Gastric cancer Flashcards
gastric cancer is classified into benign and malignant what are the benign tumors ?
epithelial - adenoma
mesenchymal - leiomyoma , fibroma , hemangioma , lipoma , neurinoma
what are the malignant neoplasms of the stomach ?
adenocarcinoma
adeno-squamous carcinoma
squamous cell carcinoma
small cel carcinoma
gastric MALT lymphoma
GIST - gastrointestinal stromal tumor
leiomyosarcoma
neuroendocrine tumors - carcinoids
metastatic - melanoma and breast
what is the most common malignant cancer in the stomach ?
adenocarcinoma
adenocarcinoma is histologically classified into what categories ?
Lauren classification :
intestinal
diffuse type
and mixed morphology
describe intestinal gastric adenocarcinoma ?
majority of patients have this
different grades due to different differentiation usually retained glandular structure
minimum invasiveness
SHARP margins
associated with atrophic gastritis - intestinal metaplasia and dysplastic changes
often polypoid or exophytic bulky lesions
associated with environmental risk factor and diet
describe diffuse type of gastric cancer according to lauren classification
infiltrative - into the stomach wall without making obvious mass lesions/ deceptive margins - ulcerating lesions
and often intraperitoneal metastasis
WORST PROGNOSIS - POORLY DIFFRENTIATED - SIGNET RING CELLS
no associated with environmental risk factors and diet - more often in younger population and and family history of E catherine mutations
what is a diffuse type of gastric cancer according to lauren classification called ?
LITNIS PLASTICA - submucosal spread
what are the epidemiological factors in diffuse type and intestinal type gastric cancer
in intestinal type - most often affecting elder age
in diffuse type - often affecting younger age
in diffuse type - women affected more than man
and intestinal type- man more than women
what causes a higher risk for diffuse ype of gastric cancer occurring?
blood type A
how does intestinal type of gastric cancer spread ?
Early hematogenous rouute
how does the diffuse type of gastric cancer spread ?
Late lymphatic regionally and transmurally
in the cardia of the stomach the most common type of gastric cancer is ?
diffuse type
in the corpus antrum of the stomach the most common type of gastric cancer is ?
intestinal type
what are the established risk factors for gastric cancer ?
over 60
familial
geographical - japan , korea , south america
blood group A
smoking
helicobacter pylori infection
heavy metal exposition
nutrition - salt intake , tinned food , fried food , ad fatty food , alcohol , dyes , plastic packaging
high intact of zinc or copper in drinking water
previous gastric surgery / gastrectomy
pernicious anemia - atrophic gastritis
obesity - gastric cardia
helicobacter pylori infection increases the incidence of what type of gastric cancer the most ?
intestinal type in the corpus and antrum
what are the specific carcinogens for causing gastric cancer ?
nitrosamines , benspirene aflatoxin
what type of food gives protection for gastric cancer ?
fresh fruits and veg - tomatoes , onion , strawberries , grapes
aspirin
content of vit c , vit E , sélénium
b carotene
milk products , green tea
freshly cooked food
what is the change in the prevalence of the type of stomach cancer ?
the intestinal type has reduced however the diffuse type remains unchanged
what has happened to incidence of gastric cancer ?
it has decreased also its premalignant conditions
h pylori increases the chance of what type of gastric cancer ?
intestinal type
how does h pylori cause gastric cancer ?
long term sequel - through inflammation , atrophy , gastritis and achlorhydria and increase gastrin levels
the clinical outcome of H p infection is determined by what ?
pathogenic potential of the hp strain
and the secretory status
in what case does hp infection lead to higher risk of acquiring cancer ?
in low hcl secretion - ph of more than 4
hp progresses into pangastritis
chronic atrophic gastritis
and malignant transformation
hypo and achlorhydria
in what case does hp have more risk for becoming ulcers ?
in high hcl secretion = ph of less than 2
mainly leading to antra gastritis
increase gastrin secretion and HYPERCHLORHDRIA
which strains of h pylori are associated with increased risk for gastric cancer ? and why ?
