Gastric Cancer

Question 1

… cancer is the 17th most common malignancy in adults in the UK.

Answer 1

Gastric (stomach) cancer is the 17th most common malignancy in adults in the UK.

Question 2

The stomach is a muscular organ that is part of the gastrointestinal (GI) tract. It is located at the distal end of the … beyond the gastro-… junction. The stomach is essential for digestion.

Answer 2

The stomach is a muscular organ that is part of the gastrointestinal (GI) tract. It is located at the distal end of the oesophagus beyond the gastro-oesophageal junction (GOJ). The stomach is essential for digestion.

Question 3

The stomach is divided into five anatomical components known at the cardia, …, body, … and …. The pylorus marks the entry into the duodenum and the whole stomach is composed of columnar epithelium. For more information see our notes on gastrointestinal physiology.

Answer 3

The stomach is divided into five anatomical components known at the cardia, fundus, body, antrum and pylorus. The pylorus marks the entry into the duodenum and the whole stomach is composed of columnar epithelium. For more information see our notes on gastrointestinal physiology.

Question 4

Over 90% of gastric cancers are …, which is historically divided into two histological subtypes known as intestinal and diffuse (based on Lauren criteria):

Answer 4

Over 90% of gastric cancers are adenocarcinoma, which is historically divided into two histological subtypes known as intestinal and diffuse (based on Lauren criteria):

Intestinal-type: most common, gland-forming. Further divided into papillary, tubular or mucinous adenocarcinomas.

Diffuse-type: less common, composed of discohesive cells. Classically signet cells see on histology. Can lead to extensive infiltration of the stomach and more likely to have a familial element.

Question 5

Over 90% of gastric cancers are adenocarcinoma, which is historically divided into two histological subtypes known as intestinal and diffuse (based on Lauren criteria): which is more common?

Answer 5

Intestinal-type: most common, gland-forming. Further divided into papillary, tubular or mucinous adenocarcinomas.

Diffuse-type: less common, composed of discohesive cells. Classically signet cells see on histology. Can lead to extensive infiltration of the stomach and more likely to have a familial element.

Question 6

Histology of gastric cancer

…-type: most common, gland-forming. Further divided into papillary, tubular or mucinous adenocarcinomas.
…-type: less common, composed of discohesive cells. Classically signet cells see on histology. Can lead to extensive infiltration of the stomach and more likely to have a familial element.

Answer 6

Intestinal-type: most common, gland-forming. Further divided into papillary, tubular or mucinous adenocarcinomas.
Diffuse-type: less common, composed of discohesive cells. Classically signet cells see on histology. Can lead to extensive infiltration of the stomach and more likely to have a familial element.

Question 7

Across the world, gastric cancer is the fourth most common malignancy. The highest incidence of gastric cancer is found in ….

Answer 7

Across the world, gastric cancer is the fourth most common malignancy. The highest incidence of gastric cancer is found in Eastern Asia (e.g. Korea, Japan), Eastern Europe, and Central and Latin America.

Question 8

In fact, due to the high incidence, … has a gastric cancer screening programme.

Answer 8

In fact, due to the high incidence Japan has a gastric cancer screening programme.

Question 9

Positron emission tomography (PET) is a modern non-invasive imaging technique for quantification of radioactivity in vivo. It involves the … injection of a positron-emitting radiopharmaceutical, waiting to allow for systemic distribution, and then scanning for … and … of patterns of radiopharmaceutical accumulation in the body.

Answer 9

Positron emission tomography (PET) is a modern non-invasive imaging technique for quantification of radioactivity in vivo. It involves the intravenous injection of a positron-emitting radiopharmaceutical, waiting to allow for systemic distribution, and then scanning for detection and quantification of patterns of radiopharmaceutical accumulation in the body.

Question 10

Gastric cancer is more common in older people with >…% of patients in the UK being over 75 years old. It is more common in … and strongly linked to environmental factors (discussed in aetiology).

Answer 10

Gastric cancer is more common in older people with >50% of patients in the UK being over 75 years old. It is more common in men and strongly linked to environmental factors (discussed in aetiology).

