1 tocsection-12"><a href="#References"><font color="#002bb8"><span class="tocnumber">6</span> <span class="toctext">References</span></font></a> </li>
<li class="toclevel-1 tocsection-13"><a href="#External_links"><font color="#002bb8"><span class="tocnumber">7</span> <span class="toctext">External links</span></font></a> </li>
</ul>
</td>
</tr>
</tbody>
</table>
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<h2><span id="Signs_and_symptoms" class="mw-headline">Signs and symptoms</span></h2>
<div class="thumb tright">
<div style="WIDTH: 182px" class="thumbinner"><a class="image" href="/wiki/File:Linitis_plastica_2.jpg"><img class="thumbimage" alt="" src="http://upload.wikimedia.org/wikipedia/commons/thumb/9/94/Linitis_plastica_2.jpg/180px-Linitis_plastica_2.jpg" width="180" height="165" /></a>
<div class="thumbcaption">
<div class="magnify"><a class="internal" title="Enlarge" href="/wiki/File:Linitis_plastica_2.jpg"><img alt="" src="http://bits.wikimedia.org/skins-1.5/common/images/magnify-clip.png" width="15" height="11" /></a></div>
Endoscopic image of <a title="Linitis plastica" href="/wiki/Linitis_plastica"><font color="#002bb8">linitis plastica</font></a>, a type of stomach cancer where the entire <a title="Stomach" href="/wiki/Stomach"><font color="#002bb8">stomach</font></a> is invaded, leading to a leather bottle-like appearance with <a title="Bleeding" href="/wiki/Bleeding"><font color="#002bb8">blood</font></a> coming out of it.</div>
</div>
</div>
<p>Stomach cancer is often <a title="Asymptomatic" href="/wiki/Asymptomatic"><font color="#002bb8">asymptomatic</font></a> or causes only <a class="mw-redirect" title="Nonspecific symptoms" href="/wiki/Nonspecific_symptoms"><font color="#002bb8">nonspecific symptoms</font></a> in its early stages. By the time symptoms occur, the cancer has generally <a title="Metastasis" href="/wiki/Metastasis"><font color="#002bb8">metastasized</font></a> to other parts of the body, one of the main reasons for its poor prognosis. Stomach cancer can cause the following signs and symptoms:</p>
<p>Early</p>
<ul>
<li><a class="mw-redirect" title="Indigestion" href="/wiki/Indigestion"><font color="#002bb8">Indigestion</font></a> or a burning sensation (<a title="Heartburn" href="/wiki/Heartburn"><font color="#002bb8">heartburn</font></a>) </li>
<li><a class="mw-redirect" title="Loss of appetite" href="/wiki/Loss_of_appetite"><font color="#002bb8">Loss of appetite</font></a>, especially for meat </li>
</ul>
<p>Late</p>
<ul>
<li><a title="Abdominal pain" href="/wiki/Abdominal_pain"><font color="#002bb8">Abdominal pain</font></a> or discomfort in the upper abdomen </li>
<li><a title="Nausea" href="/wiki/Nausea"><font color="#002bb8">Nausea</font></a> and <a title="Vomiting" href="/wiki/Vomiting"><font color="#002bb8">vomiting</font></a> </li>
<li><a title="Diarrhea" href="/wiki/Diarrhea"><font color="#002bb8">Diarrhea</font></a> or <a title="Constipation" href="/wiki/Constipation"><font color="#002bb8">constipation</font></a> </li>
<li><a title="Bloating" href="/wiki/Bloating"><font color="#002bb8">Bloating</font></a> of the stomach after meals </li>
<li><a title="Weight loss" href="/wiki/Weight_loss"><font color="#002bb8">Weight loss</font></a> </li>
<li><a title="Weakness" href="/wiki/Weakness"><font color="#002bb8">Weakness</font></a> and <a class="mw-redirect" title="Fatigue (physical)" href="/wiki/Fatigue_(physical)"><font color="#002bb8">fatigue</font></a> </li>
<li><a title="Bleeding" href="/wiki/Bleeding"><font color="#002bb8">Bleeding</font></a> (<a class="mw-redirect" title="Vomiting blood" href="/wiki/Vomiting_blood"><font color="#002bb8">vomiting blood</font></a> or having <a class="mw-redirect" title="Blood in the stool" href="/wiki/Blood_in_the_stool"><font color="#002bb8">blood in the stool</font></a>) which will appear as black. This can lead to <a title="Anemia" href="/wiki/Anemia"><font color="#002bb8">anemia</font></a>. </li>
<li><a title="Dysphagia" href="/wiki/Dysphagia"><font color="#002bb8">Dysphagia</font></a>; this feature suggests a tumor in the cardia or extension of the gastric tumor in to the <a title="Esophagus" href="/wiki/Esophagus"><font color="#002bb8">esophagus</font></a>. </li>
</ul>
