“Victor Babe

“Victor Babe?” UNIVERSITY OF MEDICINE
AND PHARMACY TIMI?OARA

FACULTY OF MEDICINE
Department of Internal Medicine II
Discipline of Gastroenterology

VALESCA KIRCHHOFF

LICENCE THESIS

Scientific Coordinator
Assist. Prof. BOGDAN MIU?ESCU

T i m i ? o a r a
2 0 1 8
“Victor Babe?” UNIVERSITY OF MEDICINE
AND PHARMACY TIMI?OARA

FACULTY OF MEDICINE
Department of Internal Medicine II
Discipline of Gastroenterology

VALESCA KIRCHHOFF

LICENCE THESIS
RESULTS OF GASTRIC CANCER EVALUATION IN A TERTIARY GASTROENTEROLOGICAL CARE CENTER

Scientific Coordinator
Assist. Prof. BOGDAN MIU?ESCU

T i m i ? o a r a
2 0 1 8

Table of Content
LIST OF ABBREVIATIONS 3
PART I. INTRODUCTION 4
PART II REVIEW OF THE LITERATURE 5
1. Definition 5
2. Epidemiology 5
3. Aetiology 5
3.1 Exogenous risk factors 5
3.2 Endogenous risk factors 5
4. Diagnosis 7
4.1 Premalignant conditions 7
4.2 Types of gastric cancer 7
4.3 Clinical symptoms 9
4.4 Paraclinical examinations 10
4.5 Staging 10
5. Treatment 14
PART II: PERSONAL CONTRIBUTIONS 16
1. Introduction 16
2. Material and Method 16
3. Results 17
4. Discussion 31
5. Conclusion 33
ACKNOWLEDGEMENTS 34
REFERENCES 35
Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J, et al.Cancer incidence and mortality patterns in Europe: Estimates for 40 countries in 2012. European Journal of Cancer (2013) 49, 1374-1403. 35

LIST OF ABBREVIATIONS

CT Computer Tomography
EGJ Oesophageal-gastric Junction
ESMO European Society of Medical Oncology
EUS Endoscopic Ultrasound
GI Gastrointestinal
HER2 Human Epidermal Growth Factor Receptor 2
HP Helicobacter Pylori
IM Intestinal Metaplasia
JGCA Japanese Gastric Cancer Association
M Mucosa
MP Muscularis Propria
OR Odds Ratio
pH Power of Hydrogen
PPI Proton Pump Inhibitor
SE Beyond Serosa
SI Invading adjacent structures
SM Submucosa
SS Subserosa
WHO World Health Organisation