Question 11

If an upper GI cancer involves the GOJ, it may be classified and treated as an oesophageal or gastric cancer:

Epicentre of the tumour ≤2 cm from the GOJ: … cancer
Epicentre of the tumour >2cm from the GOJ: … cancer

Answer 11

If an upper GI cancer involves the GOJ, it may be classified and treated as an oesophageal or gastric cancer:

Epicentre of the tumour ≤2 cm from the GOJ: oesophageal cancer
Epicentre of the tumour >2cm from the GOJ: gastric cancer

Question 12

If an upper GI cancer involves the GOJ, it may be classified and treated as an oesophageal or gastric cancer:

Epicentre of the tumour ≤… cm from the GOJ: oesophageal cancer
Epicentre of the tumour >…cm from the GOJ: gastric cancer

Answer 12

If an upper GI cancer involves the GOJ, it may be classified and treated as an oesophageal or gastric cancer:

Epicentre of the tumour ≤2 cm from the GOJ: oesophageal cancer
Epicentre of the tumour >2cm from the GOJ: gastric cancer

Question 13

Traditionally, gastric cancer was classified based on the Lauren criteria (1965) into two histological subtypes:

Intestinal: more commonly seen in …, … ages and better prognosis
Diffuse: equal sex prevalence, seen in … patients, worse prognosis.

Answer 13

Traditionally, gastric cancer was classified based on the Lauren criteria (1965) into two histological subtypes:

Intestinal: more commonly seen in males, older ages and better prognosis
Diffuse: equal sex prevalence, seen in younger patients, worse prognosis.

Question 14

Traditionally, gastric cancer was classified based on the Lauren criteria (1965) into two histological subtypes:

…: more commonly seen in males, older ages and better prognosis
…: equal sex prevalence, seen in younger patients, worse prognosis.

Answer 14

Traditionally, gastric cancer was classified based on the Lauren criteria (1965) into two histological subtypes:

Intestinal: more commonly seen in males, older ages and better prognosis
Diffuse: equal sex prevalence, seen in younger patients, worse prognosis.

Question 15

Intestinal: more commonly seen in males, older ages and better prognosis
Diffuse: equal sex prevalence, seen in younger patients, worse prognosis.

These subtypes have very different clinical, pathological and molecular features. If diffuse gastric cancer involves a major portion, or all of the stomach, it may be referred to as linitis plastica or ‘… … stomach’.

Answer 15

These subtypes have very different clinical, pathological and molecular features. If diffuse gastric cancer involves a major portion, or all of the stomach, it may be referred to as linitis plastica or ‘leather bottle stomach’.

Question 16

More recently, the World Health Organisation (WHO) classified gastric cancers based on defined histological subtypes, which include:

…, tubular and mucinous adenocarcinoma: these correlate with the intestinal type based on the Lauren criteria
…-ring cell and other poorly cohesive carcinomas: these correlate with the diffuse type based on the Lauren criteria

Answer 16

More recently, the World Health Organisation (WHO) classified gastric cancers based on defined histological subtypes, which include:

Papillary, tubular and mucinous adenocarcinoma: these correlate with the intestinal type based on the Lauren criteria
Signet-ring cell and other poorly cohesive carcinomas: these correlate with the diffuse type based on the Lauren criteria

Question 17

More recently, the World Health Organisation (WHO) classified gastric cancers based on defined histological subtypes, which include:

Papillary, tubular and mucinous adenocarcinoma: these correlate with the … type based on the Lauren criteria
Signet-ring cell and other poorly cohesive carcinomas: these correlate with the … type based on the Lauren criteria

Answer 17

More recently, the World Health Organisation (WHO) classified gastric cancers based on defined histological subtypes, which include:

Papillary, tubular and mucinous adenocarcinoma: these correlate with the intestinal type based on the Lauren criteria
Signet-ring cell and other poorly cohesive carcinomas: these correlate with the diffuse type based on the Lauren criteria

Question 18

Early versus advanced gastric cancer

Classifying gastric cancers based on whether they are ‘early’ or ‘advanced’ refers to the extent of spread through the stomach wall, which includes the mucosa, submucosa, muscularis externa and serosa.

Difference between them?

Answer 18

Early: cancer confined to the mucosa or submucosa. May or may not be associated with lymph node involvement. Much better prognosis (>90% five-year survival). Further divided based on Paris classification of superficial GI lesions.

Advanced: cancer invades the muscularis and beyond. Much worse prognosis with five year survival ≤60%. May be associated with lymph node and distant metastasis. Described using Borrmann’s classification into four subtypes.

Question 19

Early gastric cancer - confined to…
Prognosis?
Classification?

Answer 19

Early: cancer confined to the mucosa or submucosa. May or may not be associated with lymph node involvement. Much better prognosis (>90% five-year survival). Further divided based on Paris classification of superficial GI lesions.

Question 20

Advanced gastric cancer - confined to…
Prognosis?
Classification?