<p>These can be symptoms of other problems such as a <a class="mw-redirect" title="Stomach virus" href="/wiki/Stomach_virus"><font color="#002bb8">stomach virus</font></a>, <a class="mw-redirect" title="Gastric ulcer" href="/wiki/Gastric_ulcer"><font color="#002bb8">gastric ulcer</font></a> or <a title="Tropical sprue" href="/wiki/Tropical_sprue"><font color="#002bb8">tropical sprue</font></a> and diagnosis should be done by a <a class="mw-redirect" title="Gastroenterologist" href="/wiki/Gastroenterologist"><font color="#002bb8">gastroenterologist</font></a> or an <a class="mw-redirect" title="Oncologist" href="/wiki/Oncologist"><font color="#002bb8">oncologist</font></a>.</p>
<h2><span id="Causes" class="mw-headline">Causes</span></h2>
<p>Infection by <a title="Helicobacter pylori" href="/wiki/Helicobacter_pylori"><font color="#002bb8">Helicobacter pylori</font></a> is believed to be the cause of most stomach cancer while autoimmune atrophic <a title="Gastritis" href="/wiki/Gastritis"><font color="#002bb8">gastritis</font></a>, <a title="Intestinal metaplasia" href="/wiki/Intestinal_metaplasia"><font color="#002bb8">intestinal metaplasia</font></a> and various genetic factors are associated with increased risk levels. It is not currently believed that diet has any role to play.<sup id="cite_ref-Merck-1_1-0" class="reference"><a href="#cite_note-Merck-1-1"><font size="2"><font color="#002bb8"><span>[</span>2<span>]</span></font></font></a></sup></p>
<p>In more detail, <em>H. pylori</em> is the main risk factor in 65–80% of gastric cancers, but in only 2% of such infections.<sup id="cite_ref-GVRF-4_2-0" class="reference"><a href="#cite_note-GVRF-4-2"><font size="2"><font color="#002bb8"><span>[</span>3<span>]</span></font></font></a></sup> Approximately ten percent of cases show a genetic component.<sup id="cite_ref-3" class="reference"><a href="#cite_note-3"><font size="2"><font color="#002bb8"><span>[</span>4<span>]</span></font></font></a></sup> In Japan and other countries <a title="Bracken" href="/wiki/Bracken"><font color="#002bb8">bracken</font></a> consumption and spores are correlated with incidence of stomach cancer, though causality has yet to be established.<sup id="cite_ref-4" class="reference"><a href="#cite_note-4"><font size="2"><font color="#002bb8"><span>[</span>5<span>]</span></font></font></a></sup></p>
<p>Gastric cancer shows a male predominance in its incidence as up to three males are affected for every female. Estrogen may protect women against the development of this cancer form.<sup id="cite_ref-5" class="reference"><a href="#cite_note-5"><font size="2"><font color="#002bb8"><span>[</span>6<span>]</span></font></font></a></sup> A very small percentage of diffuse-type gastric cancers (see Histopathology below) are thought to be genetic. Hereditary Diffuse Gastric Cancer (HDGC) has recently been identified and research is ongoing. However, genetic testing and treatment options are already available for families at risk.<sup id="cite_ref-pmid15235021_6-0" class="reference"><a href="#cite_note-pmid15235021-6"><font size="2"><font color="#002bb8"><span>[</span>7<span>]</span></font></font></a></sup></p>
<p>Some researchers <sup id="cite_ref-7" class="reference"><a href="#cite_note-7"><font size="2"><font color="#002bb8"><span>[</span>8<span>]</span></font></font></a></sup> showed a correlation between <a title="Iodine" href="/wiki/Iodine"><font color="#002bb8">Iodine</font></a> deficiency or excess, iodine-deficient goitre and gastric cancer; a decrease of the incidence of death rate from stomach cancer after implementation of the effective I-prophylaxis was reported too.<sup id="cite_ref-8" class="reference"><a href="#cite_note-8"><font size="2"><font color="#002bb8"><span>[</span>9<span>]</span></font></font></a></sup> The proposed mechanism of action is that iodide ion can function in gastric mucosa as an antioxidant <a title="Redox" href="/wiki/Redox"><font color="#002bb8">reducing</font></a> species that can detoxify poisonous <a title="Reactive oxygen species" href="/wiki/Reactive_oxygen_species"><font color="#002bb8">reactive oxygen species</font></a>, such as <a title="Hydrogen peroxide" href="/wiki/Hydrogen_peroxide"><font color="#002bb8">hydrogen peroxide</font></a>. <a title="China" href="/wiki/China"><font color="#002bb8">China</font></a> being member of <a title="International Cancer Genome Consortium" href="/wiki/International_Cancer_Genome_Consortium"><font color="#002bb8">International Cancer Genome Consortium</font></a> is leading efforts to map stomach cancer's complete <a title="Genome" href="/wiki/Genome"><font color="#002bb8">genome</font></a>.</p>
