Gastric Cancer Flashcards
What is the genetic mutation implicated in Hereditary Gastric Cancer? What other cancer is implicated? For those that are carriers what do you do?
CDH-1/E-cadherin gene. It is autosomal dominant and can also be assoc with lobular breast cancer. Those who are carriers you do gastrectomy. CTNAA1 is another mutation that can lead to this syndrome as well.
I don’t think it’s useful to remember this in isolation, but just take note of the genetic syndromes that can cause gastric cancer.
Lynch syndrome, FAP (APC gene) which is auto dominant, Juvenile Polyposis (SMAD4, BMPR1A, BMPR1A, ENG), Puetz Jeghers (STK11), Li Fraumeni (Tp53, auto dominant). BRCA-although low risk.
For patients with gastric cancer that have a T3 or N+ disease what diagnostic test should be done?
They need ex-lap to rule out peritoneal disease.
What did the Dutch study show for survival benefit for a D1 vs D2 resection (15 years worth of data)?
There is a greater survival benefit with a D2 resection. Remember D2 takes away additionally the celiac, gastrohepatic, and splenic nodes (lesser and greater curvature nodes at baseline)
For patients that have any type of nodal disease (locally advanced dx) what is the optimal treatment approach?
T1b-go to surgery. T2 lesions-Cat 1 rec is to give perioperative tx before and after surgery with FLOT regimen. You can proceed directly to surgery, but this isn’t preferred. Chemo/RT is a Cat2B rec. IO for MSI-H/dMMR
What are the IO options for N+ disease where you want to give perioperative tx before surgery?
Nivo/Ipi followed by Nivolumab maintenance-given neoadjuvant and then adjuvant Nivo
Pembro-given neoadjuvant
Tremelimumab and durvalumab for neoadjuvant only.
If you have less than a D1 resection or a D1 resection, what adjuvant tx should you get?
You need chemo/RT using CAPOX or FOLFOX
For those who have disease that is unresectable what are their tx options?
Chemo/RT or chemo alone
For those that got perioperative chemo and undergo resection but have R1 or R2 dx what do you do?
R1 and R2-chemo/RT if they didn’t receive before surgery (FOLFOX or CAPOX)
You can consider re-resection for R1 dx
What are the first line tx options for metastatic gastric cancer that is HER2 neg?
Remember it is essentially the same as the options for esophageal. FOLFOX/CAPOX with Nivoumab (CPS of 5 or more) or you can use Pembro (CPS of 1 or higher, but only Cat 1 for 10 or higher, Cat2B for less than 10). FOLFOX or CAPOX alone for those who don’t qualify for IO. Cisplatin can be exchanged for Oxali.
What are the options for metastatic gastric ca that is HER2+?
FOLFOX or CAPOX w/Trastuzumab. You can also add Pembro to the above regimen for those with CPS of 1 or higher. You can also Cisplatin as opposed to Oxali and add Pembro or just with Trastuzuamb alone (w/o Cisplatin).
What are the options for MSI-H/dMMR metastatic gastric cancer?
Pembro, Dostarlimab, Ipi/Nivo, FOLFOX w/Nivo or Pembro
What is the Cat 1 rec for second line therapy in metastatic disease?
Paclitaxel/Ramucirmab. If they can’t use a taxane, you can do FOLFIRI w/Ramucirumab. Other options: Docetaxel, Paclitaxel, Irinotecan.
When can Lonsurf (trifluridine/tipiracil) be used in metastatic gastric cancer?
You can only use it in third line and beyond
Be aware of the options for targeted therapy in the 2nd line setting for metastatic disease. NTRK, BRAF, RET, MSI-H/dMMR?
NTRK-Entrectinib, Larotrectinib, Repotrectinib
RET-Selpercatinib
BRAF-Dabrafenib/Trametinib
MSI-H/dMMR-Pembro, Dostarlimab, or Ipi/Nivo
TMB-H-Pembro (10 or higher)