Answer 20

Advanced: cancer invades the muscularis and beyond. Much worse prognosis with five year survival ≤60%. May be associated with lymph node and distant metastasis. Described using Borrmann’s classification into four subtypes.

Question 21

Type IV advanced gastric cancer based on Borrmann’s classification is similar to diffuse gastric cancer with a linitis plastica appearance (leather bottle stomach)

Answer 21

Type IV advanced gastric cancer based on Borrmann’s classification is similar to diffuse gastric cancer with a linitis plastica appearance.

Question 22

Gastric cancers are highly heterogeneous with numerous somatic mutations (i.e. occurring in the tumour) that differ significantly between individuals. TP.., also known as the ‘guardian of the genome’ because of its crucial role in the cell cycle is the most commonly identified mutation.

Answer 22

Gastric cancers are highly heterogeneous with numerous somatic mutations (i.e. occurring in the tumour) that differ significantly between individuals. TP53, also known as the ‘guardian of the genome’ because of its crucial role in the cell cycle is the most commonly identified mutation.

Question 23

Identifying molecular abnormalities (gastric cancer) has different clinical implications:

Guide treatment: identification of … positive tumours may be treated with trastuzumab (blocks the … receptor).
Determine prognosis: certain mutations are associated with more unstable tumours and worse prognosis.
Suggest hereditary aggregation: mutations in … are linked to hereditary diffuse gastric cancer (see below).

Answer 23

Identifying molecular abnormalities has different clinical implications:

Guide treatment: identification of HER2 positive tumours may be treated with trastuzumab (blocks the HER2 receptor).
Determine prognosis: certain mutations are associated with more unstable tumours and worse prognosis.
Suggest hereditary aggregation: mutations in CDH1 are linked to hereditary diffuse gastric cancer (see below).

Question 24

The gram negative bacterium … … has a significant role in the aetiology of gastric cancer.

Answer 24

The gram negative bacterium Helicobacter pylori has a significant role in the aetiology of gastric cancer.

Question 25

Gastric cancer is a very heterogeneous condition, which is influenced by a variety of environmental, infectious, and patient-related factors (e.g. genetics).

Environmental factors?

Answer 25

Smoking and diet are important environmental risk factors for gastric cancer formation

Smoking: increase risk of gastritis, peptic ulcers and malignancy
High salt intake: risk combined with presence of H. pylori infection. Thought to directly damage mucosa.
Inadequate intake of fruit and vegetables
Meat consumption: only possible link

Question 26

Smoking and diet are important environmental risk factors for gastric cancer formation - why?

Answer 26

Smoking: increase risk of gastritis, peptic ulcers and malignancy
High salt intake: risk combined with presence of H. pylori infection. Thought to directly damage mucosa.
Inadequate intake of fruit and vegetables
Meat consumption: only possible link

Question 27

Helicobacter pylori is a gram … spiral bacterium, which colonises the stomach. It has been implicated in up to 89% of … gastric cancers.

Answer 27

Helicobacter pylori is a gram negative spiral bacterium, which colonises the stomach. It has been implicated in up to 89% of non-cardia gastric cancers.

Question 28

H. pylori infection usually begins in childhood, although the precise mechanism for acquirement and transmission of the organism is not fully understood. It causes both acute and chronic inflammation that promotes abnormal cellular growth, genetic …, and … (discussed in pathophysiology).

Answer 28

H. pylori infection usually begins in childhood, although the precise mechanism for acquirement and transmission of the organism is not fully understood. It causes both acute and chronic inflammation that promotes abnormal cellular growth, genetic mutations, and dysplasia (discussed in pathophysiology).

Question 29

One of the main proteins involved in its pathogenies is CagA, which is an oncogenic protein that can disrupt epithelial intercellular junctions, increase cell proliferation, reduce apoptosis, and promote formation of adenocarcinomas

Answer 29

One of the main proteins involved in its pathogenies is CagA, which is an oncogenic protein that can disrupt epithelial intercellular junctions, increase cell proliferation, reduce apoptosis, and promote formation of adenocarcinomas

Question 30

Other infections linked to gastric cancer include …

Answer 30

Other infections linked to gastric cancer include Epstein-Barr virus (EBV).

Question 31

Patient-related factors include genetic polymorphisms (i.e. unique mutations that increase risk of gastric cancer), … anaemia (autoantibodies directed against parietal cells leading to vitamin B12 deficiency) and … disease (rare condition associated with overgrowth of glandular mucous cells).

