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A1-G Surg Note Stomach > Gastric Adenocarcinoma > Flashcards

Gastric Adenocarcinoma Flashcards

1
Q

What common pathway do many risk factors for gastric cancer share?

A

Chronic inflammation leading to dysplasia.

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2
Q

What are some environmental risk factors for gastric cancer?

A

Long-term H. pylori infection
atrophic gastritis
gastroesophageal reflux disease
pernicious anemia
tobacco use
high-salt foods
and smoked meats high in nitrates.

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3
Q

What role does ascorbic acid play in reducing gastric cancer risk?

A

from fresh fruits and vegetables can neutralize carcinogenic nitrogen compounds and oxygen free radicals.

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4
Q

What genetic factors are linked to an increased risk of gastric cancer?

A

Overexpression of COX2
cyclin D2
p53 mutations
microsatellite instability (MSI).

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5
Q

Name some inherited syndromes associated with familial gastric cancer.

A

Hereditary diffuse gastric cancer
hereditary nonpolyposis colorectal cancer
Li-Fraumeni syndrome
and polyp-associated gastric cancer syndromes.

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6
Q

What percentage of primary gastric malignancies are adenocarcinomas?

A

95% of primary gastric malignancies are adenocarcinomas

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7
Q

What are the two other types of primary gastric malignancies besides adenocarcinoma?

A

Lymphoma (4%) and gastrointestinal stromal tumor (GIST, <1%).

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8
Q

What is the Borrmann classification of gastric cancer?

A

A classification based on the gross appearance of endoscopic findings:

Type I: Polypoid
Type II: Fungating
Type III: Ulcerated
Type IV: Diffusely infiltrating (linitis plastica)

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9
Q

What is linitis plastica in the context of gastric cancer?

A

Type IV gastric cancer that is diffusely infiltrating, leading to a rigid, thickened stomach wall.

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10
Q

What are the two histologic subtypes of gastric adenocarcinoma according to the Lauren classification?

A

Intestinal type and diffuse type

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11
Q

What characteristics are associated with the intestinal type of gastric adenocarcinoma?

A

increasing incidence with age
often linked to environmental risk factors
or precancerous conditions like atrophy and metaplasia.

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12
Q

What cell type characterizes the diffuse type of gastric adenocarcinoma?

A

Tiny clusters of small, uniform, signet ring cells.

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13
Q

How does the diffuse type of gastric adenocarcinoma typically spread?

A

It has high rates of early metastasis through
submucosal lymphatic spread and transmural extension.

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14
Q

Which type of gastric adenocarcinoma is more likely to be poorly differentiated?

A

The diffuse type

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15
Q

Why is gastric cancer often diagnosed at a late stage?

A

Symptoms are typically vague and nonspecific, often mistaken for dyspepsia, peptic ulcer disease, or gastritis

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16
Q

What are some common symptoms of gastric cancer?

A

Early satiety, weight loss, obstruction, dysphagia, and bleeding, with 40% of patients having some form of anemia at diagnosis.

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17
Q

What is Sister Mary Joseph’s node, and what does it signify?

A

A palpable periumbilical node that indicates distant metastatic nodal disease, historically observed as predictive of advanced intraabdominal disease

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18
Q

Name three eponymous signs of distant metastatic disease in gastric cancer

A

Virchow’s node (supraclavicular adenopathy)
Krukenberg tumor (ovarian metastases)
Blumer’s shelf (peritoneal metastases palpated in the pouch of Douglas).

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19
Q

What are the primary tools for clinical staging and diagnosis of gastric cancer?

A

Endoscopy
endoscopic ultrasound (EUS)
CT
PET
MRI
diagnostic laparoscopy with peritoneal washings.

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20
Q

How is endoscopy used in the diagnosis of gastric adenocarcinoma?

A

It confirms diagnosis, obtains biopsy specimens, and localizes the tumor for surgical planning, especially in relation to the gastroesophageal junction (GEJ).

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21
Q

What is the Siewert-Stein classification, and what does it describe?

A

It classifies proximal gastric tumors based on their location relative to the GEJ:

Type I: Distal esophagus, 1–5 cm above GEJ
Type II: Cardia, up to 1 cm above and 2 cm below GEJ
Type III: Subcardial, 2–5 cm below GEJ

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22
Q

Who undergoes selective screening with upper endoscopy for gastric cancer in the United States?

