Submit Your Article CMED MEACR meeting
Home Print this page Email this page Users Online: 580
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 3  |  Issue : 1  |  Page : 3-8

Epidemiological, clinical, pathological, and therapeutic aspects of gastric cancer in Morocco


1 Department of Radiotherapy, National Institute of Oncology, Rabat, Morocco
2 Department of Medical Oncology, University Hospital of Mohammed VI, Marrakech, Morocco

Date of Web Publication27-Jan-2014

Correspondence Address:
Nabil Ismaili
Medical Oncology, University Hospital Mohammed VI, and Faculty of Medicine, Marrakech
Morocco
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-0513.125770

Rights and Permissions
  Abstract 

Purpose: Gastric cancer is a relatively frequent cancer and has poor prognosis. The present study is the first Moroccan study to investigate the epidemiological, clinical, pathological, therapeutic characteristics, and outcomes of gastric cancer. Materials and Methods: We conducted a retrospective study including 154 cases of gastric cancer treated at the National Institute of Oncology between January 2007 and December 2007. Results: The mean age at diagnosis was 55 years (18-87 years) and the sex ratio was 2.14. Risk factors were dominated by tobacco use (30.5%) and gastric ulcer (4.5%). The average interval between symptom presentation and consultation was 8.7 months (1-48 months). The clinical symptoms were dominated by epigastric pain (88.7%), vomiting (62.3%), and weight loss (80.5%). Oeso-gastric fibroscopy was performed in all patients and showed an ulcerated aspect in 77.9% of the cases. The location of the tumor was antropyloric in 42.2% of the cases. The most common histology was adenocarcinoma (72.8%), followed by non-Hodgkin lymphoma (22%), gastrointestinal stromal tumors (GIST; 3.2%), and neuroendocrine tumors (NET; 2%). Tumor stage was metastatic in 62% of the cases, locally advanced in 18.5% of the cases, and localized in only 8% of the cases; however, 11.5% of patients were not staged. Also, 46% of the patients with adenocarcinoma (n = 111) were not treated, 6.4% received chemotherapy first (non-resectable) (one patient was operated), 20.6% received surgery first followed by adjuvant treatment, 4.5% received chemo-radiotherapy, 5.4% received chemotherapy only, and 27% received palliative chemotherapy. In the sub-group of patients diagnosed with non-Hodgkin lymphoma (n = 35), 48.5% received chemotherapy based on Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone (CHOP) regimen. In the sub-group diagnosed with GIST (n = 5) histology, all cases received surgery first and 2 cases received adjuvant chemotherapy based on doxorubicin. Finally, in the NET (n = 3) sub-group, 2 patients received surgery and 1 was not treated. The mean follow-up was 10 months for locally advanced tumors and 7.6 months for metastatic tumor. The overall survival rate at 3 years was not exceeding 20%. Conclusion: Clinical and pathological aspects of Moroccan patients are the same of those in developing countries. The majority of our patients were diagnosed at late stages, which explains the poor prognosis of gastric cancers in our population.

Keywords: Developing countries, epidemiology, gastric cancer, histology, treatment


How to cite this article:
Elmajjaoui S, Ismaili N, Zaidi H, Elkacemi H, Hassouni K, Kebdani T, Benjaafar N. Epidemiological, clinical, pathological, and therapeutic aspects of gastric cancer in Morocco. Clin Cancer Investig J 2014;3:3-8

How to cite this URL:
Elmajjaoui S, Ismaili N, Zaidi H, Elkacemi H, Hassouni K, Kebdani T, Benjaafar N. Epidemiological, clinical, pathological, and therapeutic aspects of gastric cancer in Morocco. Clin Cancer Investig J [serial online] 2014 [cited 2019 Nov 19];3:3-8. Available from: http://www.ccij-online.org/text.asp?2014/3/1/3/125770