PART I. INTRODUCTION
The term cancer describes a group of diseases characterized by their uncontrolled division of abnormal cells as well as their ability to invade and spread to other tissues .
The WHO (World Health Organisation) refers to cancer as the second leading cause of mortality worldwide with a number of 8.8 million deceased in 2015. 14.1 million cases of cancer were newly diagnosed in the year of 2012.
In the WHO cancer statistics of 2017 gastric cancer is named among the 5 deadliest malignancies, being responsible for the fourth highest number of cancer related deaths worldwide . In 2012 8.2 million deaths as a consequence of cancer where accounted, 46% of these due to common cancers – malignancies of lung, liver, stomach and bowel .
Problematic of diagnosis in advanced stages; rarely early symptoms
Comparison to development in Japan with screening program;
Importance of topic due to high mortality;
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PART II REVIEW OF THE LITERATURE
1. DEFINITION
Gastric cancer describes a malignant tumour deriving from the epithelium of the stomach .
2. Epidemiology
The incidence in Romania in the year 2012 was 15.1/100 000, with a significantly higher value in men 23.7/100 000 in comparison to 8.5/100 000 in women . Therefore it ranks as the seventh most common form of a malignant neoplasia in Romania. In the countries of the European Union it accounts for 10.7 cases of gastric cancer per 100 000 inhabitants, with a male incidence of 15.2/100 000 and a female incidence of 7.1/100 000 . According to the WHO gastric cancer is accountable for the fourth highest number of cancer deaths worldwide in the year 2015, ranking after lung cancer, hepatic cancer and colorectal cancer 1.
3. Aetiology
3.1 Exogenous risk factors
As in many forms of malignant neoplasia wide spread health risks our modern society is dealing with impact the probability to develop gastric cancer. Among others these include alcohol and tobacco consumption. Adiposity owns a special validity regarding cancers of the oesophageal-gastric junction , .
Furthermore an alimentation rich in nitrate has been proven to be of significant impact .
Following a diet low in fresh fruits and vegetables favours the appearance of a stomach malignancy. A study conducted on 521 457 men and women originating from 10 different European countries concludes in an increased meat consumption being an important risk factor especially in combination with a simultaneous HP infection .
3.2 Endogenous risk factors
One of the essential risk factor for gastric cancer is a chronic Helicobacter Pylori (HP) infection. Even before Marshall and Warren discovered Helicobacter Pylori in the 1980s a connection between chronic gastritis and gastric cancer incidence was seen . The association between HP infection and chronic atrophic gastritis increases the risk of developing gastric cancer, particularly of the malignancy being located in the gastric antrum, body or fundus . Even though Prinz et al. presented the prevalence rates as declining in Western countries, HP infection remains the strongest risk factor for gastric cancer .
Proton pump inhibitors (PPI) are part of HP infection treatment and often used long-term. According to a study conducted by Cheung et al. on 63 397 patients an association between the persistent use of PPIs and risk of gastric cancer development has been proven .
A previously performed gastric operative intervention is counted as a risk factor for gastric cancer based on the its´ influence on the stomachs´ pH which may result in dysplastic and metaplastic changes . The development of gastric cancer may also take place after a partial gastrectomy in the remnant body of the stomach or on the ground of a benign gastric ulcer , . Especially the formerly common performed ulcer surgery resulted in an incidence rise.
Furthermore some genetic disorders seem to be in cumulative relation to gastric cancer cases. These include:
Familial adenomatous polyposis
Peutz-Jeghers syndrome
Li-Fraumeni syndrome
Hereditary non-polypous colorectal cancer
Neurofibromatosis type 1 (Morbus Recklinghausen)
Cowden syndrome 13
A family history with affection of a first degree relative by gastric cancer also raises the risk of developing this pathology. In 2010 a meta-analysis was published showing the increase of the odds-ratio of 1,98 (95% CI, 1,36-2,88) in case of a first-degree relative with gastric cancer in the family history , .
Patients with blood type A appear to have a higher risk to develop gastric cancer .
Other affections going along with gastric cancer are chronic atrophic autoimmune gastritis (type A), adenomatous gastric polyps and Ménétrier´s disease. Latter is a rare form of idiopathic hypertrophic gastropathy.
4. Diagnosis
4.1 Premalignant conditions
Metaplasia is defined as the reversible transformation of a differentiated tissue to another differentiated tissue, especially in the context of regeneration as a result of chronic irritation by inflammatory, chemical or mechanical factors 2. In case of intestinal metaplasia (IM) this signifies “the loss of gastric epithelium and replacement with an intestinal phenotype containing goblet cells, Paneth cells and absorptive cells” 14.
Intestinal metaplasia is a known premalignant condition exposing the patient to risk up to 6-fold higher than average to develop gastric cancer 14. This causality is based on the fact of IM being the groundwork for dysplasia and finally the progression to an adenocarcinoma as it has been described by Correa in 1988 14, , whereat the intermediate step of dysplasia is defined as pre-neoplastic cellular atypia of different severity in connection with a disturbed epithelial structure 2.
The progression of IM to gastric cancer has been investigated by at least 2 separate studies, one in Japan following up on 1246 patients with gastric IM for a average period of 7,8 years leading to a relative risk of progression of 6,4 (95% CI, 2,6-16,1) 14, . In the Western world a large study has been performed by a Dutch team coming to a conclusion of a 10 year incidence of 1,8% after investigating 61 707 patients of whom 874 developed gastric cancer 14, .
4.2 Types of gastric cancer
Histologically gastric cancer is subclassified in 5 categories:
Adenocarcinoma
Gastrointestinal stromal tumors
Carcinoids
Adenoacanthomas
Squamous cell carcinomas
Regardless of this categorization gastric cancer specimens may also be grouped by their gross appearance as being ulcerative, polypoid, scirrhous, superficially spreading, multicentric or Barret ectopic adenocarcinomas .
Out of the previously mentioned types the adenocarcinoma is the most prevalent form presenting 90 to 95% of malignancies developing in the stomach. According to their histological description they are further subcategorized into tubular, papillary, mucinous and signet-ring cell carcinomas 1.