A

Patients with specific risk factors
such as gastric polyps, pernicious anemia, or certain genetic disorders

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23
Q

What is recommended by the NCCN regarding biopsy for gastric cancer diagnosis?

A

Taking multiple biopsy specimens from different areas of the lesion.

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24
Q

How are Siewert type III lesions classified and treated?

A

They are considered gastric cancers and should be treated according to gastric cancer protocols, ensuring adequate esophageal resection to achieve negative margins

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25
Q

What is the role of endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) in gastric adenocarcinoma?

A

EMR or ESD can be definitive treatment for small lesions (< 2 cm) confined to Tis or T1a tumors limited to the mucosa

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26
Q

Why is PET sometimes used alongside CT in gastric cancer staging?

A

To identify occult metastatic disease or evaluate suspicious lesions found on CT; PET can also assess response to neoadjuvant therapy

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27
Q

What is the role of endoscopic ultrasound (EUS) in the staging of gastric adenocarcinoma?

A

EUS provides accurate assessment of tumor depth and perigastric lymph node involvement; fine-needle aspiration (FNA) is used for suspicious nodes.

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28
Q

What does the NCCN recommend for staging laparoscopy in gastric cancer patients?

A

Staging laparoscopy is recommended for all patients with T2 or greater gastric cancer with no prior evidence of metastatic disease on imaging

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29
Q

What is the significance of positive peritoneal cytology in gastric cancer staging?

A

It indicates occult carcinomatosis and is associated with a poorer prognosis and lower disease-free survival

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30
Q

What is the typical treatment strategy for patients with T1 gastric tumors without nodal involvement or distant disease?

A

They are usually offered upfront surgery.

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31
Q

When is neoadjuvant chemotherapy indicated for gastric adenocarcinoma patients?

A

with T2 or T3 invasion depth
or any evidence of adenopathy

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32
Q

What is hyperthermic intraperitoneal chemotherapy (HIPEC), and when is it considered in gastric cancer treatment?

A

offered to patients with low-burden or occult peritoneal disease after neoadjuvant therapy and during gastrectomy to treat peritoneal metastasis.

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33
Q

What types of nodal involvement or conditions exclude gastric cancer patients from resection for cure?

A

Distant metastasis
N3 (root of mesentery nodal involvement)
N4 (paraaortic nodal involvement)
major vascular encasement (excluding splenic vessels).

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34
Q

What is the purpose of molecular profiling in gastric cancer?

A

To understand the biological behavior of the tumor and identify targets for biologic immune therapy.

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35
Q

Why is HER2 testing recommended for gastric adenocarcinoma patients with metastatic disease?

A

can influence treatment options, as HER2-targeted therapies are available

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36
Q

What role does PD-L1 expression play in gastric cancer treatment?

A

PD-L1 expression influences treatment decisions, as its pathway inhibits T cell proliferation and is targeted in immunotherapy

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37
Q

What demographic and clinical features are associated with MSI in gastric cancer?

A

MSI is associated with older age, female sex, fewer lymph node metastases, and a distal stomach location.

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38
Q

How does MSI status affect survival outcomes compared to microsatellite stable (MSS) gastric tumors?

A

Patients with MSI gastric tumors generally have superior survival outcomes compared to MSS patients

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39
Q

Why is chemotherapy typically not recommended for MSI gastric cancer patients?

A

chemotherapy may worsen survival in MSI patients, unlike in MSS patients.

40
Q

What immunologic characteristic is reported in MSI gastric cancer subtypes?

A

Strong immunogenicity with increased expression of checkpoint ligands like PD-L1, making these patients more suitable for immunotherapy

41
Q

What does a D1 nodal dissection involve?

A

Gastrectomy with resection of the greater and lesser omenta and perigastric lymph nodes (stations 1 to 7).

42
Q

Which nodal stations are included in a D2 nodal dissection?

A

D1 stations plus those along the left gastric, common hepatic, celiac, splenic artery, and splenic hilum (stations 1 to 12).

43
Q

What additional clearance does a D3 nodal dissection include?

A

Periaortic nodes (stations 1 to 16)

44
Q

What were the findings of the Dutch Gastric Cancer Trial regarding D2 lymphadenectomy?

A

It showed improved disease-specific survival for D2 dissection over D1.

45
Q

What are the NCCN guidelines for lymphadenectomy in gastric cancer?

A

They recommend a D2 dissection without splenectomy.