  Introduction Top


Gastric cancer is a relatively common cancer accounting for 8% of the total cases and 10% of total deaths due to cancer. [1] Gastrointestinal cancers are unevenly distributed around the world and has undergone significant changes in incidence over time. [1],[2],[3],[4],[5],[6],[7] The highest incidences have been observed in Eastern Asia, Eastern Europe, and South America, and the lowest incidence have been observed in North America and in most parts of Africa. [1] The most predominant histological type was adenocarcinoma. Most patients were diagnosed at advanced stages of the disease. Surgery is the standard treatment of operable gastric adenocarcinoma. Adjuvant treatments based on radiotherapy and chemotherapy improved loco-regional control rate and overall survival. Chemotherapy remained the only treatment of patients with advanced stages. The prognosis of gastric cancer is poor with a five-year survival, not exceeding 15% for all stages combined. The aim of our study was to analyze the epidemiological, clinical, histological, and therapeutic aspects of gastric cancer in Morocco. We have reported here a series of 154 gastric cancers diagnosed during 2007 at the National Institute of Oncology, Rabat, Morocco.


  Materials and Methods Top


This is a retrospective study of 154 cases of gastric cancers diagnosed at the National Institute of Oncology in Rabat between January 2007 and December 2007. For each case studied, the information used to the collection of data were demographic information of the patient, date of diagnosis, topography, histological type, and treatment modalities.

  • Marital status, age, sex, profession
  • Eating habits and toxic habits
  • Data from the clinical examination
  • Results of additional tests (upper gastro-intestinal endoscopy and histology)
  • Surgery report
  • Treatments.


Statistical analyses were performed using SPSS version 17 software. Kaplan-Meier method was used to estimate survival of patients. Overall survival was calculated from the pathological diagnosis of gastric cancer to death from any case. The groups of patients were compared using the log-rank test. P < 0.05 was considered significant.


  Results Top


Epidemiological data

Frequency

Gastric cancer is the most common gastrointestinal cancer in our cancer center. It represents the fifth most common cancer.

Age

The median age of our patients was 56 years (18-87 years). The study of the distribution of cases by age showed that the incidence of gastric cancer is closely related to age. The first few cases were diagnosed in the interval of age ranged 35-44 years, and the number of cases increased with age. For men, the first peak of frequency was 45-54 years and the second peak was 65-74 years. For women, the peak of frequency was 55-64 years, and then gradually the incidence decreased, as reported in [Figure 1].
Figure 1: Distribution of gastric cancer according to age and sex

Click here to view


Gender

As showed in [Figure 1], there is a male predominance with a sex ratio of 2.08. The risk of gastric cancer increased in men aged 15-24 years and in women aged 25-34 years [Figure 1].

Risk factors

Risk factors were not mentioned in all cases.

  • A history of gastric ulcer was reported in 6.5% of cases [Figure 2]
  • Toxic habits included smoking in 47 patients (30.5%) [Figure 2]
  • Family history: One patient aged 74 years had family history of gastric cancer; his brother died from gastric adenocarcinoma
  • Helicobacbacter pylori infection (HP): No case of infection with HP was detected before diagnosis, even in patients previously treated for ulcer. The HP infections in our patients were diagnosed at the time of histological study of biopsy specimen. Research was performed in a specimen of 17 patients: HP was present in 12 biopsies (7.8%) (3 with adenocarcinomas, 8 with lymphoma, and 1 with neuroendocrine carcinoma) and was absent in 5 biopsies.
  • Diet: Unfortunately, we were not able to identify the diet information from our patients.
Figure 2: Symptoms of gastric cancer

Click here to view


Clinico-pathological data

In our series, we found that only 6 patients consulted within 1 month, while the majority of patients consulted after 1 months (range: 1-48 months). The average interval between the first symptom and consultation was 8.7 months. The most predominant clinical symptoms were epigastralgia (88.7%), weight loss (80.5%), and vomiting (62.3%) [Figure 3].
Figure 3: Epidemiological characteristics

Click here to view


Oeso-gastric endoscopy was performed in all patients and showed an ulcerated aspect in 121 cases (78.5%), infiltrative aspect in 30 cases (19.5%), and plastic linitis in 3 cases (2%).

Topography

Among the 154 gastric cancers, topography of 39 cases (25.3%) was unknown. Among the 115 patients in which information about the topography was available, we have highlighted the predominance of antropyloric topography in 65 cases (42.2%), followed by the location at the fundus in 29 cases (18.8%), at the cardia in 16 cases (11.7%), and at the large tuberosity in 3 cases (2%) [Figure 4].
Figure 4: Topography of gastric cancer

Click here to view


Macroscopic appearance

Most often, the aspect of tumors was ulcerated.