Complementary gastric malignancies may be classified according to the 1965 established Laurén classification. Its’ division into an intestinal, diffuse and later added indeterminate type enables us to conclude clinically relevant information; nonetheless its’ prognostic value is still controversial . German S3 Guidelines e. g. refers to the Laurén classification when recommending different resection margins for the intestinal and diffuse type 8.
The intestinal type is associated with chronic atrophic gastritis, limited invasiveness and a clearly defined margin, pathologically classified as epidemic and maintaining a glandular structure. A strong relation to environmental risk factors – as HP infection – has been shown as well as the absence of a family history of gastric cancer 25.
On the other hand the diffuse, infiltrative, endemic type defines itself by poorly differentiated scattered cell clusters with deceitful difficultly definable margins. Studies show a higher incidence in younger patients and women with less influence of environmental factors and a greater significance of genetic factors and family history 25, 26.
The review of Berlth et al takes these different epidemiologic and risk factor relationships as an indicator there might be different developmental pathways for gastric intestinal and diffuse adenocarcinomas 26.
Laurén classification WHO classification
Intestinal type Papillary adenocarcinoma
Tubular adenocarcinoma
Mucinous adenocarcinoma
Diffuse type Signet-ring cell carcinoma and other poorly cohesive carcinomas
Indeterminate type Mixed carcinoma
Adenosquamous carcinoma
Squamous cell carcinoma
Hepatoid carcinoma
Carcinoma with lymphoid stroma
Choriocarcinoma
Carcinosarcoma
Parietal cell carcinoma
Malignant rhabdoid tumor
Mucoepidermoid carcinoma
Paneth cell carcinoma
Undifferentiated carcinoma
Mixed adeno-neuroendocrine carcinoma
Endodermal sinus tumor
Embryonal carcinoma
Pure yolk sac carcinoma
Oncocytic adenocarcinoma
Table 6 Laurén classification 26
4.3 Clinical symptoms
Unfortunately gastric cancer rarely leads to early symptoms and even if it does these are difficult to interpret accordingly do to their highly unspecialized character.
Patients later diagnosed with gastric cancer are often hospitalized complaining about loss of appetite, progressive weight loss occurring over a longer period of time and fatigue, all of which are highly unspecific symptoms.
Besides the previously mentioned symptoms abdominal pain especially epigastrically localized, dysphagia, dyspepsia, upper GI (gastrointestinal) bleeding and anaemia are indicators for the need of further evaluation.
Depending on the localization of the “growth” and its´ extension it may impact other organs resulting in diffuse or localized pain, as well as an aversion to certain food or food in general due to a partial, total or mixed dysphagia in relation with a site of proliferation near the EGJ (esophagogastric junction).
In case of a stomach lesion causing bleeding the patient presents himself with hematemesis, melena, anaemia or a combination of these symptoms depending on the localization and quantity of blood loss.
These clinical symptoms have been proven to be relevant in the prognosis of gastric cancer survival. In a study by Stephens the link between the presence of “alarm symptoms” and the stage of the tumour has been shown. Stating that the patients with the most alarm symptoms at presentation where also the ones diagnosed with the most advanced stages of the disease. In the cited article the expression “alarm symptoms” describes the conglomerate of weight loss, dysphagia, signs and symptoms of upper GI bleeding, anaemia and persistent vomiting .
4.4 Paraclinical examinations
Apart from the obligatory clinical examination of the patient technology gives us the chance to evaluate a suspected gastric cancer with the help of more or less invasive methods.
Gold Standard in the evaluation of gastric and oesophageal cancer is the endoscopy of the upper GI tract. Gastroscopy enables us to evaluate the whole oesophagus and stomach visually, localize suspicious lesions as well as to take biopsies for histopathological investigations whereby only a very low case fatality rate must be accepted 8. Another benefit is its´ high diagnostic accuracy of 95% 25, as well as its´ ability to attend to eventual bleedings.
Complementary to esophagogastroduodenoscopy endoscopic ultrasound (EUS) can be used. The role of EUS lies in its´ ability to assess the depth of invasion of the neoplasia. Problematic is its´ limitation by the capability and experience of the operator and its´ overall accuracy of 46,2% for T classification and 66,7% for N classification in a large multi-institutional study regarding the use and accuracy of EUS in patients undergoing resections of gastric adenocarcinoma with a curative intention , . Despite its´ limitations EUS is a useful tool regarding staging if its´ results are interpreted in combination with other paraclinical examinations.
In case of severe restrictions of endoscopy due to the oesophagus or a part of the stomach being obstructed and circumvent the passage of the endoscope the possibility remains to obtain information by Barium swallow or double contrast upper GI series. Due to their accuracy of 75% their value in optimal conditions of evaluations is limited 25.
CT and MRI studies of the chest, abdomen and pelvis are necessary for the assessment of local disease as well as potential metastasis and invaded lymph nodes 1.
Radiographies of the chest are also commonly performed in order to determine the presence of metastasis.
4.5 Staging
Staging describes the specific extent of a malignant neoplasia by clinical examination or operative exploration, enabling physicians to informed decision making regarding treatment planning and providing prognostic data. 4,
4.5.1 TNM classification
The aim of the TNM classification of malignant tumours is to describe the anatomical extension of a solid neoplasia in a universally accepted way. This is obtained by the use of 3 parameters – T describing the size of the original tumour and its´ eventual invasion of nearby situated structures, N describing the affection of regional lymph nodes and M the presence of distant metastasis .
Primary Tumour (T)
TX Primary tumour cannot be assessed
T0 No evidence of primary tumour
Tis Carcinoma in situ: intraepithelial tumour without invasion of the lamina propria
T1 Tumour invades lamina propria, muscularis mucosae, or submucosa
T1a Tumour invades lamina propria or muscularis mucosae
T1b Tumour invades submucosa
T2 Tumour invades muscularis propria
T3 Tumour penetrates subserosal connective tissue without invasion of visceral peritoneum or adjacent structures
T4 Tumour invades serosa (visceral peritoneum) or adjacent structures
T4a Tumour invades serosa (visceral peritoneum)
T4b Tumour invades adjacent structures

