Surgical Oncology for Stomach Cancer: Ask Dr. Waddah Al-Refaie

Surgical Oncology for Stomach Cancer: Ask Dr. Waddah Al-Refaie

Articles Blog


I’m Dr. Waddah Al-Refaie, I serve
as the chief of surgical oncology at MedStar Georgetown University Hospital, I also serve as the surgeon in chief for
the Lombardi Comprehensive Cancer Center. I have the high privilege of caring
for patients with GI cancer, soft tissue sarcoma,
gastrointestinal stormal tumors and malignant melanoma. To be diagnosed with cancer is a
devastating diagnosis, and it impacts the way you think
and it impacts your lifestyle and all the future decisions
that you have. As a surgical oncologist,
I see the glass half full. There’s a treatment option for nearly
every individual. So we’re here to help our patients
the best that we can and offer those patients hope at their
very vulnerable times of their life. Surgical oncology is specialty that
evolved over the last 2-3 decades. Surgeons spend 2-3 years at the major
Comprehensive Cancer Center learning tools and techniques,
and I’m a member of a team and feel intensely committed to this
team approach to individuals with these cancers. It’s challenging, it keeps you
thinking all the time at how can we help our patients and
offer them the best outcomes that we can. The diagnosis itself can be at times
challenging and require our specialized pathologist. Some of the diseases, you have 50 types
of sarcoma different from each other. So again, you’d like to be at a center
where your pathologists, surgeons, medical oncologists, radiologists
are working together, familiar with these diseases
and be able to streamline the treatment decision
for complex diseases. So this is an environment where
we’re stimulated challenged constantly to help our patients, and I thrive in
these kinds of environments where it’s research driven based on
the latest treatment options to offer our patients here at
MedStar Georgetown University Hospital. What we offer
at MedStar Georgetown University Hospital is an array of highly specialized physicians
in various aspect of the continuum of cancer care. We have specialized surgeons with
fellowship training in surgical oncology, you have specialized medical oncologists,
you have radiation therapists who are very familiar with that various
typse of disease sites, and we have a very robust partnership with
the Lombardi Comprehensive Cancer Center, one of the few cancer canters
in the nation that has a Comprehensive Cancer
Center designation, and it’s the only one in the D.C metro area.
So we feel that we offer our patients cutting-edge, the latest in access
to cancer clinical trials that very few centers in the country
are able to offer these kinds of treatment options
to our patients with cancer. So stomach cancer is a similar word
to gastric cancer, and allow me here to explain to you
some use of words that may confuse patients as well.
So at times, patients will refer to their intestines
as their stomach and from a medical perspective, we refer
to the stomach or the gastric as an organ on its own. And that’s a pear-shaped organ that digests
the food and propels it out of the stomach to the rest of the intestines.
So when individuals diagnose with a gastric cancer or stomach cancer,
it’s not the rest of the intestine, it is the organ itself, and the words
“stomach cancer” or “gastric cancer” are interchangeable. Gastric cancer is the
most common cancer of the stomach itself. It occurs in about 80% or 90%
of patients with stomach cancer. There are other less common ones such
as lymphoma of the stomach, gastrointestinal stromal tumor…
but the most common one gastric adinocarcinoma
or gastric cancer. The most common one is gastric cancer
or stomach cancer, the other medical terminology is
gastric adinocarcinoma. Less common tumors or cancers
of the stomach are lymphoma, carcinoid tumors or just
gastrointestinal stormal tumors. The vast majority of patients who present
with one or more of the following symptoms, patients do present sometimes
with weight-loss, they lose their appetite for eating,
they feel full after meals, nausea, vomiting
or excessive weight-loss. Bear in mind that some of these
symptoms overlap with patients who have inflammation of the stomach
or ulcer disease itself, but it’s a constellation of the symptoms
that I mentioned along with feeling full
or abdominal distention as well. So diagnosis of gastric cancer
starts with an upper GI endoscopy. It’s a camera that the gastroenterologist
or a surgeon place in the stomach, you identify an area of abnormality
of the stomach, a biopsy is performed,
the diagnosis is made. We add other treatment, other diagnostic
modalities as well, that is an ultrasound of the stomach itself
to assess the thickness of the cancer and whether lymph nodes are
involved or not. And then following that,
a radiographic imaging, either a CT scan or MRI of the abdomen
to assess whether the gastric cancer has spread to other organs, namely
the liver or the lung itself. At times we combine the CT scan
with a PET scan that’s a radioactive sugar that’s injected
in the vein of a patient to see whether the tumor
has spread to other organs or not. In addition, at the time of surgery,
because CT scans can underestimate the ability of stomach cancer to spread
to other organs, we perform a procedure, it’s called
diagnostic laparoscopy, it’s done under general anesthesia
through 2 small incisions. A small camera is placed
in the abdominal cavity to look for evidence of spread
from gastric cancer. So the stage is based
on several factors. One, the thickness of the cancer itself,
how many layers of the stomach did it invade, and the more layers that
it invades, the worse the prognosis. The other aspect of the stage itself depends