Histological type

Among the 154 cases of gastric cancer, adenocarcinoma is the most common histological type representing 72% of the cases, followed by malignant lymphoma representing 22.8% of the cases. Five patients were diagnosed with gastrointestinal stromal tumors (3.2%) and 3 patients were diagnosed with neuroendocrine carcinoma (2%) [Figure 5].
Figure 5: Histological types

Click here to view


Staging

The stage was assessed by clinical examination, chest, abdomino-pelvic CT scan, and exploratory laparotomy. Lymph node metastases were the most frequent site of metastases (39 cases, 25%), followed by the liver (22 cases, 14%), the peritoneum (26 cases or 16.8%), and the ovary (1 case) [Figure 6]. Tumors are diagnosed at metastatic disease in 62% of the cases, at locally advanced stage in 18.5%, and at localized stage in 8%. About 11.5% of patients were unstaged. Exploratory laparotomy was performed in 18 cases (11.6%) and showed inoperable tumors (invasion of adjacent organs, peritoneal carcinomatosis, or liver metastases). The classification of patients according to histological types is detailed in [Figure 7].
Figure 6: Metastatic sites according to histology

Click here to view
Figure 7: Stage of disease according to histology

Click here to view


Treatment and outcomes

Treatment characteristics were analyzed according to histological type in [Figure 8]. Forty-six percent of the patients with adenocarcinoma (n = 111) were not treated, 6.4% received primary chemotherapy (inoperable disease), and among them, 1 patient received surgery. About 20.6% of the patients received surgery first, and 9.9% of the cases received adjuvant treatment based on radio-chemotherapy, according to the McDonald protocol in 5% of the cases and chemotherapy alone in 5.4% of the cases. Finally, 27% of patients received palliative chemotherapy. In the sub-group of patients diagnosed with non-Hodgkin lymphoma (n = 35), 48.5% of the cases were traded with Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone (CHOP)-based chemotherapy. All patients with GIST (n = 5) received surgery first, among them, 2 received adjuvant chemotherapy based on doxorubicin. Finally, among the 3 patients with neuroendocrine tumor, 2 patients were operated and 1 patient received best supportive care. The mean follow-up was 10 months for locally advanced tumors and 7.6 months for metastatic tumor. The overall survival rate at 3 years for all patients combined was not exceeding 20% [Figure 9]. The main prognostic factor was stage of disease with a significant difference (Log-rank test; P = 0.002).
Figure 8: Treatment according to histology

Click here to view
Figure 9: (a) Survival curve of all patients (b) Survival curves according to stages of disease

