Gastric cancer Flashcards
What are the main risk factors for gastric cancer?
H.Pylori
Preserved meats / salted foods
Lack of vegetables/greens
? prolonged PPI use
Inherited - CDH-1 mutation (E-cadherin)
- FAP
- Li-Fraumeni syndrome
- HNPCC/Lynch syndrome
Polyps
What are the differences between intestinal and diffuse gastric cancer?
What are the main symptoms of gastric cancer?
Epigastric pain (not relieved by eating), early satiety, weight loss
Advanced - gastric outlet obstuction or dysphagia or anaemia
How many LNs are required for adequate staging of adenocarcinoma
16
What is the siewert classifcation system used for?
Type 1 (2-5cm above GO junction) and 2 (1cm above GO junction) are treated as oesophageal adenocarcinoma while Type 3 (2-5cm caudad to GO junction) is treated as gastric adenocarcinoma
What are the recommendations for number of biopsy to maximise diagnostic yield?
6-8
At what size for a gastric lesion can endoscopic mucosal resection be used?
< 2cm
Why does staging laparoscopy alter management for gastric cancer?
Peritoneal disease not picked up with imaging. 20-30% of patients with gastric cancer and no prior evidence of metastases with have metastasis found.
How does staging laparoscopy help in the work up for patients with gastric cancer?
Postive peritoneal washings without overt metastasis may be an indication for neoadjuvant therapy
Reduces need for laparotomy
Consider repeat after neoadjuvant chemotherapy
What are the contraindications for surgical resectrion with curative intent for gastric cancer?
No metastasis
No invasion of unresectable vascular structures (aorta, celiac trunk, proximal common hepatic, proximal splenic artery)
What are the criteria for endoscopic resection of gastric adenocarcinoma?
Intestinal adenocarcinoma
Tumour confined to mucosa
No LV invasion
Non ulcerated tumour
What is the role of PET/CT in work up of gastric cancer?
Useful in locally advanced cancer and for patients considered for neoadjuvant therapy. This is because the detection rate for PET/CT of metastasis is better than CT alone
NCCN guidelines recommend considering PET/CT as part of staging for patients with greater than T1 disease without evidence of metastatic disease on initial CT.
Townsend, Courtney M.. Sabiston Textbook of Surgery E-Book (p. 2823). Kindle Edition.
What is the criteria for surgical resection gastric cancer?
No metastasis
No involvement or irresectable vascular structures (aorta, coeliac artery, proximal common hepatic, proximal splenic)
T4 - needs adjacent structures to be taken enbloc
What are the locations of transection for distal gastrectomy?
Proximal margin: level of incisura, 2-3 cm for early gastric cancer and 4-6cm for advanced cancer
Distal margin: prox duodenum, just distal to pylorus
What are the reconstruction options for distal gastrectomy?
Roux-en-Y
Billroth
What are the surgical options for middle gastric cancer?
Early cancers - pylorus preserving segmental gastrectomy versus distal gastrectomy
What are the management options for proximal gastric cancers?
Total gastrectomy with roux en y reconstruction
Proximal gastrectomy (reflux esophagitis and oesophageal stenosis rates higher). Also LN harvest may be inadequate
What is the difference between D1 and D2 dissection for gastric cancer?
D1 is perigastric (1-7)
D2 is clearance of coeliac axis with or without splenectomy (1-12a)
Is D1 or D2 resection recommended for curative intent of gastric cancer?
D2, cochrane review of 5 RCTs showed improved hazard ratio of 0.81 in favor of D2
What is the MAGIC trial for gastric cancer?
RCT 503 patients with resectable GE cancer
perioperative chemoTx and surgery versus surgery alone
resected tumours smaller and less advanced in perioperative chemtx group
Overall survival HR 0.75 (CI 0.6 - 0.93), 5 year survival 36% v 23, progression free survival 0.66 (CI o.53-0.81)
Not all completed pre and post oeprative chemotx
What is the FLOT4 trial?
RCT, locally advanced resectable gastric cancer (>T2 &/or N+, M0)
(Siewert classification included)
4 cycles of FLOT and 3 cycles of ECF pre and post operatively
Overall survival: HR 0.77 (CI 0.63-0·94)
Median overall survival 50 v 35 months
Similar adverse effects