46
Q

What is “D1 over” and when is it used?

A

“D1 over” is a modified D2 dissection where only certain nodes are removed without full dissection of the splenic artery and hilum

47
Q

What is the typical approach for cancers in the distal stomach?

A

Distal or subtotal gastrectomy, with a 4- to 5-cm gross margin (Proximal)

distal transection > Across the first portion of the duodenum, just distal to the pylorus.

48
Q

What vessel is divided in the process of a distal gastrectomy?

A

The right gastroepiploic artery.

49
Q

Which lymph nodes are targeted with high ligation of the left gastric artery?

A

Station 7 lymph nodes.

50
Q

What is the common reconstruction method after distal or subtotal gastrectomy?

A

Roux-en-Y reconstruction

51
Q

What is a Billroth II gastrojejunostomy typically reserved for?

A

Patients with stage IV disease due to its risk of alkaline reflux gastritis

52
Q

What is the role of frozen section analysis during gastrectomy?

A

To assess surgical margins before reconstruction, with further resection needed if margins are positive.

53
Q

What is recommended if a distal gastrectomy shows a positive margin?

A

Further resection is mandated.

54
Q

When is a total gastrectomy typically used?

A

For most midbody and proximal tumors.

55
Q

What type of gastrectomy is sometimes used for small gastric tumors near the gastroesophageal junction (GEJ) but is uncommon in the United States?

A

Proximal gastrectomy

56
Q

How do oncologic outcomes of proximal gastrectomy compare to total gastrectomy?

A

They are believed to be equivalent, although the total lymph node harvest may be lower with proximal gastrectomy.

57
Q

What complications were reported in earlier studies following proximal gastrectomy?

A

Higher rates of anastomotic stenosis and reflux esophagitis

58
Q

How does contemporary proximal gastrectomy differ from earlier versions?

A

Contemporary proximal gastrectomy does not typically resect the majority of the stomach, allowing for a larger remnant pouch.

59
Q

What advantage does a larger remnant stomach pouch offer in proximal gastrectomy?

A

It may improve postoperative nutrition

60
Q

According to Japanese studies, what percentage of the stomach should remain for proximal gastrectomy to offer better functional results than total gastrectomy?

A

More than 50% of the stomach should remain

61
Q

When is a total gastrectomy preferred over proximal gastrectomy due to bile reflux concerns?

A

When more than 50% of the stomach tissue needs to be removed

62
Q

For which patients might a proximal gastrectomy be particularly appropriate?

A

Patients with less physiologic reserve to tolerate a total gastrectomy

63
Q

How is exposure for dissection and reconstruction achieved in proximal gastrectomy?

A

By dividing the diaphragm in the midline after ligating the crossing phrenic vein

64
Q

What anatomical structure is mobilized by opening the diaphragmatic hiatus in proximal gastrectomy?

A

The distal mediastinal esophagus.

65
Q

What type of anastomosis is performed in proximal gastrectomy, and over what device is it done?

A

A primary esophagogastrostomy in an end-to-side manner, performed over a nasogastric (NG) tube.

66
Q

Where does the anastomosis lie after reapproximation of the diaphragm in proximal gastrectomy?

A

In the low mediastinum.

67
Q

For which patients is pylorus-preserving gastrectomy indicated?

A

Patients with early gastric cancer (T1N0M0) located in the middle-third of the stomach, at least 4.0 cm away from the pylorus.

68
Q

When might surgery be considered for advanced gastric cancer?

A

In carefully selected patients, particularly those requiring a multivisceral en bloc resection

69
Q

What is the purpose of a multivisceral en bloc resection in locally advanced gastric adenocarcinoma?

A

To achieve an R0 resection, leading to a significant survival benefit over palliative resection or chemotherapy alone

70
Q

What procedures might be involved in multivisceral resection for gastric cancer invading nearby organs?

A

Distal pancreatectomy, splenectomy, or pancreaticoduodenectomy

71
Q

For patients with limited peritoneal disease (PCI ≤ 7), what treatment may be beneficial?

A

Cytoreductive surgery (CRS) and HIPEC, in addition to systemic chemotherapy and gastrectomy.

72
Q

Why is preoperative diagnostic or staging laparoscopy important for patients with gastric cancer?

A

To identify patients who may benefit from an aggressive CRS and HIPEC approach

73
Q

What is the leak rate associated with distal gastrectomy?