Click here to view



  Discussion Top


Gastric cancer is a relatively common cancer. It represents the fifth most commonly diagnosed cancer in the word. The incidence of gastric cancer is the subject of considerable geographical variation. It is highest in Eastern Asia. [1] In Morocco, gastric cancer is the most common gastrointestinal cancer. It represents the fifth most common cancer according to Rabat registry (2005) [8],[9] . The stomach cancer rarely occurs before the age of 40 years. The incidence increased rapidly beyond, with a peak of incidence in the seventh decade. The average age of our patients was 56 years. The median age of our patients was the same as that reported a Senegal, [10] but lower than that reported in France (70 years). [11] In Africa, gastric cancer occurs in relatively young patients because of a shorter life expectancy of African population. In our series, 72% of cases were diagnosed with adenocarcinoma and 22.8% of cases were diagnosed with lymphomas. These proportions are approximately comparable to those reported in Madagascar by Peghini et al., which reported 88% of cases with adenocarcinoma and 7% of cases with lymphoma. [12] Among the risk factors, dietary factors play an important role in gastric carcinogenesis. [13] A diet high in salt is associated with an increased risk of gastric cancer. [14] Nitrites have also been implicated. [15] Several case-control and cohort studies reported an increased risk of stomach cancer in smoking population, [16] especially in cases of H. pylori infection. [17] On the other hand, the consumption of tobacco promotes the progression of preneoplastic lesions. [18] The causality of alcohol consumption in occurrence of stomach cancer has been explored by several studies; however, the relationship between alcohol and gastric cancer was not clearly confirmed. [19] H. pylori has been recognized as an etiological factor in gastric cancer since 1994, as demonstrated by several epidemiological and pathophysiological studies. Several meta-analyzes involving large epidemiological studies have shown that the relative risk of gastric cancer is 2-6 times higher in patients harboring H. pylori infection as compared with uninfected population. [20] In our series, H. pylori was reported in 8% of cases, history of tobacco use in 30.5% of cases, and history of gastric ulcer in 6.5% of cases. Cancers of the stomach are most often diagnosed in symptomatic patients with advanced disease. It was the case in our series, locally advanced and metastatic stages, III and IV, represented 38.8% and 48.6% of patients with adenocarcarcinoma, respectively. Early tumors are usually asymptomatic and rarely detected outside of country adopting a screening policy such as Japan. In our series, stages I and II represent only 3.6% and 9%, respectively. Weight loss and epigastralgias are the most common symptoms at the initial diagnosis. In our study, the most common symptoms were epigastralgias in 88.7% of cases and weight loss in 80.5% of cases. A history of gastric ulcer was found in about a quarter of cases. [21] In our series, it was found in 6.5% of cases. Externalized digestive bleeding was found in 20% of cases. The general signs are common in cases of gastric lymphoma. In our series, they were present in 31.4% of lymphomas patients (n = 35). In clinical practice, the confirmatory diagnosis was based on gastroduodenal endoscopy-associated with biopsies. [22] Endoscopy was performed for all patients in our series. Tumor may have a polypoid, ulcerated, or infiltrative tumor. Abdominal and pelvic CT scan is the initial step of staging. However, this radiological test tends to underestimate the locoregional extension of disease. Depending on the series, the correlation was 51-67% with cT and pT, 51-73% with cN and pN, and 30-71% with peritoneal carcinomatosis. In our series, the CT scan was performed in 114 cases (74%). Laparoscopy is proposed by some authors as an essential step of staging before curative resection. This intervention avoids unnecessary laparotomy in up to 38% of patients, especially in the case of peritoneal carcinomatosis or liver metastases. [23] The standard treatment for patients with operable adenocarcinoma is surgery. Radiotherapy and chemotherapy improve rates of loco-regional control and survival. Adjuvant radio-chemotherapy and peri-operative chemotherapy are two standard of care. Chemotherapy remains the only treatment of advanced disease.


  Conclusion Top


In Morocco, gastric cancer is the most common gastrointestinal cancer. It represents the fifth most common cancer in concordance with that in developed countries. Tobacco use is a frequent cause. Our patients diagnosed with gastric cancer were younger and diagnosed at advanced stages. Stomach cancer incidence was about twice as high in males than in females in concordance with global statistics. Adenocarcinoma was the frequent histological type. Prognosis was poor; 3-year survival was not exceeding 20%.

 
  References Top

1.Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin 2011;61:69-90.  Back to cited text no. 1
[PUBMED]    
2.van der Merwe CF, te Winkel W, Marwa AO, Lemmer LB. Malignant disease of the gastro-intestinal tract in blacks. Incidence and frequency distribution by age, sex and site at Ga-Rankuwa Hospital, Pretoria, 1976-1986. S Afr Med J 1988;74:209-11.  Back to cited text no. 2
[PUBMED]    
3.Oddes B, Jaud V, Brunetti G, Vitris M, Delanoue G, Seurat PL, et al. Duodenal adenocarcinoma. Apropos of a case. Dakar Med 1984;29:135-40.  Back to cited text no. 3
[PUBMED]    
4.Arigbabu AO. Gastric cancer in Nigeria. Trop Doct 1988;18:13-5.  Back to cited text no. 4
[PUBMED]    
5.Angate YA, Beda B, Echimane KA, Kanga JM, Khoury J, Uhl G, et al. Etude épidémiologique et anatomo-clinique de 122 cas de cancers de l′estomac observés en 10 ans au CHU d′Abidjan. Rev Méd Côte d′Ivoire 1985;57:6-14.  Back to cited text no. 5
    
