Gastric Cancer

Question 1

Epidemiology / trends

1. ranking
2. trend

Answer 1

• 5th malignoma
• global diminution but increase in proximal tumors
• decrease in intestinal tumors

Question 2

Risk factors

Answer 2

H. Pylori - Chronic atrophic gastritis
Pernicious anemia
Adenomatous megapolypes
Morbus Ménétrier
Previous gastric surgery (gastric stump carcinoma)

Question 3

Morbus Ménétrier

Answer 3

Premalignant disease
Excessive secretion of TGFα
Massive gastric folds
Excessive mucous secretion (protein loss, weight loss, edema)
Little or no acid secretion.
Seldom bleeding (erosion)
Cetuximab (EGFR monoclonal antibody)
Anticholinergic, prostaglandins, PPI
or Surgical
Typical age 40-60

Question 4

Most common types of gastric cancer

Answer 4

Adenocarcinoma
Lymphome (MALT)
Stroma tumor

Question 5

Classification (endoscopic aspect)

Answer 5

I : protruding
II : superficial
III : excavated

Question 6

Classification (histologic)

Answer 6

Lauren

• intestinal type (limited to glandular cells, limited growth)
• diffuse carcinoma (increased extension risk), E-Cadherin mutation and loss of cellular adhesion. Associated with linitis plastica

Question 7

Clinical signs (Hx and PE)

Answer 7

Unspecific
Sensation of stomach fullness
Loss of appetite
Dysphagia (advanced)
Weight loss (advanced)
Upper GI bleeding (20% of cases)
Hepatomegaly, icterus, ascitis (advanced)
Virchow (supraclavicular lymph nodes)

Question 8

Diagnostic

Answer 8

Endoscopy and Biopsy (histology + H. Pylori)
EndoUS (depth, lymph node) but less efficient than Eso and rectum
CT abdomen thorax
Staging laparoscopy +/- jejunostomy

Question 9

Resection margin

Answer 9

Intestinal type 5cm

Diffuse type 10cm

Question 10

If submucosa involved

Answer 10

20% lymphnode metastasis

Question 11

Type of resection

Answer 11

• Wedge resection : GIST and benin tumors
• Distal gastrectomy : only for distal, intestinal type
• Subtotal gastrectomy : only for distal intestinal type, A. gastrica sin. is also taken.
• Total gastrectomy : proximal type, signet cell carcinoma >uT2, Kardia Siewert II and III.

Question 12

Type of lymphadenectomy

Answer 12

D1 : Station 1-6, only in palliative situations and high risk patients
D2 : Statin 1-11, Goldstandard

Question 13

D1

Answer 13

CRAWL, OLGA, PSI
C:RL, O:LG, P:SI

1 RC Right cardia
2 LC Left cardia
3 LO Lesser omentum
4 GO Greater omentum
5 SP Suprapyloric
6 IP Infrapyloric

Question 14

D2

Answer 14

7 LG Left Gastric
8 CH Common Hepatic
9 Coeliac
10 Splenic hilum
11 Splenic artery

Question 15

D3

Answer 15

12 HD Hepatoduodenal
13 PHD Posterior Head of Pancreas
14 SMA

Question 16

Type of reconstructions

Answer 16

Total
- Roux Y
- Ileocoecal interponat
Subtotal
- Roux Y
- Omega Loop with Braunscher Anastomosis
Gastro-enterostomy
- cross section with fusspunkt

Question 17

Distant lymph nodes (Eponyms)

Answer 17

Periumbilical (Sister Mary Joseph)
Subclavicular (Virchow)
Blumer’s shelf (prerectal metastases)

Question 18

Staging Laparoscopy

Answer 18

Identifies metastases in up to 40% of patients with negative staging CT

Question 19

Operative approach

Answer 19

uT1 m1-sm1 No, <3cm : endoscopic resection
cT1N0 and cT2N0 : resection + adjuvant therapy
cT1/2 N1-2 and cT3/4 N0-2 : neoadjuvant, resection, adjuvant
M1 : palliative