<h2><span id="Diagnosis" class="mw-headline">Diagnosis</span></h2>
<p>To find the cause of symptoms, the doctor asks about the patient's medical history, does a physical exam, and may order laboratory studies. The patient may also have one or all of the following exams:</p>
<ul>
<li><a class="mw-redirect" title="Gastroscopic exam" href="/wiki/Gastroscopic_exam"><font color="#002bb8">Gastroscopic exam</font></a> is the diagnostic method of choice. This involves insertion of a <a class="mw-redirect" title="Fibre optics" href="/wiki/Fibre_optics"><font color="#002bb8">fibre optic</font></a> camera into the stomach to visualize it. </li>
<li><a class="mw-redirect" title="Upper GI series" href="/wiki/Upper_GI_series"><font color="#002bb8">Upper GI series</font></a> (may be called barium roentgenogram) </li>
<li><a class="mw-redirect" title="Computed tomography" href="/wiki/Computed_tomography"><font color="#002bb8">Computed tomography</font></a> or CT scanning of the abdomen may reveal gastric cancer, but is more useful to determine invasion into adjacent tissues, or the presence of spread to local lymph nodes. </li>
</ul>
<p>Abnormal tissue seen in a gastroscope examination will be <a title="Biopsy" href="/wiki/Biopsy"><font color="#002bb8">biopsied</font></a> by the <a title="Surgery" href="/wiki/Surgery"><font color="#002bb8">surgeon</font></a> or <a class="mw-redirect" title="Gastroenterologist" href="/wiki/Gastroenterologist"><font color="#002bb8">gastroenterologist</font></a>. This tissue is then sent to a <a title="Pathology" href="/wiki/Pathology"><font color="#002bb8">pathologist</font></a> for <a title="Histology" href="/wiki/Histology"><font color="#002bb8">histological</font></a> examination under a microscope to check for the presence of cancerous cells. A biopsy, with subsequent histological analysis, is the only sure way to confirm the presence of cancer cells.</p>
<p>Various gastroscopic modalities have been developed to increased yield of detect mucosa with a dye that accentuates the cell structure and can identify areas of dysplasia. <em>Endocytoscopy</em> involves ultra-high magnification to visualize cellular structure to better determine areas of dysplasia. Other gastroscopic modalities such as <a title="Optical coherence tomography" href="/wiki/Optical_coherence_tomography"><font color="#002bb8">optical coherence tomography</font></a> are also being tested investigationally for similar applications.<sup id="cite_ref-9" class="reference"><a href="#cite_note-9"><font size="2"><font color="#002bb8"><span>[</span>10<span>]</span></font></font></a></sup></p>
<p>A number of cutaneous conditions are associated with gastric cancer. A condition of darkened hyperplasia of the skin, frequently of the axilla and groin, known as <a title="Acanthosis nigricans" href="/wiki/Acanthosis_nigricans"><font color="#002bb8">acanthosis nigricans</font></a>, is associated with intra-abdominal cancers such as gastric cancer. Other cutaneous manifestations of gastric cancer include <em>tripe palms</em> (a similar darkening hyperplasia of the skin of the palms) and the sign of <a class="mw-redirect" title="Leser-Trelat sign" href="/wiki/Leser-Trelat_sign"><font color="#002bb8">Leser-Trelat</font></a>, which is the rapid development of skin lesions known as <a title="Seborrheic keratosis" href="/wiki/Seborrheic_keratosis"><font color="#002bb8">seborrheic keratoses</font></a>.<sup id="cite_ref-pmid15230897_10-0" class="reference"><a href="#cite_note-pmid15230897-10"><font size="2"><font color="#002bb8"><span>[</span>11<span>]</span></font></font></a></sup></p>
<h3><span id="Histopathology" class="mw-headline">Histopathology</span></h3>
<div class="thumb tright">
<div style="WIDTH: 182px" class="thumbinner"><a class="image" href="/wiki/File:Adenocarcinoma_low_differentiated_(stomach)_H%26E_magn_400x.jpg"><img class="thumbimage" alt="" src="http://upload.wikimedia.org/wikipedia/commons/thumb/8/85/Adenocarcinoma_low_differentiated_%28stomach%29_H%26E_magn_400x.jpg/180px-Adenocarcinoma_low_differentiated_%28stomach%29_H%26E_magn_400x.jpg" width="180" height="144" /></a>
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Poor to moderately differentiated adenocarcinoma of the stomach. <a title="H&E stain" href="/wiki/H%26E_stain"><font color="#002bb8">H&E stain</font></a>.</div>