6.Randriamahefa RR. Le cancer de l′estomac. Etude fibroscopique et anatomo-pathologique après biopsies. Thèse Méd Antanarivo 1990.  Back to cited text no. 6
    
7.Kadende P, Engels D, Ndocricimpa J, Ndabaneze E, Aubry P. Les cancers digestifs au Burundi. Méd Afrique Noire 1990;37:552-61.  Back to cited text no. 7
    
8.Registre des cancers à Rabat 2005.  Back to cited text no. 8
    
9.Tazi MA, Er-Raki A, Benjaafar N. Cancer incidence in Rabat, Morocco: 2006-2008. Ecancermedicalscience. 2013 Aug 8;7:338.  Back to cited text no. 9
    
10.Tuyns AJ, Quenum C. Registre des cancers au Sénégal. In: Parkin DM, editor. Cancer in Africa. Epidemiology and Prevention. vol. 153. Lyon: IARC Scientific Publications; 2003.  Back to cited text no. 10
    
11.Parkin DM, Whelan SL, Ferley J, Raymond L, Young J. Cancer incidence in five continents. vol. 143. Lyon: IARC Scientific Publications; 1997. p. 7.  Back to cited text no. 11
    
12.Peghini M, Rajaonarison P, Pecarrere JL, Razafindramboa H, Richard J, Morin D. Épidémiologie des cancers du tube digestif à Madagascar: Apport de 14 000 endoscopies effectuées au centre hospitalier de Soavinandriana à Antananarivo. Med Afr Noire 1997;44:518-21.  Back to cited text no. 12
    
13.Howson CP, Hiyama T, Wynder EL. The decline in gastric cancer: Epidemiology of an unplanned triumph. Epidemiol Rev 1986;8:1-27.  Back to cited text no. 13
    
14.Palli D. Epidemiology of gastric cancer: An evaluation of available evidence. J Gastroenterol 2000;35 Suppl 12:84-9.  Back to cited text no. 14
    
15.Mirvish SS. The etiology of gastric cancer. Intragastric nitrosamide formation and other theories. J Natl Cancer Inst 1983;71:629-47.  Back to cited text no. 15
    
16.Chao A, Thun MJ, Henley SJ, Jacobs EJ, McCullough ML, Calle EE. Cigarette smoking, use of other tobacco products and stomach cancer mortality in US adults: The Cancer Prevention Study II. Int J Cancer 2002;101:380-9.  Back to cited text no. 16
    
17.Siman JH, Forsgren A, Berglund G, Floren CH. Tobacco smoking increases the risk for gastric adenocarcinoma among Helicobacter pylori-infected individuals. Scand J Gastroenterol 2001;36:208-13.  Back to cited text no. 17
    
18.Kneller RW, You WC, Chang YS, Liu WD, Zhang L, Zhao L, et al. Cigarette smoking and other risk factors for progression of precancerous stomach lesions. J Natl Cancer Inst 1992;84:1261-6.  Back to cited text no. 18
    
19.Correa P, Fontham E, Pickle LW, Chen V, Lin YP, Haenszel W. Dietary determinants of gastric cancer in south Louisiana inhabitants. J Natl Cancer Inst 1985;75:645-54.  Back to cited text no. 19
    
20.Eslick GD, Lim LL, Byles JE, Xia HH, Talley NJ. Association of Helicobacter pylori infection with gastric carcinoma: A meta-analysis. Am J Gastroenterol 1999;94:2373-9.  Back to cited text no. 20
    
21.Wanebo HJ, Kennedy BJ, Chmiel J, Steele G Jr, Winchester D, Osteen R. Cancer of the stomach. A patient care study by the American College of Surgeons. Ann Surg 1993;218:583-92.  Back to cited text no. 21
    
22.Dekker W, Tytgat GN. Diagnostic accuracy of fiberendoscopy in the detection of upper intestinal malignancy. A follow-up analysis. Gastroenterology 1977;73:710-4.  Back to cited text no. 22
    
23.Molloy RM, Sonnenberg A. Relation between gastric cancer and previous peptic ulcer disease. Gut 1997;40:247-52.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed1678    
    Printed32    
    Emailed0    
    PDF Downloaded113    
    Comments [Add]    

Recommend this journal