Answer 31

Patient-related factors include genetic polymorphisms (i.e. unique mutations that increase risk of gastric cancer), pernicious anaemia (autoantibodies directed against parietal cells leading to vitamin B12 deficiency) and Menetrier’s disease (rare condition associated with overgrowth of glandular mucous cells).

Question 32

In addition, some genetic mutations can be inherited in an autosomal dominant pattern leading to a very high risk of gastric cancer including … … gastric cancer (HDGC).

Answer 32

In addition, some genetic mutations can be inherited in an autosomal dominant pattern leading to a very high risk of gastric cancer including hereditary diffuse gastric cancer (HDGC).

Question 33

… is a diffuse type of gastric cancer most commonly due to an inherited mutation in CDH1.

Answer 33

HDGC is a diffuse type of gastric cancer most commonly due to an inherited mutation in CDH1.

Question 34

… is inherited in an autosomal dominant pattern. The lifetime risk of gastric cancer is 70% in men and 56% in women. The median age at diagnosis is 38 years old.

Answer 34

HDGC is inherited in an autosomal dominant pattern. The lifetime risk of gastric cancer is 70% in men and 56% in women. The median age at diagnosis is 38 years old.

Question 35

The Correa cascade describes the classic sequence of histological lesions for the most common gastric cancer: intestinal type adenocarcinoma.

The sequence progresses from … to gastric …, which is high-risk of developing invasive carcinoma

Answer 35

The sequence progresses from normal gastric mucosa to gastric dysplasia, which is high-risk of developing invasive carcinoma:

Normal gastric mucosa
Chronic non-atrophic gastritis
Chronic atrophic gastritis (CAG)
Intestinal metaplasia
Dysplasia

Question 36

Distal gastric cancers (i.e. antrum or pylorus) are more commonly seen in countries with high incidence. Distal cancers are more likely to be intestinal type and associated with … infection. … gastric cancers (i.e. cardia) are more likely in low incidence countries and unrelated to H. pylori infection.

Answer 36

Distal gastric cancers (i.e. antrum or pylorus) are more commonly seen in countries with high incidence. Distal cancers are more likely to be intestinal type and associated with H. pylori infection. Proximal gastric cancers (i.e. cardia) are more likely in low incidence countries and unrelated to H. pylori infection.

Question 37

Symptoms of gastric cancer

Answer 37

Constitutional symptoms: fevers, anorexia, lethargy, weight loss
Dysphagia: if involvement of gastric cardia
Indigestion
Dyspepsia
Nausea/vomiting
Haematemesis/melaena
Post-prandial fullness

Question 38

Signs of gastric cancer

Answer 38

Usually absent unless late presentation with distant spread

Pallor
Cachexia
Lymphadenopathy
Virchow node: left supraclavicular node
Metastatic lesions
Hepatomegaly
Sister Mary Joseph nodule: periumbilical metastasis

Question 39

… node: left supraclavicular node

Answer 39

Virchow node: left supraclavicular node

Question 40

Sister Mary Joseph nodule: … metastasis

Answer 40

Sister Mary Joseph nodule: periumbilical metastasis

Question 41

… syndromes - These refer to the non-metastatic manifestations of malignancy.

Answer 41

These refer to the non-metastatic manifestations of malignancy.

Question 42

Paraneoplastic syndromes - gastric cancer

Answer 42

Acanthosis nigricans: velvety hyperpigmentation of the skin, usually in skin folds (e.g. axilla)
Dermatomyositis: inflammatory myopathy characterised by a helicotropic rash (purple rash around the eyes) and Gottron’s papules (red areas over the knuckles).
Erythema gyratum repens: erythematous rash with an annular (ring-shaped) appearance. Usually involves limbs and trunk.

Question 43

Gastric outlet obstruction (GOO) - when may this happen? What are some classic features of this?

Answer 43

GOO occurs when there is obstruction to emptying of the stomach at the pylorus. This may occur due to a fibrotic stricture of obstructing tumour.

Classic features include early satiety, abdominal fullness, nausea, vomiting, weight loss. On auscultation of the stomach there may be a succussion splash (sloshing sound heard on patient movement due to a full stomach).

Question 44

On auscultation of the stomach there may be a succussion splash (sloshing sound heard on patient movement due to a full stomach) - what is this describing?

Answer 44

Gastric outlet obstruction (GOO)

Question 45

Urgent (two week wait) referral

This means referring a patient for appropriate investigations (e.g. gastroscopy) for suspected gastric cancer within two weeks. It is usually combined with a clinic appointment and CT imaging.