</div>
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<div style="WIDTH: 182px" class="thumbinner"><a class="image" href="/wiki/File:Gastric_signet_ring_cell_carcinoma_histopatholgy_(1).jpg"><img class="thumbimage" alt="" src="http://upload.wikimedia.org/wikipedia/commons/thumb/1/11/Gastric_signet_ring_cell_carcinoma_histopatholgy_%281%29.jpg/180px-Gastric_signet_ring_cell_carcinoma_histopatholgy_%281%29.jpg" width="180" height="135" /></a>
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Gastric signet ring cell carcinoma. <a title="H&E stain" href="/wiki/H%26E_stain"><font color="#002bb8">H&E stain</font></a>.</div>
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<div style="WIDTH: 182px" class="thumbinner"><a class="image" href="/wiki/File:Gastric_adenocarcinoma.jpg"><img class="thumbimage" alt="" src="http://upload.wikimedia.org/wikipedia/commons/thumb/5/56/Gastric_adenocarcinoma.jpg/180px-Gastric_adenocarcinoma.jpg" width="180" height="135" /></a>
<div class="thumbcaption">
<div class="magnify"><a class="internal" title="Enlarge" href="/wiki/File:Gastric_adenocarcinoma.jpg"><img alt="" src="http://bits.wikimedia.org/skins-1.5/common/images/magnify-clip.png" width="15" height="11" /></a></div>
Adenocarcinoma of the stomach and <a title="Intestinal metaplasia" href="/wiki/Intestinal_metaplasia"><font color="#002bb8">intestinal metaplasia</font></a>. <a title="H&E stain" href="/wiki/H%26E_stain"><font color="#002bb8">H&E stain</font></a>.</div>
</div>
</div>
<ul>
<li><em>Gastric <a title="Adenocarcinoma" href="/wiki/Adenocarcinoma"><font color="#002bb8">adenocarcinoma</font></a></em> is a malignant epithelial tumor, originating from glandular epithelium of the gastric mucosa. It invades the gastric wall, infiltrating the <a title="Muscularis mucosae" href="/wiki/Muscularis_mucosae"><font color="#002bb8">muscularis mucosae</font></a>, the submucosa and thence the muscularis propria. Histologically, there are two major types of gastric cancer (Lauren classification): intestinal type and diffuse type. </li>
<li><em>Intestinal type adenocarcinoma</em>: tumor cells describe irregular tubular structures, harboring pluristratification, multiple lumens, reduced stroma ("back to back" aspect). Often, it associates intestinal metaplasia in neighboring mucosa. Depending on glandular architecture, cellular pleomorphism and mucosecretion, adenocarcinoma may present 3 degrees of differentiation: well, moderate and poorly differentiate. </li>
<li><em>Diffuse type adenocarcinoma (mucinous, colloid):</em> Tumor cells are discohesive and secrete mucus which is delivered in the interstitium producing large pools of mucus/colloid (optically "empty" spaces). It is poorly differentiated. If the mucus remains inside the tumor cell, it pushes the nucleus at the purpley- "<em><a class="mw-redirect" title="Signet-ring cell" href="/wiki/Signet-ring_cell"><font color="#002bb8">signet-ring cell</font></a></em>". </li>
</ul>
<h3><span id="Staging" class="mw-headline">Staging</span></h3>
<p>If cancer cells are found in the tissue sample, the next step is to <a title="Cancer staging" href="/wiki/Cancer_staging"><font color="#002bb8">stage</font></a>, or find out the extent of the disease. Various tests determine whether the cancer has spread and, if so, what parts of the body are affected. Because stomach cancer can spread to the liver, the pancreas, and other organs near the stomach as well as to the lungs, the doctor may order a <a class="mw-redirect" title="CT scan" href="/wiki/CT_scan"><font color="#002bb8">CT scan</font></a>, a <a class="mw-redirect" title="PET scan" href="/wiki/PET_scan"><font color="#002bb8">PET scan</font></a>, an <a title="Endoscopic ultrasound" href="/wiki/Endoscopic_ultrasound"><font color="#002bb8">endoscopic ultrasound</font></a> exam, or other tests to check these areas. Blood tests for <a title="Tumor marker" href="/wiki/Tumor_marker"><font color="#002bb8">tumor markers</font></a>, such as <a title="Carcinoembryonic antigen" href="/wiki/Carcinoembryonic_antigen"><font color="#002bb8">carcinoembryonic antigen</font></a> (CEA) and carbohydrate antigen (CA) may be ordered, as their levels correlate to extent of metastasis, especially to the liver, and the cure rate.</p>
