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Cirugía paraguaya

versão On-line ISSN 2307-0420

Cir. parag. vol.46 no.3 Asunción dez. 2022

https://doi.org/10.18004/sopaci.2022.diciembre.7 

Original article

Clinical and sociodemographic characteristics of patients diagnosed with gastric cancer at the Itauguá National Hospital. 2019-2020

Miguel Angel Aranda-Wildberger1 
http://orcid.org/0000-0002-0088-4462

Francisco Hiroyuki Yanagida-Arakawa1 
http://orcid.org/0000-0002-1913-8363

Camila Petry Bottini2 
http://orcid.org/0000-0002-9575-8783

1Ministerio de Salud Pública y Bienestar Social, Centro Médico Nacional, Hospital Nacional, Departamento de Cirugía. Itauguá, Paraguay.

2Ministerio de Salud Pública y Bienestar Social, Centro Educativo Superior en Salud. Departamento de Extensión e Investigación. Ypacaraí, Paraguay.


RESUMEN

Introducción: El cáncer gástrico es la quinta neoplasia más frecuente en el mundo y posee una alta mortalidad.Los síntomas al inicio son inespecíficos. El estándar de diagnóstico es la gastroscopía. Objetivos: Conocer las Características clínicas y sociodemográficas de pacientes con diagnóstico de cáncer gástrico en el Hospital Nacional de Itauguá. Periodo 2019 - 2020. Material y métodos: estudio observacional, descriptivo, de corte transversal; con muestreo no probabilístico de casos consecutivos, de Pacientes con diagnóstico de cáncer gástrico, que acudieron al Servicio de Cirugía General del Hospital Nacional de Itauguá, periodo 2019 - 2020.Se recabaron 24 expedientes clínicos de pacientes que cumplían con los criterios de inclusión. Resultados: De 24 pacientes, 87,5% fueron hombres. Con edad media de 61 años ± 10. El motivo de consulta más frecuente fue el síndrome constitucional 47%. Se encontró infección por Helycobacter pylori en un 42%. El estadio prequirúrgico TNM fue estadio 4 en un 50%, con el tipo histológico más frecuente fue el Adenocarcinoma tipo intestinal 50% seguido del tipo difuso 46%. Conclusión: El cáncer gástrico afecta predominantemente al sexo masculino, con una media de edad superior a 60 años. El síndrome constitucional es el motivo de consulta más frecuente. El tipo Histológico más frecuente es el Adenocarcinoma intestinal.

Palabras claves: cáncer gástrico; Helicobacter pylori; Diagnóstico; clasificación

ABSTRACT

Introduction: Gastric cancer is the fifth most common neoplasm worldwide and has a high mortality rate. Early symptoms are non-specific. The diagnostic standard tool is gastroscopy. Objectives: To know the clinical and social and demographic characteristics of patients diagnosed with gastric cancer at the Itauguá National Hospital, Asunción, Paraguay from 2019 through 2020. Material and methods: This is an observational, descriptive, cross-sectional study with non-probabilistic sampling of consecutive cases of patients diagnosed with gastric cancerand treated at the General Surgery Unit of Itauguá National Hospital, Asunción, Paraguay from 2019 through 2020. A total of 24 health records from patients who met the inclusion criteria were collected. Results: A total of 87.5% out of 24 patients were men with a mean age of 61 years ± 10. The most common reason for consultation was constitutional syndrome (47%). Helycobacter pylori infection was found in 42% of the cases. The preoperative TNM stage was stage 4 in 50% of the cases whilethe most common histological type was the intestinal-type adenocarcinoma (50%) followed bydiffuse-type adenocarcinoma (46%). Conclusion: Gastric cancer predominantly affects men with a mean age > 60 years. Constitutional syndrome is the most common reason for consultation. The most frequent histological type is intestinal adenocarcinoma

Key words: gastric neoplasm; helycobacter pylori; Diagnosis; classification

INTRODUCTION

Gastric cancer is the fifth most common neoplasm worldwide. According to the World Health Organization (WHO)( 1), in 2018, there were nearly 1 034 000 new cases of gastric cancer across the world (5.7% of all the cases of cancer reported). These data show that, although its incidence rate has gone down, mortality rate still remains high2. The 5-year survival rate is 20% due to delayed diagnosis. However, in countries with advanced cancer screening programs, the 5-year survival rate is nearly 90%3.

Factors predisposing towards this neoplasm are the use of fatty, salty, and smoked food, alcohol, hot drinks, and a diet soft on fiber, fruit and vegetables, and the use of N-nitroso compounds.4 Another predisposing factor is infection due to Helicobacter pylori that is a class I human carcinogen for gastric cancer of both subtypes (diffuse and intestinal) (5,6).

