CT 2.3 Oesophago-gastric cancer

Question 1

what is dyspepsia

Answer 1

complex of upper GI symptoms that are present for >4 weeks

indigestion
epigastric pain
heartburn
bloating or fullness post prandial
N+ V

Question 2

what are the categories that dyspepsia can be split into

Answer 2

HPB - hepatopancreatobiliary

functional dyspepsia

GORD

peptic ulcer disease

Question 3

in patients over 60 how is dyspepsia investigated

Answer 3

refer for OGD and gastric biopsy

if any red flag symptom - fast track the OGD via 2wwr

Question 4

what is achalasia

Answer 4

disorder of the lower esophageal sphincter which fails to relax and does not allow passage of food into stomach. may have issues with contractions as well

causes:
- nerve damage?
- autoimmune?
- certain viral infections?

symptoms:
- dysphagia
- regurgitation
- weight loss
- chest pain
- coughing or choking
- heartburn

diagnosed via:
- manometry
- barium swallow
- endoscopy

Question 5

what can cause chronic heartburn

Answer 5

scleroderma
peptic stricture

Question 6

what questions to ask in a patient with dysphagia

Answer 6

• clarify whether difficulty occurs on initiation or a couple of seconds are swallowing
• any pain?
• difficulty with solids, liquids or both?
• progression…
• GORD symptoms positive or negative?
• red flag symptoms?
• haematemesis?

Question 7

what investigations to do in a patient presenting with UGI symptoms

Answer 7

• OGD and biopsy
• USS for biliary disease?
• CT thorax, abdo and pelvis in presence of red flag symptoms
• baseline bloods:
  FBC, U+E, LFTs, TSH, CRP, Calcium, HbA1C, Coeliac
  Serology, +/- HIV/HCV based on risk profile

Question 8

what investigations for biliary disease

Answer 8

• USS
• MRCP
• ERCP
• CT

Question 9

what investigation allows staging of oesophageal cancer

Answer 9

OGD and CT TAP

PET or CT for assessing distant mets

Question 10

what classification is used for tumours occurring at the GOJ

Answer 10

siewert-stein

Type I: adenocarcinoma of the distal oesophagus
Type II: adenocarcinoma of the cardia
Type III: sub-cardial type adenocarcinoma

Question 11

what nodes does oesophageal cancer spread to

Answer 11

cervical
paratracheal or mediastinal
celiac

Question 12

what nodes does gastric cancer spread do

Answer 12

perigastric nodes (those near the greater and lesser curvatures)

celiac nodes

supraclavicular

Question 13

how is adenocarcinoma of the oesophagus treated

Answer 13

neoadjuvant chemo or chemoradiotherapy

proceeded by surgical resection

can be followed with adjuvant chemo or radio

Question 14

how is SCC of the oesophagus treated

Answer 14

radical chemoradiotherapy.

if this is not effective can consider same route as adenocarcinoma

Question 15

what is familial gastric cancer

Answer 15

accounts for 1-3% of gastric cancers

caused by mutation in CDH1 gene which encodes for e-cadherin protein

causes diffuse gastric cancer which doesn’t form a lump but infiltrates through the wall of the stomach

• autosomal dominant inheritance pattern

Question 16

what therapies are avilable for advanced metastatic gastric cancer

Answer 16

systemic chemo
stenting/bypass obstruction
radiotherapy bleeding
best supportive care

Question 17

gastric cancer aetiology can be broadly categorised into which 4 categories

Answer 17

1) chromosomal instability - frequent p53 mutations
associated with aneuploidy

typically occur in GOJ and body of stomach

intestinal type gastric cancer

2) genomically stable - mutations in CDH1 gene (cadherin)
typically in fundus and body of stomach

diffuse type gastric cancer

3) microsatellite instability = high levels of hypermutation and defective mismatch repair (MLH1 gene)

typically in body and antrum of stomach

intestinal type gastric cancer

4) EBV associated
predominantly in fundus or body