What criteria needs to be met for this?

Answer 45

Upper abdominal mass consistent with gastric cancer, OR
Dysphagia, OR
> 55 years with weight loss and one of the following:
Upper abdominal pain
Reflux
Dyspepsia

Question 46

This means referral for a non-urgent gastroscopy to assess for gastric pathology. Usually performed within 6 weeks. What is the criteria?

Answer 46

Haematemesis, OR
> 55 years with treatment resistant dyspepsia, OR
> 55 years with upper abdominal pain and anaemia, OR
Thrombocytosis with one of the following:
Nausea/vomiting
Weight loss
Reflux
Dyspepsia
Upper abdominal pain
Nausea/vomiting with one of the following:
Weight loss
Reflux
Dyspepsia
Upper abdominal pain

Question 47

NOTE: Upper and lower gastrointestinal (GI) investigations should also be considered to investigate for GI malignancy (inc. gastric cancer) in all postmenopausal female and male patients where … has been confirmed unless there is a history of significant overt non-GI blood loss. British Society of Gastroenterology guidelines 2011.

Answer 47

NOTE: Upper and lower gastrointestinal (GI) investigations should also be considered to investigate for GI malignancy (inc. gastric cancer) in all postmenopausal female and male patients where IDA has been confirmed unless there is a history of significant overt non-GI blood loss. British Society of Gastroenterology guidelines 2011.

Question 48

Gastric cancer may be suspected based on clinical features or incidental finding on imaging (i.e. thickening of the gastric mucosa). However, definitive diagnosis is made using …

Answer 48

Gastric cancer may be suspected based on clinical features or incidental finding on imaging (i.e. thickening of the gastric mucosa). However, definitive diagnosis is made using upper GI endoscopy, known as gastroscopy.

Question 49

Bloods for suspected gastric cancer

Answer 49

Full blood count
Serum iron, transferrin saturation, total iron binding capacity (TIBC)
Urea & electrolytes
Liver function tests
Bone profile
Clotting screen
Renal function

Question 50

Imaging in suspected gastric cancer

Answer 50

CT chest/abdomen/pelvis: patients with suspected gastric cancer undergo CT imaging to help stage the cancer, which means assessing how locally advanced it is and looking for distant spread.
Abdominal ultrasound: may be used to assess for liver metastasis. Usually superseded by CT.
PET-CT: offered to patients with potentially resectable disease (i.e. candidates for surgery) to assess for distant disease not detected by conventional CT.

Question 51

Special tests in suspected gastric cancer

Answer 51

Gastroscopy: principle investigation for diagnosis
Endoscopic ultrasound (EUS): performed at time of endoscopy. Sometimes completed to help more accurately stage gastric cancer if it will change management
Diagnostic laparoscopy: can be offered to more accurately stage gastric cancer. Particularly important if the disease is locally advanced but potentially resectable.

Question 52

… testing should be completed on patients with metastatic gastric cancer as treatment directed against the … receptor may be used in treatment regimens.

Answer 52

Human epidermal growth factor receptor 2 (HER2) testing should be completed on patients with metastatic gastric cancer as treatment directed against the HER2 receptor may be used in treatment regimens.

Question 53

There are numerous treatment options for the management of gastric cancer:

Answer 53

Surgery: resection of gastric or gastro-oesophageal tumours (e.g. gastrectomy).
Endoscopic techniques: mucosal resection or mucosal dissection
Radiotherapy: use of high energy rays to destroy cancer cells.
Chemotherapy: use of anti-cancer medications to destroy cancer cells
Targeted cancer drugs: monoclonal antibodies against certain receptors (e.g. HER2)
Palliative care: use of chemotherapy or radiotherapy for disease or symptom control without aiming to cure
Best supportive care: focus primarily on symptoms and quality of life without systemic treatments.

Question 54

Determining choice

Surgical resection of gastric cancer is potentially curable. However, patients with locally advanced disease are high risk of recurrence so a combination of therapies is needed.

How do we decide between operable and non-operable?

Answer 54

Operable (early stage): refers to patients with T1 tumours without lymph node involvement or metastasis. Endoscopic or limited surgical resection may be suitable
Operable (advanced stage): refers to patients with >T1N0 tumours. All patients with stage IB-III gastric cancer may be considered for resection if fit enough. This needs to be combined with chemotherapy or chemoradiotherpy.
Non-operable: refers to patients who are not suitable for operative management or there is evidence of distant spread. Chemotherapy is the main option. A small proportion may be considered for surgery if significant response.