Regional lymph nodes (N)
NX Regional lymph node(s) cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in 1-2 regional lymph nodes
N2 Metastasis in 3-6 regional lymph nodes
N3 Metastasis in seven or more regional lymph nodes
N3a Metastasis in 7-15 regional lymph nodes
N3b Metastasis in 16 or more regional lymph nodes

Distant metastasis (M)
M0 No distant metastasis
M1 Distant metastasis
Table 1 TNM classfication 25
Stage T N M
0 Tis N0 M0 IIIA T4a N1 M0
IA T1 N0 M0 T3 N2 M0
IB T2 N0 M0 T2 N3 M0
T1 N1 M0 IIIB T4b N0 M0
IIA T3 N0 M0 T4b N1 M0
T2 N1 M0 T4a N2 M0
T1 N2 M0 T3 N3 M0
IIB T4a N0 M0 IIIC T4b N2 M0
T3 N1 M0 T4b N3 M0
T2 N2 M0 T4a N3 M0
T1 N3 M0 IV Any T Any N M1
Table 2 Anatomic stage/ prognostic groups of the TNM classification 25
4.5.2 Japanese classification
In comparison to the previously mentioned TNM classification, the Japanese Gastric Cancer Association has a slightly different approach to staging. Even though the clinical examination also acts as the foundation of staging it focusses on a much more detailed description of the tumour. In order to achieve this, imaging studies, endoscopic, laparoscopic and surgical findings, biopsies, cytology and biological investigations are consulted. Among the differences lies the subclassfication according to macroscopic tumour morphology in superficial (T1) and advanced (T2-T4) types, as well as the categorization of lymph nodes in 33 stations. The group of the first 12 lymph nodes and 14v are denominated are regional gastric lymph nodes, the involvement of any of the other LN is counted as metastases 30.
Macroscopic types of advanced gastric cancer
Type 0 (superficial) Typical of T1 tumours.
Type I (mass) Polypoid tumours, sharply demarcated from the surrounding mucosa.
Type II (ulcerative) Ulcerated tumours with raised margins surrounded by a thickened gastric wall with clear margins.
Type III (infiltrative ulcerative) Ulcerated tumours with raised margins, surrounded by a thickened gastric wall without clear margins.
Type IV (diffuse infiltrative) Tumours without marked ulceration or raised margins, the gastric wall is thickened and indurated and the margin is unclear.
Type V (unclassifiable) Tumours that cannot be classified into any of the above types
Table 3 Macroscopic types of advanced gastric cancer according to Japanese classification 30

Figure 1Subclassification of type 0 30
Depth of tumour invasion (T)
TX Depth of tumour unknown
T0 No evidence of primary tumour
T1 Tumour confined to the mucosa (M) or submucosa (SM)
T1a Tumour confined to the mucosa
T1b Tumour confined to the submucosa
T2 Tumour invades the muscularis propria (MP)
T3 Tumour invades the subserosa (SS)
T4 Tumour invasion is contiguous to or exposed beyond the serosa(SE) or tumor invades adjacent structures (SI)
T4a Tumour invasion is contiguous to the serosa or penetrates the serosa and is exposed to the peritoneal cavity (SE)
T4b Tumour invades adjacent structures

Lymph node metastasis (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in 1–2 regional lymph nodes
N2 Metastasis in 3–6 regional lymph nodes
N3 Metastasis in 7 or more regional lymph nodes
N3a Metastasis in 7–15 regional lymph nodes

Distant metastasis (M)
MX Distant metastasis status unknown
M0 No distant metastasis
M1 Distant metastasis
Table 4 Japanese classification 30

N0 N1 N2 N3
T1a (M), T1b (SM) IA IB IIA IIB
T2 (MP) IB IIA IIB IIIA
T3 (SS) IIA IIB IIIA IIIB
T4a (SE) IIB IIIA IIIB IIIC
T4b (SI) IIIB IIIB IIIC IIIC
M1 (any T, any N) IV
Table 5 Stage grouping according to Japanese classification 30