<p>Staging may not be complete until after surgery. The surgeon removes nearby lymph nodes and possibly samples of tissue from other areas in the abdomen for examination by a pathologist.</p>
<p>TNM staging is used</p>
<h2><span id="Management" class="mw-headline">Management</span></h2>
<p>Like any cancer, treatment is adapted to fit each person's individual needs and depends on the size, location, and extent of the tumor, the stage of the disease, and general health. Cancer of the stomach is difficult to cure unless it is found in an early stage (before it has begun to spread). Unfortunately, because early stomach cancer causes few symptoms, the disease is usually advanced when the diagnosis is made. Treatment for stomach cancer may include surgery, <a title="Chemotherapy" href="/wiki/Chemotherapy"><font color="#002bb8">chemotherapy</font></a>, and/or <a title="Radiation therapy" href="/wiki/Radiation_therapy"><font color="#002bb8">radiation therapy</font></a>. New treatment approaches such as biological therapy and improved ways of using current methods are being studied in clinical trials.</p>
<h4><span id="Surgery" class="mw-headline">Surgery</span></h4>
<p>Surgery is the <strong>most common treatment</strong> and is the only hope of cure for stomach cancer. The surgeon removes part or all of the stomach, as well as the surrounding <a class="mw-redirect" title="Lymph nodes" href="/wiki/Lymph_nodes"><font color="#002bb8">lymph nodes</font></a>, with the basic goal of removing all cancer and a margin of normal tissue. Depending on the extent of invasion and the location of the tumor, surgery may also include removal of part of the intestine or pancreas. Tumors in the lower part of the stomach may call for a <a title="Billroth I" href="/wiki/Billroth_I"><font color="#002bb8">Billroth I</font></a> or <a title="Billroth II" href="/wiki/Billroth_II"><font color="#002bb8">Billroth II</font></a> procedure. Endoscopic mucosal resection (EMR) is a treatment for early gastric cancer (tumor only involves the mucosa) that has been pioneered in Japan, but is also available in the United States at some centers. In this procedure, the tumor, together with the inner lining of stomach (mucosa), is removed from the wall of the stomach using an electrical wire loop through the endoscope. The advantage is that it is a much smaller operation than removing the stomach. Endoscopic submucosal dissection (ESD) is a similar technique pioneered in Japan, used to resect a large area of mucosa in one piece. If the pathologic examination of the resected specimen shows incomplete resection or deep invasion by tumor, the patient would need a formal stomach resection.</p>
<p>Surgical interventions are currently curative in less than 40% of cases, and, in cases of metastasis, may only be <a class="mw-redirect" title="Palliative" href="/wiki/Palliative"><font color="#002bb8">palliative</font></a>.</p>
<h4><span id="Chemotherapy" class="mw-headline">Chemotherapy</span></h4>
<p>The use of <a title="Chemotherapy" href="/wiki/Chemotherapy"><font color="#002bb8">chemotherapy</font></a> to treat stomach cancer has no established <a title="Standard of care" href="/wiki/Standard_of_care"><font color="#002bb8">standard of care</font></a>. Unfortunately, stomach cancer has not been especially sensitive to these drugs until recently, and historically served to palliatively reduce the size of the tumor and increase survival time. Some drugs used in stomach cancer treatment include: <a class="mw-redirect" title="5-FU" href="/wiki/5-FU"><font color="#002bb8">5-FU</font></a> (fluorouracil), BCNU (carmustine), methyl-CCNU (Semustine), and <a title="Doxorubicin" href="/wiki/Doxorubicin"><font color="#002bb8">doxorubicin</font></a> (Adriamycin), as well as Mitomycin C, and more recently <a title="Cisplatin" href="/wiki/Cisplatin"><font color="#002bb8">cisplatin</font></a> and <a class="mw-redirect" title="Taxotere" href="/wiki/Taxotere"><font color="#002bb8">taxotere</font></a> in various combinations. The relative benefits of these drugs, alone and in combination, are unclear.<sup id="cite_ref-pmid17425475_11-0" class="reference"><a href="#cite_note-pmid17425475-11"><font size="2"><font color="#002bb8"><span>[</span>12<span>]</span></font></font></a></sup> Scientists are exploring the benefits of giving chemotherapy before surgery to shrink the tumor, or as adjuvant therapy after surgery to destroy remaining cancer cells. Combination treatment with chemotherapy and radiation therapy is also under study. Doctors are testing a treatment in which anticancer drugs are put directly into the abdomen (<a title="Intraperitoneal hyperthermic chemoperfusion" href="/wiki/Intraperitoneal_hyperthermic_chemoperfusion"><font color="#002bb8">intraperitoneal hyperthermic chemoperfusion</font></a>). Chemotherapy also is being studied as a treatment for cancer that has spread, and as a way to relieve symptoms of the disease. The side effects of chemotherapy depend mainly on the drugs the patient receives.</p>