CagA (+) due to increased colonisation in the gastric epithelium and pathogenicity
and induce secretion of IL-11/ 17
LESS GASTRIC acid secretion and more inflammation
WHAT ARE THE HERIDITORY RISK FACTORS FOR GASTRIC CANCER ?
hereditary diffuse gastric cancer - autosomal dominant
E- cadherin gene
non polyposis colorectal cancer
FAP - familial adenomatous polyposis
peutz jeghers
li - fraumeni syndrome
hereditary etiology has what type of gastric cancer ?
diffuse gastric cancer
hereditary diffuse gastric cancer also increases the risk for what types of cancer ?
breast cancer , colorectal cancer
what is the criteria for genetic counselling in hereditary diffuse gastric cancer ?
one relative with histologically confirmed diffuse type GC before 50 years of age
two relatives wit histologically confirmed diffuse HG at any age
leading to screening and prophylactic gastrectomy
what are the precancerous conditions for stomach cancer which are very rare ?
atrophic gastritis - chronic autoimmune gastritis
=15-20 percent
infections with h pylori = less than 1 percent
gastric polyposis - has some sort of connection where gastric cancer was found concomitant with adenomatous polyposis which was synchronous and metachronous - so gastric polps are removed due to the possibility in progression to neoplasia as a preventive measure
gastric ulcer
what ca be the primary prophylaxis of gastric cancer ?
screening and eradication of hp in young
screening of risk group such as relatives of first degree , or hereditary gene mutation , over the age of 50 - through fluoroscopy , endoscopy , blood work
all patients with dyspepsia should be screened clinically and endoscopically
good nutrition
chemoprevention by giving cox 2 inhibitors - celecoxib and indomethacin
Polypectomy
new blood test for cancer screening proposed in japan
IgG antibodies against Hp
pepsinogen 1 and pepsinogen 2
acyl greyly and deacyl greyly
there are four macroscopic forms of gastric cancer ?
polypoid - most likely the intestinal type
ulcerated
infiltrative
mixed forms
with the diffuse the of gastric cancer what is there an excess production of ?
mucin production
- lintis plastica
what is the japanese classification of early gastric cancer ?
protruding (polyp like)
superficial - (gastritis like) elevated plaque flat plaque depressed plaque confined to the mucosa
excavated (ulcer like) - the lowest point is in the submucosa
which lymph nodes does gastric cancer metastasise into ?
the perigastric lymph nodes
what are the symptoms go GC ?
unspecific early symptoms / or no symptoms at all.
heaviness after meals and stomach discomfort - patient begins to feel his stomach.
belching
distension of epigastrium
early satiety
epigastric pain - NOT THE INITIAL SYMPTOM
dyspepsia
nausea and vomiting
advanced gastric cancer :
weight loss / loss of appetites bleeding from GIT
anemia
when endoscopy is done special attention to be paid to if there is ?
Local hyperemia
Local whitening
Abnormal vascular pattern
how do we diagnose gastric cancer ?
1) upper Gi tract endoscopy with biopsy
2) CT with oral intravenous contrast
3) complete blood count
4) endoscopic ultrasound if no M1 disease is found
pathological pseudo kidney in epigastrium in advanced stages of CA
how many biopsies should be taken when diagnosing gastric cancer ? and where are the taken from ?
6-10 biopsies
6-10 biopsies
from the base and from the four quadrants of the edges
more malignant tissues are present in th edge that the necrotic crater or centre
metastasis of gastric cancer location is where ?
direct - momentum , pancreases , diaphragm
to the ovaries - tumor of krukenberg
and the douglas space
to the liver
periumbilical
dd of gastric cancer ?
chronic gastritis
chronic callus gastric ulcer
benign stomach tumors
what is the treatment of gastric cancer ?
stage 1 - endoscopic mucosal or endoscopic submucosal resection
more than stage 1 - preoperative chemotherapy
surgery - partial gastrectomy , / lymphnodectomy
splenectomy / total gastrectomy
and post operative chemotherapy
stage 4 - palliative radiotherapy - decreases bleeding , obstruction pain
surgery - pain relief and oral intake of food
palliative chemotherapy
in metastatic stage 4 gastric cancer as chemotherapy what is given to achieve partial response and increase survival ?