5. Treatment
Depending on the preoperative stage, general state of the patient, paraclinical and clinical results a multidisciplinary team decides about the most appropriate treatment strategy. In the optimal case this team is composed of gastroenterologists, surgeons, oncologists and pathologists discussing the specific case and coming to a joint conclusion.
Gold standard in a case with curative intention is a surgical approach consisting of a total or subtotal gastrectomy and a systemic lymphadenectomy 17. The relationship between the extent of lymph node dissection and improved survival rates has been evaluated by several studies with different results in Asian and Western countries. The European Society of Medical Oncology recommends medically fit patients to undergo D2 resection in high-volume surgical centres. LN group D1 is defined as perigastric LN, the D2 group as perigastric LN as well as the ones along the left gastric, common hepatic and splenic arteries as well as the coeliac axis .
In case of an early gastric cancer (T1a) the European Society of Gastrointestinal Endoscopy guideline recommends endoscopic submucosal dissection as the treatment of choice. Therefor the following criteria have to be met:
Clearly confined to mucosa
Well defined
? 2cm
Non-ulcerated 32
As a matter of principal chemosensibility of gastric malignancies perioperative (pre- and postoperative) chemotherapy is recommended by the ESMO guideline, as well as postoperative chemoradiotherapy and adjuvant chemotherapy. On the other hand due to studies still being ongoing, recommendations regarding intraoperative radiotherapy and intraperitoneal chemotherapy are not indicated 17. Polychemotherapies show a remission rate between 30 and 50% with median remission duration of 6 to 9 months.
In case of palliative treatment of a patient in good general state, systemic chemotherapy aims for enhanced survival and preservation of quality of life. Furthermore it is important to test the tumour tissue in advanced cases of gastric cancer for HER2 receptors. A positive result stipulates the treatment with Trastuzumab in combination with a polychemotherapy 32.
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PART II: PERSONAL CONTRIBUTIONS
1. Introduction
Gastric cancer is one of the malignancies not commonly presenting early symptoms. This among other factors leads to patients being diagnosed in advanced stages, diminishing their chances of a curative treatment. The study performed with the aim of analysing data of gastric cancer patients admitted to the gastroenterological department of “Pius Brînzeu” county hospital Timi?oara, Romania, a tertiary care centre, provides structured insight in all those cases. According to Pschyrembel medical dictionary being a tertiary referral centre is defined as offering highly specialized medical care and complex diagnostic capabilities for patients referred from primary or secondary care . Taking into consideration the general problem of late establishment of gastric cancer diagnosis the obtained information might be used to train the eye of medical professionals in primary and secondary care centres with the aim of facilitating an earlier referral.
2. Material and Method
In the framework of this license thesis all patients with a biopsy result positive for gastric cancer admitted to the gastroenterological department of “Pius Brînzeu” county hospital Timi?oara, Romania, in the time between January 2016 and October 2017 were studied.
The medical charts of the patients were reviewed and demographic variables as well as specific risk factors, patient medical history, results of clinical, paraclinical examinations and subsequent treatment recommendations were extracted and collected in a database.
The study includes 43 patients diagnosed with gastric cancer by biopsy in the time between January 2016 and October 2017 in the gastroenterological department of “Pius Brînzeu” county hospital, Timi?oara.
On the basis of the following inclusion criteria the selection of the patients was performed:
Biopsy result positive for gastric cancer
First admission with given diagnosis in the time interval of January 2016 and October 2017
The statistical analysis including all tables and diagrams was conducted using Microsoft Excel and Microsoft Word.
3. Results
If not stated otherwise the following results given in percentages are referred to the studied population as a whole (100% = 43 patients).
The studied group of 43 patients diagnosed with gastric cancer is composed by 24 males (55,81%) and 19 females (44,19%).

Figure 2 Gender distribution
The age of the patients at admission to the hospital ranges between 47 and 80 years with a median of 64 years. The distribution of age has the highest incidence of gastric cancer cases in the age group 61-65 with 25,58% (11), followed by the age group 66-70 with 18,60% (8) and 76-80 years with 16,28% (7). The age groups 56-60 and 71-75 account for 11,63% (5) of the gastric cancer cases each. 9,30% (4) of the cases can be allocated to the age group 45-50 and 6,98% (3) to the range between 51-55 years.

Figure 3 Age distribution
The 43 studied patients were hospitalized for a period between 1 and 24 days after their admission with a median of 3 days. The more than half of the patients (53,49% (23)) were hospitalized for 3 days or less. 30,23% (13) left the hospital after 4-7days and 16,28% (6) of patients were discharged after more than a week.

Figure 4 Distribution of days of hospitalization
As mentioned in the general part several risk factors are related to the likelihood of developing gastric cancer. The risk factor with the most widespread distribution in the evaluated population is male gender with 55,81% (24), followed by the presence of a gastric ulcer with 30,23% (13). Risk factors in relationship with (an unhealthy) lifestyle can be found in the form of alcohol consumption in 25,58% (11), smoking in 23,25% (10) and a BMI>25 in 20,93% (9). Local risk factors apart from gastric ulcers are intestinal metaplasia and atrophic gastritis with 18,6% (8) each and reflux esophagitis with 6,98% (3). Apart from that 9,3% (4) have blood type A, 2,32% (1) present pernicious anaemia and 2,32% (1) showcase a positive family history.