<h4><span id="Radiation_therapy" class="mw-headline">Radiation therapy</span></h4>
<p><a title="Radiation therapy" href="/wiki/Radiation_therapy"><font color="#002bb8">Radiation therapy</font></a> (also called radiotherapy) is the use of high-energy rays to damage cancer cells and stop them from growing. When used, it is generally in combination with surgery and chemotherapy, or used only with chemotherapy in cases where the individual is unable to undergo surgery. Radiation therapy may be used to relieve pain or blockage by shrinking the tumor for <a class="mw-redirect" title="Palliation" href="/wiki/Palliation"><font color="#002bb8">palliation</font></a> of incurable disease</p>
<h4><span id="Multimodality_therapy" class="mw-headline">Multimodality therapy</span></h4>
<p>While previous studies of multimodality therapy (combinations of surgery, chemotherapy and radiation therapy) gave mixed results, the Intergroup 0116 (SWOG 9008) study<sup id="cite_ref-pmid11547741_12-0" class="reference"><a href="#cite_note-pmid11547741-12"><font size="2"><font color="#002bb8"><span>[</span>13<span>]</span></font></font></a></sup> showed a survival benefit to the combination of chemotherapy and radiation therapy in patients with nonmetastatic, completely resected gastric cancer. Patients were randomized after surgery to the standard group of observation alone, or the study arm of combination chemotherapy and radiation therapy. Those in the study arm receiving chemotherapy and radiation therapy survived on average 36 months; compared to 27 months with observation.</p>
<h2><span id="Epidemiology" class="mw-headline">Epidemiology</span></h2>
<div class="thumb tright">
<div style="WIDTH: 182px" class="thumbinner"><a class="image" href="/wiki/File:Stomach_cancer_world_map_-_Death_-_WHO2004.svg"><img class="thumbimage" alt="" src="http://upload.wikimedia.org/wikipedia/commons/thumb/a/a7/Stomach_cancer_world_map_-_Death_-_WHO2004.svg/180px-Stomach_cancer_world_map_-_Death_-_WHO2004.svg.png" width="180" height="79" /></a>
<div class="thumbcaption">
<div class="magnify"><a class="internal" title="Enlarge" href="/wiki/File:Stomach_cancer_world_map_-_Death_-_WHO2004.svg"><img alt="" src="http://bits.wikimedia.org/skins-1.5/common/images/magnify-clip.png" width="15" height="11" /></a></div>
<a title="Age adjustment" href="/wiki/Age_adjustment"><font color="#002bb8">Age-standardized</font></a> death from stomach cancer per 100,000 inhabitants in 2004.<sup id="cite_ref-13" class="reference"><a href="#cite_note-13"><font size="1"><font color="#002bb8"><span>[</span>14<span>]</span></font></font></a></sup>
<div style="-moz-column-count: 3; column-count: 3" class="references-small"><span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #b3b3b3 1px solid; BORDER-LEFT: #b3b3b3 1px solid; BACKGROUND-COLOR: #b3b3b3; COLOR: #b3b3b3; BORDER-TOP: #b3b3b3 1px solid; BORDER-RIGHT: #b3b3b3 1px solid"> </span> no data</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ffff65 1px solid; BORDER-LEFT: #ffff65 1px solid; BACKGROUND-COLOR: #ffff65; COLOR: #ffff65; BORDER-TOP: #ffff65 1px solid; BORDER-RIGHT: #ffff65 1px solid"> </span> less than 3.5</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #fff200 1px solid; BORDER-LEFT: #fff200 1px solid; BACKGROUND-COLOR: #fff200; COLOR: #fff200; BORDER-TOP: #fff200 1px solid; BORDER-RIGHT: #fff200 1px solid"> </span> 3.5-8</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ffdc00 1px solid; BORDER-LEFT: #ffdc00 1px solid; BACKGROUND-COLOR: #ffdc00; COLOR: #ffdc00; BORDER-TOP: #ffdc00 1px solid; BORDER-RIGHT: #ffdc00 1px solid"> </span> 8-12.5</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ffc600 1px solid; BORDER-LEFT: #ffc600 1px solid; BACKGROUND-COLOR: #ffc600; COLOR: #ffc600; BORDER-TOP: #ffc600 1px solid; BORDER-RIGHT: #ffc600 1px solid"> </span> 