Question 55

Treatment algorithm based on the European Society of Medical Oncology (ESMO) for gastric cancer (operable)

Answer 55

Question 56

Surgical resection involves removal of the whole stomach or only a portion of the stomach. The remnant stomach or oesophagus is then joined to the jejunum. Options include: (3)

Answer 56

Subtotal gastrectomy
Total gastrectomy
Oesophago-gastrectomy (if GOJ involvement)

The choice of surgery depends on the location and size of the tumour and presence of lymph node involvement. Patients with lymph node involvement will usually undergo lymph node dissection at the time of surgery.

Question 57

Patients with small, early gastric cancers that are confined to the mucosa may be considered for endoscopic resection. There are two options:

Answer 57

Endoscopic mucosal resection (EMR)

Endoscopic submucosal dissection (ESD): treatment of choice

Question 58

The principle anti-cancer therapy in gastric cancer is chemotherapy. Pre-operative chemotherapy, which includes a combination of platinum/fluoropyrimidine should be offered to all patients with ≥stage … resectable gastric cancer.

Answer 58

The principle anti-cancer therapy in gastric cancer is chemotherapy. Pre-operative chemotherapy, which includes a combination of platinum/fluoropyrimidine should be offered to all patients with ≥stage IB resectable gastric cancer.

If patients undergo surgery before administration of chemotherapy, it should be offered post-operatively and may be combined with radiotherapy.

Question 59

Patients with advanced non-operable or metastatic gastric cancer should be offered … if fit enough.

Answer 59

Patients with advanced non-operable or metastatic gastric cancer should be offered chemotherapy if fit enough.

Question 60

The principle treatment for metastatic or non-operable gastric cancer is …

Answer 60

The principle treatment for metastatic or non-operable gastric cancer is chemotherapy. This is usually platinum/fluoropyrimidine combinations. Those who are not fit enough to undergo systemic treatment should undergo best supportive care, which focuses on symptom control and quality of life.

Question 61

Chemotherapy forms the principle treatment in patients with metastatic or non-operable gastric cancer, which improves quality of life and survival. Chemotherapy combination regimens depend on whether the tumour is … positive.

Answer 61

Chemotherapy forms the principle treatment in patients with metastatic or non-operable gastric cancer, which improves quality of life and survival. Chemotherapy combination regimens depend on whether the tumour is HER2 positive.

Question 62

HER2-… advanced/metastatic gastric cancer: double/triple chemotherapy regimens (e.g. oxaliplatin, 5-Fluorouracil +/- epirubicin)
HER-2-… advanced metastatic gastric cancer: Trastuzumab (monoclonal antibody against HER2-receptor) in combination with platinum/fluoropyrimidine chemotherapy.

Answer 62

HER2-negative advanced/metastatic gastric cancer: double/triple chemotherapy regimens (e.g. oxaliplatin, 5-Fluorouracil +/- epirubicin)
HER-2-positive advanced metastatic gastric cancer: Trastuzumab (monoclonal antibody against HER2-receptor) in combination with platinum/fluoropyrimidine chemotherapy.

Question 63

Performance status

This describes a patients’ level of functioning in terms of their ability to care for themselves, what they can do as part of their daily activities and their physical ability.

Performance status can be measures using the World Health Organisation (WHO) / Eastern Cooperative Oncology Group (ECOG) scale.

Answer 63

Grade 0: Fully active, able to carry out all normal activities.
Grade 1: Restricted physical activity but ambulatory and able to carry out light sedentary work (e.g. office work).
Grade 2: Ambulatory and capable of all self care but unable to carry out any work activities. Out of bed >50% of day.
Grade 3: Capable of only limited self-care, confined to bed or chair > 50% of waking hours.
Grade 4: Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair.
Grade 5: Death.

Question 64

Endoscopic therapy including insertion of pyloric stents or palliative surgical diversions (e.g. palliative gastro-jejunostomy) may be needed in patients with significant gastric … …

Answer 64

Endoscopic therapy including insertion of pyloric stents or palliative surgical diversions (e.g. palliative gastro-jejunostomy) may be needed in patients with significant gastric outlet obstruction.

Question 65

The five year survival of gastric cancer is poor at -…%.

Answer 65

The five year survival of gastric cancer is poor at ~20%.

Question 66

Why is gastric cancer survival poor?

Answer 66

The overall survival is poor because the disease is usually advanced at presentation and is more common in elderly patients who are likely to have multiple co-morbidities.