Gastric Cancer, Hereditary Diffuse

Alternative Names

  • Gastric Cancer, Familial Diffuse
  • HDGC
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WHO-ICD-10 version:2010

Neoplasms

Malignant neoplasms

OMIM Number

137215

Gene Map Locus

1p34.3-p32.1,2q14.1, 2q33-q34,3q26.3,5q21-q22, 5q31.1,10p15, 10q26,12p12.1,16q22.1,17q21.1

Description

Gastric cancer, or cancer of the stomach, is the second most common cause of death due to cancers worldwide. About 95% of gastric cancers are adenocarcinomas. Other forms seen rarely include lymphomas, carcinoid tumors, and gastrointestinal stromal tumors. Infection of the stomach with Helicobacter pylori is the most important risk factor for the development of this disease, since infection may lead to pre-cancerous changes in the gastric lining. The condition may be aggravated by eating foods high in salt and low in fiber, smoking, and consumption of alcohol. Unfortunately, since the initial clinical features of the condition are very similar to other less serious disorders, such as peptic ulcers, most patients report the illness and are diagnosed at a late stage of the condition. Usual features of gastric cancer include abdominal discomfort, indigestion and heartburn, internal bleeding visible in the stool, vomiting blood, and anemia and associated fatigue. This condition is more pronounced in Asian countries like Japan, China, and Korea, where it is the leading cause of mortality. This could be due to the high amount of salted, pickled, and smoked food in the diet of these regions. In addition, the condition is slightly more common in men than in women.

Initial diagnosis may include an upper endoscopy and/or a stomach X-ray with a barium swallow. Confirmation is based upon findings of CT/MRI scans. Any spread of the cancer to the lungs needs to be checked with a pulmonary X-ray. Similarly, the presence of tumor markers, such as carcinoembryonic antigen, in the blood may be checked for, to estimate the extent of metastasis, if any. The most common treatment method for gastric cancer is surgical resection of the affected tissue. Some surrounding tissue as well as lymph nodes may also need to be removed. This is usually followed up by chemotherapy and/or radiation therapy. Antibiotics may also be used in individuals infected with H. pylori. Prognosis is largely dependent upon the stage of the cancer at the time it is first diagnosed. The 5-year survival rate after surgical resection is 30-50% and 10-25% for patients diagnosed at stage II and III, respectively. The management of families with hereditary diffuse gastric cancer is challenging as screening for cancer in CDH1 mutation carriers is insufficiently sensitive and the commonly recommended option, prophylactic total gastrectomy, is associated with certain morbidity and even potential mortality.

As in all cancers, gastric cancer also manifests itself due to changes in the genetic structure of cells, causing them to over-multiply. Mutations in various genes have been implicated in the development of stomach cancer. Some of these are the APC gene, Interferon Regulatory Factor 1 (IRF1), Kruppel-Like Factor 6 (KLF6), MUTYH, KRAS, Caspase 10, Oncogene ERBB2, and Fibroblast Growth Factor Receptor 2 (FGFR2). Most interestingly, it has been noted that about 10% of gastric cancers are familial in origin. The most well-studied of these cases have shown germ-line mutations in the E-cadherin (CDH1) gene, resulting in an autosomal dominant and highly penetrant form of the condition.

Molecular Genetics

As in all cancers, gastric cancer also manifests itself due to changes in the genetic structure of cells, causing them to over-multiply. Mutations in various genes have been implicated in the development of stomach cancer. Some of these are the APC gene, Interferon Regulatory Factor 1 (IRF1), Kruppel-Like Factor 6 (KLF6), MUTYH, KRAS, Caspase 10, Oncogene ERBB2, and Fibroblast Growth Factor Receptor 2 (FGFR2). Most interestingly, it has been noted that about 10% of gastric cancers are familial in origin. The most well-studied of these cases have shown germ-line mutations in the E-cadherin (CDH1) gene, resulting in an autosomal dominant and highly penetrant form of the condition.

Epidemiology in the Arab World

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Other Reports

Jordan

Bani-Hani (2005) studied the records 176 Jordanian patients with gastric adenocarcinoma managed between 1991 and 2001 (Patients 40 yr of age, n=159). In the young group, in comparison with older group, females were more predominant (p=0.049), family history of gastric cancer was more common (p=0.006), proximal location and involvement of the entire stomach were more (p<0.001), and diffuse cancers (65% vs 13%) and poorly differentiated carcinomas (47% vs 26%) were more prevalent.

Lynch et al. (2011) studied a preliminary pedigree of four individuals from a single family with gastric cancer. All four individuals tested positive for a c.1137G>A mutations in the CDH1 gene. A family information service was then conducted where 40 family members gathered and were provided with proper counseling. Twenty-three family members have been tested for CDH1; 13 were positive and 10 were negative. The proband, a CDH1 mutation carrier, has undergone successful prophylactic total gastrectomy.

Oman

Kabir and Daar (1995) studied the role of pro- and anti-inflammatory cytokines in patients with gastric cancer. Serum samples from a total of 21 patients with advanced gastric cancer were compared to 17 healthy control individuals. IL-6 and IL-1 beta levels were found to be significantly increased by about six times in the patient group as compared to the controls.

Prognostic factors determining the survival outcome in Omani patients with gastric cancer were studied retrospectively by Al-Moundhri et al. (2006). The factors studies included TNM stage, histological type, tumor differentiation, the site of the primary tumor, and the treatment modalities used. All records (medical, surgical and pathological) of the 339 patients (221 males and 118 females) with overall mean age of 59.8 years (range 14-90 years with 10% less than 40 years), who were diagnosed with primary gastric adenocarcinoma between 1993 till 2004 were studied and evaluated as regarding the age, sex, location of tumor, gross type (Lauren's classification), histological type, depth of wall invasion, number of positive lymph nodes, as well as management modalities which included surgical intervention (R0-curative resection with no residual tumor, or palliative resection with residual microscopic or macroscopic residues-R1/R2) and adjuvant treatment (chemotherapy or chemo-radiotherapy). Among the cohort, the predominant tumor was an ulcerative, intestinal, adenocarcinoma (64.1%). About 59% were located in the lower third, with most of the tumors having deeply penetrated the stomach wall with stages of T3 (55.7%) and T4 (14.3%) at presentation. In addition, 75.9% of the patients had lymph node involvement. R0 resection constituted 46.6% of the 237 patients who were operated on, while 19% had extensive D2 lymph node resection. In addition to surgery, 26.6% received adjuvant treatment as well (neoadjuvant chemotherapy, adjuvant chemotherapy or chemo-radiotherapy). The entire study group was followed up for a mean of 29.3 months (3-103 months). In this period, 75.5% (died 256 deaths, 11 were early postoperative) and 21.2% were alive giving a median survival time of 12.3 months with 5-year survival rate of 16.5%. The non-metastatic group had a longer survival time of 23.5 months with a 5-year survival rate of 24.1%. Better survival was found to be influenced by ulcerative macroscopic appearance, tumor size less than 5 cm, T1 and T2 stages, negative lymph node involvement, TNM stages I and II, histological grades 1 and 2, and curative surgical resection with R0 as shown by the univariate analysis, but only the T stage and lymph node involvement had independent prognostic significance on multivariate analysis.

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