on the involvement of the lymph nodes and how many lymph nodes have
been involved or not. And the stages well depend on
whether other organs have been involved,
such as the liver or lung, in other words, the word
“metastasis”. So the stage is based on the thickness
of the tumor, involvement of lymph nodes,
spread to other organs including the lining
of the intestines. So again here
at MedStar Georgetown Hospital we adopt a team approach.
Surgery is an important component of the treatment for gastric cancer,
either removing a portion of the stomach or the entire stomach, and that’s based
on the location of the gastric cancer along with an adequate number of lymph nodes
to treat the patients and stage them. And then… So stomach chemotherapy
has a role in most but not all patients with gastric cancer. This can be given
before and after surgery or given after surgery. And at times,
we actually advocate the role of radiation therapy for a certain group
of patients after removing the stomach and the aftermath of surgery.
So it is a team approach for patients with gastric cancer. In most patients with gastric cancer
the answer is yes, there are a variety of ways to employ…
so stomach chemotherapy. Again, we work in teams, we have
a multi-specialty team approach where we discuss every patient
that we have with gastric cancer and the two most common approaches
to offer patients with gastric cancer that is resectable or removable is offer
to them before and after surgery or operate on the individuals,
remove the gastric cancer with an adequate number of lymph nodes
and then offer them to send them
to chemotherapy afterwards. Not all patients with gastric cancer
will need radiation therapy. The individuals that we offer
radiation therapy – either those who did not receive
chemotherapy before surgery and received it afterwards,
then we offer then radiation therapy, or patients with disease that involves
the esophagus or the very beginning of the stomach, at times we offer them radiation therapy. Here at MedStar Georgetown
University Hospital and the Lombardi Comprehensive
Cancer Center we offer a team approach to patients with gastric
or stomach cancer. So an individual who’s newly
diagnosed with gastric cancer will need a surgeon with expertise
on stomach cancer, a medical oncologist,
a radiation therapist. We discuss those cases
in our tumor board meeting and discuss various treatment options
for those patients. We offer them clinical trials
and what are the newest treatments that are available to them as well.
So it’s a highly-specialized team approach to individuals with gastric cancer
and with access with the latest of cutting-edge
and to clinical trials as well. If the entire stomach is removed, one of
the problems patients face after surgery is their ability to keep their food down
and not have symptoms such as nausea after eating, so what we do here
at MedStar Georgetown is we have them meet with our nutritionist
before surgery and then have them be coached and trained
after surgery about changing their lifestyle in terms
of their eating habits. So we recommend that they eat fewer
frequent meals rather than 3 large meals because the new intestines
or the new stomach if you will needs to adapt to this new lifestyle
so that’s a major change in an individual’s lifestyle after surgery
and we’ll work with them as they progress after surgery. We divide gastric cancer into locations
within the stomach, so patients who have tumors in the middle
or the rest of the… what we call distal third
or the end of the stomach, we do not remove the entire stomach,
we remove nearly 70% of the stomach, ensure that the tumor has been resected
by assessing the margins and we leave a portion of the stomach behind
and connect the intestine to the stomach. These individuals tend to have less problems
tolerating their nutrition after surgery. However, individuals who have their gastric
cancer in the beginning of the stomach or involving a portion of the esophagus,
the entire stomach needs to be removed in order to re-sect the tumor itself
and then the intestine is reconnected to the esophagus itself. So there’s
no new stomach created, it’s an intestine that’s becoming
the conduit or becomes the connection between the esophagus and the rest
of the intestine. And that portion takes a while for it
to adapt to smaller frequent meals than the big large meals that we are
used to having 3 times a day. So we definitely offer patients
diagnostic laparoscopy to ensure that the tumor hasn’t spread
to other organs. One of the other techniques we’re
considering here is a sentinel lymph node biopsy
for patients with gastric cancer, that is to assess where does gastric
cancer spread to, which lymph node and that helps the pathologist identify
the lymph node. We’re not sure if this technique will help
the overall survival of patients but it’s something that we’re considering. Here at Georgetown Lombardi
Comprehensive Cancer Center patients with specific gastric cancer,
we assess them for a special mutation in their
receptor of their gastric cancer, and see if they have a mutation
in their receptor then they’re offered a specialized
chemotherapy afterwards as well.

5 thoughts on “Surgical Oncology for Stomach Cancer: Ask Dr. Waddah Al-Refaie”

  1. these docs know nothing about alternative and nutrition. so having cancer, that is scary to me.. all they want to do is kill with chemo and not repair. how can that be good thing. No wonder so many die. chemo helps like 2.1% according to major 14 yr long survey. no wonder

  2. well, have to give him a plus cause MOST cancer doctors do not even want to talk nutrition. and its so important with ALL cancers.

Leave a Reply

Your email address will not be published. Required fields are marked *