FAM - 5FU ,adriamycin , mitomycyn C
how to treat gastric malt lymphoma ?
low grade malignancy - complete resolution of neoplasm
high grade malignancy eradication of just h pylori is not only recommenced
neuroendocrine gastric tumors of less than how many cm are of low risk ?
1cm
neuroendocrine tumors of bigger than what cm are at high risk ?
2cm or more can metastasise
neuroendocrine tumors arise in two pathways which are ?
de novo malignant transformation
- single , larger and more aggressive
loss of normal response to high serum gastrin
multiple and smaller size neoplasm
what Lethe protective factors for neuroendocrine tumors ?
aspirin
what are the risk factors specifically for neuroendocrine tumors ?
heavy smoking
family history or first line relatives of colorectal cancer
GIST tumors are what kind of tumors ?
gastrointestinal stromal tumors arise from the interstitial cells of Canal
what size predictable for the GIST tumor to be malignant ?
2-3cm
GIST tumors respond to which type of treatment the best and why ?
GIST are kit positive (tyrosine kinase and CD 117 )
respond well to tyrosine kinase inhibitors - imatinib
what type of cells are founding the carpia of the stomach ?
mucus secreting cells
what is found in the antrum and the pylorus of the stomach ?
mucus producing and neuroendocrine cells
gastric cancer is usually located where ?
40 percent the lower part
40 percent the middle part
incidence in the upper part such as the cardia of the stomach is increasing and the lower part is increasing
eradication of h pylori is absolutely necessary when ?
patents with family history of gastric cancer
in the pathophysiologof h pylori what type of cascade is triggered when infected with h pylori to lead to malignancy ?
correa cascade
h pylori usually affects for what part of the stomach ?
antrum , body , fundus. NOT CARDIA
what are the late complications of gastric cancer ?
pleural effusion
ascites
gastric outlet obstruction
intra or extra hepatic jaundice
what are the signs for gastric cancer
low serum iron
accl ESR - medium
late stage :
palpable enlarged stomach with succession splash
hepatomegaly
metastasis - sister mary joseph nodule
virchow gland
irish node
blumer shelf - shelf like tumor anterior rectal wall
what are the paraneoplastic syndrome in gastric cancer ?
dermatomyositis
acanthus nigerians
circinate erythema
peripheral thrombophlebitis
if there is metastasise found in gastric cancer what testing should be done ?
microsatellite instability and deficient mismatch repair system
HER-neu and PD-L1
when does endoscopic ultrasound become useful when detecting gastric cancer
when CT fails to define T and N stage
this can view the depth of the tumor
what is the staging of gastric cancer ?
Tis -carcinoma in situ - without invasion of lamina propria
T1 - invades lamina propria but limited to the submucosa
T2 - tumor invades muscular propria
T3 - subserosal connective tissue invasion
T4 - tumor invades the serosa or adjacent structures
what are the early post operative complications in gastric cancer ?
anastomotic failure
cholecystitis
pancreatitis
what is the classification of MALT lymphoma ?
b cell non hodgkin lymphoma
categorised as either gastric or non gastric
what is the etiology of gastric malt lymphomas ?
h pylori
what is the etiology of non gastric Malt lymphoma ?
autoimmune diseases such as hashimoto thyroiditis , shores syndrome
adenocarcinoma of the stomach is histologically divided into ?
-papillary
-tubular
mucinous
-signet ring cell
adenocarcinoma of the stomach is locally classified into
cardia
- esophageal like gastric cancer
- distal stomach like cardia gastric cancer
non carda
- diffuse
- intestinal
what is another classification for early gait cancer ?
Borman classification
describe borman classification ?
polypoid
ulcerating
ulcerating and infiltrating
infiltrating- litnis plastica
what is the definition of early gastric cancer
Early gastric cancer (EGC) is defined as invasive gastric cancer that invades no more deeply than the submucosa, irrespective of lymph node metastasis