Figure 5 Distribution of risk factors
Of the 43 patients presenting gastric cancer 19 could be analysed regarding their Body Mass Index. The BMI was calculated using the formula BMI=(weight (in kg))/?height (in meter)?^2 . In the following section the percentages refer to 19 patients=100%. With normal weight being defined by the WHO as having an BMI between 18,5 and 24,9 kg/m2 47,37% (9) can be categorized in this group. 21,05% (4) presented as pre-obese with a BMI between 25 and 29,9 kg/m2. Grade I obesity (BMI 30,0-34,9 kg/m2) accounts for 15,79% (3) and grade II obesity (BMI 35,0-39,9 kg/m2) for 10,53% (2). The smallest percentage presents the group of underweight (BMI 25 kg/m2).

Figure 6 BMI distribution
A variety of symptoms were described by the patients at admission and led to their hospitalization. The symptom with the widest distribution at admission among the studied cases was secondary anaemia in 58,14% (25), followed by abdominal pain with a prevalence of 51,16% (22).
Of the 22 patients describing abdominal pain (22=100%), 12 (54,55%) specified it as localized in the epigastric region, 5 (22,73%) as having a diffuse character and 1 (4,55%) as flank pain.

Figure 7 Distribution of abdominal pain localization
39,53% (17) complained about unintentional weight loss in the months previous to admission. 32,56% (14) were hospitalized with the objective of re-evaluating a suspicious ambulant ultrasound or endoscopy result. Fatigue and dysphagia were symptoms present in 23,25% (10) each. The latter being described in 10 cases of which 50% (5) were a dysphagia for solids, 30% (3) mixed dysphagia and 20% (2) were not further specified.

Figure 8 Distribution of dysphagia
20,98% (9) stated nausea and emesis as a symptom, also documented in 20,98% (9) of cases was asthenia. 16,28% (7) were diagnosed with upper GI bleeding. Another 16,28% (7) complained about loss of appetite. 6,98% (3) stated pyrosis and 2,32% (1) each cachexia, difficulties of gastric evacuation and absent intestinal transit.

Figure 9Distribution of symptoms and reason of admission
39,53% (17) of the evaluated population presented the cancer at the oesophageal-gastric junction, in 20,93% (9) in the antrum of the stomach, in 18,6% (8) the affected part of the stomach was not further specified or overlapped several areas. In 9,3% (4) the cancer was situated at each gastric curvature and in 2,32% (1) at the gastric angle.

Figure 10 Distribution of gastric cancer localization
The biopsy results giving the positive gastric cancer diagnosis also provided further information about the histological type. With 69,77% (30) adenocarcinomas account for the majority of gastric cancers in the evaluated population. As stated in the general part the adenocarcinomas are being composed of different subtypes. Out of the 30 adenocarcinomas (30=100%), 30% (9) are tubular adenocarcinomas, 20% (6) are signet ring cell carcinomas, 10% (3) tubulo-papillary adenocarcinomas, 3,33% (1) mucus secreting adenocarcinomas, 36,67% (11) were poorly differentiated and 37,53% (9) were not further specified.

Figure 11Distribution of adenocarcinoma subtypes
Mixed carcinomas constitute the second largest histological group with 11,63% (5), followed by epidermoid carcinomas with 4,65% (2) and 2,32% (1) neuroendocrine carcinomas. In 11,63% (5) of the population the type of gastric carcinoma was not further specified in the histological report.

Figure 12Distribution of types of gastric cancer
In all of the cases some kind of further investigations were performed in order to achieve a more comprehensive view of each case.
In 32 of the cases an ultrasound was performed (100%=32), leading to the following results: 43,75% (14) of the population presented with metastases. In 34,37% (11) the US revealed a thickening of the gastric wall. 28,12% (9) demonstrated ascites, 15,62% (5) demonstrated adenopathies and in 6,25% (2) the visualization of a formation within the stomach was possible.

Figure 13 Distribution of ultrasound results
In 41 cases a gastroscopy was performed showcasing a proliferation within the stomach in 80,95% (34). A gastric ulceration was visualised in 61,90% (26), in 26,19% (11) bleeding was observed during the procedure, 23,81% (10) presented a stenosis of the stomach, 9,52% (4) showcased an infiltration of gastric wall.

Figure 14 Distribution of gastroscopy results
In 20 cases out of the total 43 a computer tomography was performed showcasing adenopathies in 85% (17). A thickened gastric wall was found in 70% (14). In 40% (8) metastasis were found in the CT scan and 15% (3) presented an either internal or external stenosis of the stomach.

Figure 15 Distribution of CT results
The adenopathies found in the previously described investigations can be categorized into regionally affected lymph nodes, including perigastric and perilesional lymph nodes, in 30,23% (13) of the evaluated population. Retropertioneal lymph nodes were enlarged in 23,26% (10) being defined as retropancreatic, pricoeliac, periaortic lymph nodes as well as those in proximity to the internal iliac artery. 13,95% (6) of the cases, presented with thoracic adenopathies being found in the locations of the aortopulmonary window, Loja Barety, the lung hilum and peritracheal. Another 13,95% (6) adenopathies´ can be categorized as intraperitoneal lymph nodes, including perihepatic, interaortocaval lymph nodes and lymph nodes in the splenic hilum. 2,32% of the population presented supraclavicular adenopathy.