Early symptoms are non-specific, and similar to those of other gastric conditions. Epigastric pain is an early symptom in nearly 70% of the cases. Nausea, vomiting, early satiety, and constitutional syndrome (anorexia, asthenia, and weight loss). 5 The physical examination is normal at the beginning and only a third of the patients will show hidden blood in feces5.

Early diagnosis can be achieved through screening of large populations or targeted at higher-risk populations. This will depend on the prevalence of gastric cancer in the region at stake2. The standard diagnosis is gastroscopy with biopsy samples6.

Adenocarcinoma amounts to almost 90% of all stomach neoplasms7. It can be categorized according to Lauren classification into: the intestinal type (characterized by the formation of tubular structures arranged in tubular or gland formations). This type of adenocarcinomas are the ones most commonly associated with environmental and dietary factors. Also, they are predominant in regions of high incidence rate. The second type is the diffuse type. It consists of cells that lack adhesion and infiltrate the gastric wall without glandular appearance. It appears at younger ages in women and has a grim prognosis8. When a large section of gastric tissue is involved, it is called gastric linitis plastic9. Staging used is the TNM Classification of Malignant Tumors designed by the AJCC/UICC (see table 1)(10.

Table 1.  TNM Classification of Malignant Tumors designed by the AJCC/UICC. Source: AJCC Cancer Staging Manual. 8th edition. Springer; 2017.10 

Treatment is multidisciplinary and surgery is an important part since gross total resection is the only curative option11. Access route is often selected based on the TNM stage. Endoscopic mucosal resection, open or laparoscopic gastrectomy—whether typical or atypical—associated with lymphadenectomy are some of the surgical options available11. Gastrectomy can also be performed with palliative purposes12. To reinstate transit gastroduodenal anastomosis, techniques of Billroth I reconstruction, gastrojejunal anastomosis through Billroth II, gastrojejunal anastomosis in Roux-en-Y reconstruction, and jejunal and esophago-jejunal interposition reconstruction can be used, among others10.

Although, in our country, the actual incidence rate of gastric cancer is low, there is a great social impact due to its high mortality and morbidity. Diagnosis often comes late since symptoms are non-specific, and similar to those of other non-neoplastic gastric conditions, which reduces the chances of satisfactory curative treatment13.

The objective of this study was to know the clinical and social and demographic variations of patients with a diagnosis of gastric cancer at the General Surgery Unit of Hospital Nacional de Itauguá, Itauguá, Paraguay from January 2019 through September 2020.

MATERIALS AND METHODS

This is a descriptive, observational, retrospective, and cross-sectional study with non-probabilistic sampling of consecutive cases of all patients with a diagnosis of gastric cancer admitted to the General Surgery Unit of Hospital Nacional de Itauguá, Itauguá, Paraguay from January 2019 through September 2020. Inclusion criteria were age > 18 years regardless of sex, endoscopic and anatomopathological diagnosis of gastric cancer at the General Surgery Unit of Hospital Nacional de Itauguá, uninvolved gastroesophageal junction, and patients with complete health records. The health records of 24 patients who met the inclusion and exclusion criteria were included in the study. Data were analyzed using Microsoft Excel spreadsheet and frequency (%) and dispersion measures (SD) tables were used.

Bioethical principles were observed at all times: Information obtained was analyzed under confidentiality standards. Codes of the health records of each patient were used. No informed consent was required since data were drawn from the health records. No risk of non-maleficence or discrimination existed. No conflicts of interest were reported either.

Study limitations: the size of the sample was too small, which complicates result extrapolation. It is a descriptive study that does not create data associations. The General Surgery Unit of Hospital Nacional de Itauguá does not have echoendoscopy technology available for diagnosis or staging purposed, which could have reduced the diagnostic accuracy of TNM staging.

RESULTS

Out of the 24 patients included, 12.5% (3) were women and 87.5% (21) men. In the distribution based on the age group the larger number of cases was reported from 50 through 69 years old (see Figure 1). Mean age was 61 years ± 10; median age was 62 years while mode was 52 years.

Figure 1: Distribution of patients based on age group. N = 24. 

The most common reason for consultation was constitutional syndrome (47%) followed by abdominal pain (34%), upper digestive bleeding (13%), and early satiety (6%) (see Figure 2).

Figure 2: Distribution of patients based on reason for consultation.  

Regarding the origin of the patients, 92% (22) came from rural areas while 8% (2) from metropolitan areas. Concomitant infection due to Helycobacter pylori, according to the results of anatomical pathology examination of gastric biopsies that tested positive in 42% (10) and negative in 58% of the cases (14).

Preoperative stage according to the TNM Classification of Malignant Tumors was IIA in 17% (4), IIB in 17% (4), IIA in 13% (3) IIB in 4% (1), and stage IV in 50% (12). Table 2.

