Gastric cancer

Question 1

Most common type of gastric cancer

Answer 1

• Adenocarcinoma
• Rest are connective tissue eg GIST, lymphoid, neuroendocrine malignancy

Question 2

Where is gastric cancer common?

Answer 2

• Rates fallen in many countries due to improved diet and treatment of h-pylori
• More common in far east eg Japan and Korea

Question 3

RF for gastric cancer

Answer 3

• Male
• H-pylori
• Increasing age
• Smoking
• Alcohol consumption

Question 4

Why does h-pylori increase risk?

Answer 4

• Acute gastritis
• –> metaplasia
• –> dysplasia
• –> malignancy

Question 5

Symptoms of gastric cancer

Answer 5

• VAGUE - present late
• Dyspepsia (new onset, not responsive to PPI)
• Dysphagia
• Early satiety
• Vomitting
• Melena
• Anorexia, weight loss or anaemia are markers of late stage

Question 6

Examination findings of gastric cancer

Answer 6

• Epigastric mass - late stage
• Troisier sign - palpable left supraclavicular node (Virchows node) - sign of metastatic abdominal malignancy
• Hepatomegaly, ascites, jaundice or acanthosis nigricans

Question 7

Bedside and bloods for ?gastric cancer

Answer 7

• Urgent bloods - FBC, LFT, clotting, group and save if bleeding presentation

Question 8

Imaging for gastric cancer

Answer 8

• Upper GI endoscopy - OGD with biopsies

Question 9

What should biopsies suspecting gastric cancer be sent for?

Answer 9

• Histology - classification and grading
• CLO test - h-pylori present? (rapid urease test)
• HER2/neu protein expression - targetted monoclonal therapies if present

Question 10

Problem with CT for gastric cancer

Answer 10

• May show thickening of gastric wall but does not allow direct visualisation or biopsy
• OGD is only definitive means

Question 11

Staging for gastric cancer

Answer 11

• CT chest abdomen pelvis
• Staging laparoscopy - peritoneal mets?
• PET scans rarely used due to the gastric cancers not being very ‘PET avid’ - don’t take up tracer well

Question 12

General management gastric cancer

Answer 12

• MDT
• Adequate nutrition - dietician, may need NG tube or RIG pre and post treatment

Question 13

Curative treatment for gastric cancer

Answer 13

• Peri-operative chemotherapy - 3 cycles neo, 3 cycles adjuvant
• Remove tumour and local lymph nodes - loco-regional control

Question 14

Operation for proximal vs distal gastric cancers

Answer 14

• Proximal - total gastrectomy
• Distal (antrum or pylorus) - subtotal gastrectomy
• Spleen and distal pancreas may be removed if there is direct invasion of these organs and still chance of cure

Question 15

How is reconstruction achieved post surgery?

Answer 15

• Roux-en Y reconstruction
• Distal oesophagus is end to end anastomosed directly to small bowe
• Small bowel end to end anastomosed to small bowel

Question 16

Early T1a tumour management - confined to muscularis mucosae

Answer 16

• Endoscopic mucosal resection (EMR) or
• Endoscopic submucosal dissection (ESD)

Question 17

Gastrectomy complications

Answer 17

• Death
• Anastomotic leak
• Duodenal stump leak
• Re-operation
• Dumping syndrome
• Vitamin B12 deficiency - injections

Question 18

What is dumping syndrome?

Answer 18

diarrhea, nausea, and feeling light-headed or tired after a meal, that are caused by rapid gastric emptying

Question 19

Palliative management gastric cancer

Answer 19

• Chemotherapy
• Best supportive care
• Stenting - if have GOO secondary to obstructing cancer
• Palliative surgery - distal gastrectomy or bypass (gastro-jejunostomy) if stenting fails or unavailable - caution if bleeding tumour

Question 20

Complications of gastric cancer

Answer 20

• Gastric outlet obstruction
• Iron deficiency anaemia
• Perforation
• Malnutrition