Figure 16 Distribution of adenopathies
Out of the total 43 cases of the population, 20 (46,51%) were diagnosed with metastases. 32,56% (14) of the population presented liver metastases, making those the most widespread type of metastases. Metastases of the peritoneum and carcinomatous ascites each account for 6,98% (3) and pulmonary metastases for 4,65% (2).

Figure 17Distribution of metastases
By discharge 41,86% (18) received the recommendation to consult an oncologist for their subsequent treatment, 18,60% (8) were referred to a surgeon in order to evaluate a probable indication for surgery. In 13,95% (6) the patient was advised to present himself to regular follow-ups at the gastroenterological department. In 25,58% of the cases the subsequent treatment recommendation was not further specified.

Figure 18 Distribution of subsequent treatment recommendation
In the following part some of the parameters will be evaluated in relation to one another, starting with the distribution of histological types in relation to gender. The 30 cases of adenocarcinoma are composed of 16 male and 14 female patients. The mixed form of carcinomas consists of 2 male and 3 female patients, adding up to a total of 5 cases. With just 2 cases in epidermoid carcinomas the male-female ratio is 1:1. The evaluated population included 1 case of neuroendocrine carcinoma of male gender and 5 cases not further specified histologically with a male-female ratio of 4:1.

Figure 19 Distribution of histological type in relation to gender
Evaluating the age and gender distribution in adenocarcinomas we can observe the highest incidence in the age group 61-65 years with a total number of 7 cases and a male-female ratio of 4:3. The age group 66-70 years shows the second highest deflections with a male to female ratio of 2:1 and 6 cases. The age group 71-75 years with a male to female ratio of 3:2 ranges on third place together with the cases in age group 56-60 years with a male to female ratio of 2:3. As second to last identifies the youngest age group with a male to female ratio of 1:1. The age group with the lowest incidence is 51-55 years with 1 male case.

Figure 20 Distribution of age and gender in adenocarcinomas
Looking at the distribution of the histological type in relation to age we can observe that again the age group 61-65 years accounts for the highest incidence with 7 adenocarcinomas, 1 mixed carcinoma, 1 neuroendocrine carcinoma and 2 histologically unaccounted cases, resulting in a total of 11 cases. The age group 66-70 years follows with an incidence of 8 cases (6 adenocarcinomas, 1 mixed carcinoma and 1 epidermoid carcinoma). 7 cases (4 adenocarcinomas, 1 mixed carcinoma, 1 epidermoid carcinoma and 1 histologically unaccounted case) configure the age group of 76-80 years. The age groups 71-75 and 56-60 years each comprise 5 adenocarcinomas. The age group of 45-50 is constituted of 4 patients, 2 diagnosed with adenocarcinomas and 2 with mixed carcinomas. The lowest incidence of gastric cancer cases can be observed in the age group of 51-55 years with 1 adenocarcinoma and 2 histologically unaccounted cases.

Figure 21 Distribution of histological type in relation to age
Evaluating the relation between histological type of gastric cancer and metastasis we observe a ratio of 1,1:1 in adenocarcinomas in favour of those without metastases. The mixed carcinomas constitute of 1 case without metastases and 4 with metastases. Histologically unaccounted cancers are composed by 4 cases without and 1 case with metastases. A 1:1 ratio is found in epidermoid carcinomas and neuroendocrine carcinomas constitute just out of 1 case without metastases.

Figure 22 Distribution of histological type in relation to metastases
Setting subsequent treatment in relation to gender the following results are obtained. An oncological consult or a subsequent oncological treatment being the most frequent recommended treatment has a 5:4 male to female ratio, followed by the surgical consult with a 5 to 3 ratio in favor for the male gender. A gastroenterological follow-up lies on third place of the treatment recommendations with a male-female ratio of 2:1. In 11 cases the patients were discharged without a specified subsequent treatment suggestion (5 male and 6 female).

Figure 23 Distribution of subsequent treatment in relation to gender
Assessing the suggestions of subsequent treatment in relation to the histological type of cancer we can observe in adenocarcinomas 46,67% (14) of the patients were recommended an oncological consult or subsequent oncological treatment. 20% (6) were referred to a surgeon for a consult, 3,33% (1) were advised a gastroenterological follow-up and in 30% (7) no recommendation was made. Out of the 5 cases of mixed gastric cancers 40% (2) were referred to an oncologist, 40% (2) were advised a gastroenterological follow-up and 20% (1) were suggested a surgical consult. 50% (1) of the patients diagnosed with epidermoid carcinoma received the recommendation to see an oncologist for their subsequent treatment. The other half did not receive a specified suggestion, just like the case with a neuroendocrine carcinoma diagnosis (1). Out of the histologically unclassified cases 60% (3) were recommended a gastroenterological follow-up, 20% (1) a surgical consult and 20% (1) an oncological consult or subsequent oncological treatment.