12.5-17</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ffb000 1px solid; BORDER-LEFT: #ffb000 1px solid; BACKGROUND-COLOR: #ffb000; COLOR: #ffb000; BORDER-TOP: #ffb000 1px solid; BORDER-RIGHT: #ffb000 1px solid"> </span> 17-21.5</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ff9a00 1px solid; BORDER-LEFT: #ff9a00 1px solid; BACKGROUND-COLOR: #ff9a00; COLOR: #ff9a00; BORDER-TOP: #ff9a00 1px solid; BORDER-RIGHT: #ff9a00 1px solid"> </span> 21.5-26</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ff8400 1px solid; BORDER-LEFT: #ff8400 1px solid; BACKGROUND-COLOR: #ff8400; COLOR: #ff8400; BORDER-TOP: #ff8400 1px solid; BORDER-RIGHT: #ff8400 1px solid"> </span> 26-30.5</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ff6e00 1px solid; BORDER-LEFT: #ff6e00 1px solid; BACKGROUND-COLOR: #ff6e00; COLOR: #ff6e00; BORDER-TOP: #ff6e00 1px solid; BORDER-RIGHT: #ff6e00 1px solid"> </span> 30.5-35</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ff5800 1px solid; BORDER-LEFT: #ff5800 1px solid; BACKGROUND-COLOR: #ff5800; COLOR: #ff5800; BORDER-TOP: #ff5800 1px solid; BORDER-RIGHT: #ff5800 1px solid"> </span> 35-40</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ff4200 1px solid; BORDER-LEFT: #ff4200 1px solid; BACKGROUND-COLOR: #ff4200; COLOR: #ff4200; BORDER-TOP: #ff4200 1px solid; BORDER-RIGHT: #ff4200 1px solid"> </span> 40-45</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #ff2c00 1px solid; BORDER-LEFT: #ff2c00 1px solid; BACKGROUND-COLOR: #ff2c00; COLOR: #ff2c00; BORDER-TOP: #ff2c00 1px solid; BORDER-RIGHT: #ff2c00 1px solid"> </span> 45-50</span> <span style="PADDING-BOTTOM: 1px; MARGIN: 0px; DISPLAY: block; FONT-SIZE: 90%"><span style="BORDER-BOTTOM: #cb0000 1px solid; BORDER-LEFT: #cb0000 1px solid; BACKGROUND-COLOR: #cb0000; COLOR: #cb0000; BORDER-TOP: #cb0000 1px solid; BORDER-RIGHT: #cb0000 1px solid"> </span> more than 50</span></div>
</div>
</div>
</div>
<p>Stomach cancer is the fourth most common cancer worldwide with 930,000 cases diagnosed in 2002.<sup id="cite_ref-Parkin_14-0" class="reference"><a href="#cite_note-Parkin-14"><font size="2"><font color="#002bb8"><span>[</span>15<span>]</span></font></font></a></sup> It is a disease with a high death rate (~800,000 per year) making it the second most common cause of cancer death worldwide after <a title="Lung cancer" href="/wiki/Lung_cancer"><font color="#002bb8">lung cancer</font></a>.<sup id="cite_ref-WHO_0-1" class="reference"><a href="#cite_note-WHO-0"><font size="2"><font color="#002bb8"><span>[</span>1<span>]</span></font></font></a></sup> It is more common in men and in developing countries.<sup id="cite_ref-Parkin_14-1" class="reference"><a href="#cite_note-Parkin-14"><font size="2"><font color="#002bb8"><span>[</span>15<span>]</span></font></font></a></sup><sup id="cite_ref-WHO-QA15_15-0" class="reference"><a href="#cite_note-WHO-QA15-15"><font size="2"><font color="#002bb8"><span>[</span>16<span>]</span></font></font></a></sup></p>
<p>It represents roughly 2% (25,500 cases) of all new cancer cases yearly in the United States, but it is more common in other countries. It is the leading cancer type in Korea, with 20.8% of malignant neoplasms.</p>
<p><a title="Metastasis" href="/wiki/Metastasis"><font color="#002bb8">Metastasis</font></a> occurs in 80-90% of individuals with stomach cancer, with a six month survival rate of 65% in those diagnosed in early stages and less than 15% of those diagnosed in late stages.</p>
<p>One in a million people under the age of 55 seeking medical attention for indigestion have stomach cancer <sup id="cite_ref-16" class="reference"><a href="#cite_note-16"><font size="2"><font color="#002bb8"><span>[</span>17<span>]</span></font></font></a></sup> and one in fifty of all ages seeking medical attention for burping and indigestion have stomach cancer.<sup id="cite_ref-17" class="reference"><a href="#cite_note-17"><font size="2"><font color="#002bb8"><span>[</span>18<span>]</span></font></font></a></sup> Out of 10 million people in the Czech Republic, only 3 new cases of stomach cancer in people under thirty years of age in 1999 were diagnosed.<sup id="cite_ref-18" class="reference"><a href="#cite_note-18"><font size="2"><font color="#002bb8"><span>[</span>19<span>]</span></font></font></a></sup> Other studies show that less than 5% of stomach cancers occur in people under 40 years of age with 81.1% of that 5% in the age-group of 30 to 39 and 18.9% in the age-group of 20 to 29.<sup id="cite_ref-19" class="reference"><a href="#cite_note-19"><font size="2"><font color="#002bb8"><span>[</span>20<span>]</span></font></font></a></sup></p>