Out of all the patients, a total of 58% (14) received palliative care, and 33% (8) surgical treatment. Total gastrectomy was performed in all the cases with D1 plus or D2 node drainage and esophageal-jejunal reconstruction in Roux-en-Y. A total of 8% (2) of the patients died at the hospital without any surgical or palliative care. The most common histological type found in endoscopic biopsies and the anatomopathological findings of the surgical pieces from patients treated with surgery was the intestinal type in 50% (12) of the patients followed by the diffuse type (46% (11)) and non-Hodgkin lymphoma (4% (1)).

Table 2.  Distribution of patients based on the TNM stage.  

Stage N %
IA 0 0 %
I B 0 0 %
II A 4 17 %
II B 4 17 %
III A 3 13 %
III B 1 4 %
IV 12 50 %
Total 24 100%

DISCUSSION

Regarding the sex most commonly affected, masculine predominance was seen in 88% of the cases, which is consistent with data from World Cancer Research Found International that reports rates that are 2 or 3 times higher in men14. Opposing data were found by Dávila et al. who reported feminine predominance in 33 020 patients (64%)15.

Mean age of patients with gastric cancer was 61 ± 10 years. In a study conducted by Dávila et al. in Costa Rica back in 2018, they saw that the mean age of patients with gastric cancer was 61.8 years, which are similar figures compared to those reported in our study15. Mean age of 68% of the population was somewhere between 50 and 69 years.

The most common reason for consultation was constitutional syndrome in 47% of the cases (a clinical manifestation of advanced disease) followed by abdominal pain (34%) according to the studies conducted by Carnecelli et al. who found pain as the first clinical sign of gastric cancer in 40 patients16. Upper digestive bleeding and early satiety are a rare finding as first clinical signs and are associated with advanced disease15. Similarly, the predominance of gastric cancer in patients from rural areas of 92% contradicts the data provided by Dávila et al. who found a similar distribution in metropolitan and rural areas with a large bias though15. This could be representative of sample bias because our center is geographically located outside the city limits of Asunción, Paraguay, where there is a huge population of patients from across the country.

The presence of Helicobacter pylori in 42% of the patients is slightly higher compared to the data provided by De León et al. and Hernández et al. who found prevalences of 32% and 39%, respectively17.

At diagnosis, 34% of the patients already had locoregional disease and the remaining 66% regionally advanced disease. None of the patients was diagnosed at the early stages of the disease, which can be due to delayed consultations since symptom onset. Treatment was palliative in 58% of the patients (a very high rate). However, this is what could be expected when cancer is diagnosed at late stages of the disease.

Regarding the histological type, the intestinal-type adenocarcinoma is still the most common of the two (reported in up to 50% of the cases) while the rate of diffuse-type adenocarcinoma is 46% (which is higher compared to other studies conducted in the region). For example, in Ecuador, Muñoz et al. found the intestinal type to be the most common one in 64.5% of the cases while the diffuse one was only the most common type in 29.0% of the patients18. In Brazil, Carnicelli et al. also found predominance of the intestinal type in 68% of the patients with predominance of the diffuse type in 25% of the cases only16.

CONCLUSION

Gastric cancer predominantly affects men with a mean age of 61 years ± 10 at diagnosis. Constitutional syndrome is the most common reason for consultation in our population. Upper digestive bleeding and early satiety are a rare finding as the first clinical presentation. This type of cancer is predominant in patients from rural areas.

The presence of Helicobacter pylori is commonly detected at diagnosis. According to the TNM Classification of Malignant Tumors no gastric cancer was found in its early stages in our population. The most common histological type is still intestinal adenocarcinoma with increasing figures in the diffuse type.

REFERENCES

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Conflicts of interest

4The authors declared no conflicts of interest whatsoever. Also, they observed ethics and good practices of the publishing house. No external funding was ever received to conduct this study.

5Authors’ contributions MAAW was involved in the study design and idea, reference search, drafting and critical review of the manuscript. Also, he looked for intellectually relevant content, conducted a critical review, and gave his final approval to the manuscript. He was also involved in all aspects of work to guarantee that all questions associated with precision or integrity of any aspects of the study will be investigated and resolved adequately. FHYA: contributed substantially to the study design, reference search, data mining, and data analysis. Also, he was involved in the drafting of several sections, and the manuscript final approval. CPS participated in the study idea, data analysis, chart and figure creation, drafting and final approval of the manuscript.

Received: June 07, 2022; Accepted: November 10, 2022

Corresponding author: Dr. Miguel Angel Aranda Wildberger E-mail address: maaw_94@hotmail.com Address: Ruta Mariscal Estigarribia. Numero 244. Ypacarai-Paraguay

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