A

1% to 2%.

74
Q

What is the authors’ practice regarding NG tube management after distal gastrectomy?

A

The NG tube is typically removed in the operating room

75
Q

When do patients typically begin a clear liquid diet after distal gastrectomy?

A

The night of surgery or the following day.

76
Q

What is the expected discharge timeline for distal gastrectomy patients on an ERAS pathway?

A

Postoperative day 3 to 5.

77
Q

How does the postoperative care for total gastrectomy differ from distal gastrectomy?

A

Total gastrectomy requires a longer hospital stay and a slower diet progression.

78
Q

What study is performed for total gastrectomy patients with an esophageal anastomosis, and when?

A

A fluoroscopic swallow study on postoperative day 3

79
Q

How is diet progression managed for total gastrectomy patients after a swallow study?

A

Progression from liquids to soft foods, with discharge on either a soft or regular diet

80
Q

When is a jejunal feeding tube typically used post-gastrectomy?

A

Only in select cases, such as older patients with preoperative weight loss, malnutrition, or frailty

81
Q

For which patients has systemic chemotherapy shown a survival advantage in combination with surgery?

A

Patients with gastric adenocarcinoma greater than T2N0 disease.

82
Q

What are common first-line chemotherapy regimens for gastric adenocarcinoma?

A

FLOT (5FU, leucovorin, oxaliplatin, docetaxel)

CAPOX (capecitabine and oxaliplatin)

FOLFOX (5FU, leucovorin, oxaliplatin)

ECF (epirubicin, cisplatin, 5FU).

83
Q

Why is there a shift from adjuvant to neoadjuvant therapy in gastric cancer?

A

Due to high failure rates in completing adjuvant therapy, often from surgical complications and poor patient performance status

84
Q

What were the findings of the MAGIC trial regarding perioperative chemotherapy?

A

Improved outcomes in local recurrence, distant metastases, and 5-year overall survival for patients receiving perioperative chemotherapy with ECF vs. surgery alone

85
Q

What was the outcome of the FLOT4-AIO trial comparing FLOT to the MAGIC regimen?

A

four preoperative and four postoperative cycles of FLOT.

significant improvement in median overall survival with the FLOT regimens (50 vs. 35 months)

MAGIC trial : a 3-week cycle of ECF preoperatively and three additional cycles postoperatively.

86
Q

What was the outcome of the CheckMate-649 trial regarding nivolumab for advanced gastric cancer?

A

Nivolumab combined with chemotherapy improved survival in PD-L1 positive advanced gastric, GEJ, and esophageal cancer compared to chemotherapy alone (13.8 vs. 11.6 months median survival)

87
Q

How does HER2 overexpression impact gastric cancer treatment?

A

HER2 plays a role in cell growth and proliferation, and therapies targeting HER2 (such as trastuzumab) can improve survival in HER2-positive advanced gastric cancer

88
Q

What does postoperative surveillance for gastric cancer include?

A

History and physical examination, basic laboratory tests, and a CT scan every 3 to 6 months for 1-2 years

then every 6 to 12 months until 5 years post-treatment

89
Q

When do most cases of recurrent gastric cancer present after initial treatment?

A

Within the first 4 to 5 years.

90
Q

What is the first-line therapy for recurrent gastric cancer?

A

Two-drug chemotherapy regimens, with three-drug regimens for patients with good performance status.

91
Q

Can surgery be considered for recurrent gastric cancer?

A

Yes, for resectable locoregional recurrence in medically fit patients, though not strongly supported by prospective data.

92
Q

What percentage of gastric cancer patients initially present with unresectable or metastatic disease?

A

Approximately 50%.

93
Q

What are common symptoms of progressive gastric cancer?

A

Bleeding, obstruction, nausea, and pain.

94
Q

How can bleeding from gastric cancer be managed palliatively?

A

Endoscopic coagulation
with adjuncts like external beam radiation or angiographic embolization for recurrent bleeding.

95
Q

What are some palliative options for managing gastric outlet obstruction in gastric cancer?

A

External beam radiation therapy
chemotherapy
endoscopic stent placement
surgical gastrojejunostomy
venting gastrostomy
selective palliative gastrectomy.

96
Q

What supportive options may be required for patients who cannot tolerate an oral diet due to gastric cancer?

A

A gastrostomy or jejunal feeding tube for hydration and nutritional support

A1-G Surg Note Stomach (11 decks)

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