Figure 24 Distribution of subsequent treatment in relation to histological type
Displaying the relation between subsequent treatment and the presence or absence of metastases we may observe the recommendation of oncological care being the most prominent in cases with metastases (65%, 13), followed by the surgical consult and the cases without subsequent treatment suggestion, each accounting for 15% (3). 5% (1) of gastric cancer cases with metastasis were recommended a gastroenterological follow-up. In 34,78% (8) of the cases without metastasis no treatment recommendation was expressed, 21,74% (5) were advised an oncological consult or subsequent treatment and the same amount were suggested a surgical consult. The final 17,39% (4) without metastases were told to present for a gastroenterological follow-up.

Figure 25 Distribution of subsequent treatment in relation to metastases
4. Discussion
Even though the incidence of gastric carcinomas is decreasing in Western countries it remains among the five deadliest malignancies according to the WHO. Being responsible for more than 107 000 deaths in 2012, gastric cancer is the fourth most common cause of cancer deaths in Europe.
Out of the 7.4 million males diagnosed with cancer in 2012 worldwide, gastric cancer accounts for 9% and out of the 6.7 million females diagnosed with cancer in 2012 worldwide, 5% were gastric cancer cases .
The study carried out in the gastroenterological department of the “Pius Brînzeu” county hospital Timi?oara, aimed at analysing the distribution of demographics, symptomatology, as well as results of paraclinical examinations among admitted gastric cancer patients.
The review of patient records documenting the time interval January 2016 – October 2017 concluded in a population of forty-three patients complying with the inclusion criteria of this study.
The data utilized for the study were extracted from the handwritten admission sheet, laboratory and biopsy results, as well as the discharge letters. The evaluated parameters comprise anamnestic readings, age, gender, days of hospitalization, BMI. They also include the presence of risk factors defined as tobacco and alcohol consumption, pernicious anaemia, atrophic gastritis, gastric ulcer, family history positive for gastric cancer, blood type A, reflux esophagitis and intestinal metaplasia. The utilized data picturing the symptomatology at admission were comprised by secondary anaemia, abdominal pain, weight loss, dysphagia, fatigue, asthenia, nausea and emesis, upper GI bleeding, loss of appetite, pyrosis, difficulties of gastric evacuation, absent intestinal transit and cachexia. The paraclinical analysed data comprise biopsy results, documentation of ultrasound examinations, gastroscopy and computer tomography.
The results of the study showed the population being formed by twenty-four males (55,81%) and nineteen females (44,19%). In comparison to an analysis performed by the Cancer Research UK based on the 2015 data by the Office for National Statistics of the United Kingdom resulting in the statement of 65% out of the 6 740 newly diagnosed gastric cancer cases in the UK being male and 35% female . This gender gap also reflects in the numbers of the European Network of Cancer Registries with 60% of the 139 600 newly diagnosed gastric cancer cases being male and 40% female .
The most common age for gastric cancer diagnosis in the evaluated population is between 61 and 65 years with 25,58%, followed by the age group 66-70 years with 18,60%. In the UK the highest incidence rates were found in the age groups 85-89 years, with an average of 51% of the new diagnosis being in the population 75 years or older 34. Both results correspond with the strong relation of gastric cancer incidence and age. Their difference needs to be evaluated bearing in mind the different life expectancies depending on the evaluated country. In Romania the life expectancy in the year 2015 was 75 years in comparison with the life expectancy in the UK of 83 years.
A wide variety of risk factors can be associated with gastric cancer and are found in the evaluated population Figure 5. Conform with the fact of gastric cancer developing mainly in patients with an age above 55 years, 83,72% of the studied population diagnosed with gastric cancer were older than 55 years 8. 55,81% of the patients diagnosed with gastric cancer are male, correspondent with the male gender being a risk factor. Gastric ulcers were found in 30,23% of the population. Alcohol consumption and smoking also being established risk factors for gastric cancer account for 25,58% and 23,25%.
Nine-teen out of the 43 patients could be analysed regarding their BMI, resulting in 47,37% of the gastric cancer patients whose BMI it was possible to calculate having a BMI >25. A meta-analysis of prospective cohort studies of 3 097 794 patients resulted in the statement of the gastric cancer risk being significantly higher in patients with a BMI >25 . The risk is especially higher for carcinomas of the oesophageal-gastric junction, as was the conclusion of another meta-analysis . Evaluating the seven-teen cases of cancer of the oesophageal-gastric junction accounted for in the population, 23,53% presented with a BMI >25, 35,29% with a BMI