<h2><span id="References" class="mw-headline">References</span></h2>
<div style="-moz-column-count: 2; column-count: 2" class="references-small references-column-count references-column-count-2">
<ol class="references">
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<li id="cite_note-17"><strong><a href="#cite_ref-17"><font color="#002bb8">^</font></a></strong> <span class="citation web"><a class="external text" href="http://www.cancerhelp.org.uk/help/default.asp?page=3897" rel="nofollow"><font color="#3366bb">"Stomach cancer symptoms: Cancer Research UK"</font></a>. CancerHelp UK. 2007-06-15<span class="printonly">. <a class="external free" href="http://www.cancerhelp.org.uk/help/default.asp?page=3897" rel="nofollow"><font color="#3366bb">http://www.cancerhelp.org.uk/help/default.asp?page=3897</font></a></span><span class="reference-accessdate">. Retrieved 2009-05-11</span>.</span><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=bookitem&rft.btitle=Stomach+cancer+symptoms%3A+Cancer+Research+UK&rft.atitle=&rft.date=2007-06-15&rft.pub=CancerHelp+UK&rft_id=http%3A%2F%2Fwww.cancerhelp.org.uk%2Fhelp%2Fdefault.asp%3Fpage%3D3897&rfr_id=info:sid/en.wikipedia.org:Stomach_cancer"><span style="DISPLAY: none"> </span></span> </li>
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<li id="cite_note-19"><strong><a href="#cite_ref-19"><font color="#002bb8">^</font></a></strong> <span class="citation web"><a class="external text" href="http://www.inca.gov.br/rbc/n_46/v03/english/article6.html" rel="nofollow"><font color="#3366bb">"Gastric Cancer in Young Adults"</font></a>. <em>Revista Brasileira de Cancerologia - Volume 46 n°3 Jul/Ago/Set 2000</em>. Inca.gov.br. 2000<span class="printonly">. <a class="external free" href="http://www.inca.gov.br/rbc/n_46/v03/english/article6.html" rel="nofollow"><font color="#3366bb">http://www.inca.gov.br/rbc/n_46/v03/english/article6.html</font></a></span><span class="reference-accessdate">. Retrieved 2009-05-11</span>.</span><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=bookitem&rft.btitle=Gastric+Cancer+in+Young+Adults&rft.atitle=Revista+Brasileira+de+Cancerologia+-+Volume+46+n%C2%B03+Jul%2FAgo%2FSet+2000&rft.date=2000&rft.pub=Inca.gov.br&rft_id=http%3A%2F%2Fwww.inca.gov.br%2Frbc%2Fn_46%2Fv03%2Fenglish%2Farticle6.html&rfr_id=info:sid/en.wikipedia.org:Stomach_cancer"><span style="DISPLAY: none"> </span></span> </li>
</ol>
</div>
<h2><span id="External_links" class="mw-headline">External links</span></h2>
<ul>
<li><a title="National Cancer Institute" href="/wiki/National_Cancer_Institute"><font color="#002bb8">National Cancer Institute</font></a> <a class="external text" href="http://www.cancer.gov/cancertopics/pdq/treatment/gastric/HealthProfessional/page1" rel="nofollow"><font color="#3366bb">Gastric cancer treatment guidelines</font></a> </li>
<li><a class="external text" href="http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=gene&part=hgc" rel="nofollow"><font color="#3366bb">GeneReview/NIH/UW entry on Hereditary Diffuse Gastric Cancer</font></a> </li>
<li><a class="external text" href="http://www.nostomachforcancer.org" rel="nofollow"><font color="#3366bb">No Stomach For Cancer | Be Strong Hearted</font></a> is a source of information and support for Hereditary Diffuse Gastric Cancer and carriers of the CDH1 gene mutation and their families/friends. </li>
<li><span class="citation web"><a class="external text" href="http://web.tiscali.it/iodio/" rel="nofollow"><font color="#3366bb">"Stomach Cancer. In: Iodine Deficiency: studies by dr. Sebastiano Venturi (Italy)"</font></a><span class="printonly">. <a class="external free" href="http://web.tiscali.it/iodio/" rel="nofollow"><font color="#3366bb">http://web.tiscali.it/iodio/</font></a></span><span class="reference-accessdate">. Retrieved 2008-05-15</span>.</span><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Abook&rft.genre=bookitem&rft.btitle=Stomach+Cancer.+In%3A+Iodine+Deficiency%3A+studies+by+dr.+Sebastiano+Venturi+%28Italy%29&rft.atitle=&rft_id=http%3A%2F%2Fweb.tiscali.it%2Fiodio%2F&rfr_id=info:sid/en.wikipedia.org:Stomach_cancer"><span style="DISPLAY: none"> </span></span> </li>
</ul>
