Gastric cancer

Question 1

RF’s for gastric cancer

Answer 1

H pylori
nitrates 
tobacco/alcohol
GERD
Chronic gastritis

Question 2

Protective factors

Answer 2

Diet rich in fruits and vegetables

Vitamin C

Question 3

Typical stage at presentation

Answer 3

Most have advanced, incurable disease at the time of presentation (no screening and asymptomatic cancers are infrequently detected outside of screening programs)

Question 4

Frequent preceding medical history in patients with gastric cancer

Answer 4

Ulcers (25%)

Question 5

Most common sites of mets

Answer 5

Liver, peritoneum, lymph nodes

Question 6

What is Virchow’s node

Answer 6

Left supraclaviuclar lymph node due to mets

Question 7

What is a Sister Mary Joseph/s node

Answer 7

Periumbilical nodule due to mets

Question 8

Common first indication of peritoneal carcinomatosis

Answer 8

Ascites

Question 9

Common lab abnormality with liver mets

Answer 9

Alk phos elevation

Question 10

What is sign of Leser-trelat

Answer 10

Sudden appearance of diffuse SK’s (paraneoplastic phenomenon)

Question 11

typical appearance of gastric cancer on endoscopy

Answer 11

Friable, ulcerated mass (or ulcer with folds that are nodular and clubbed can indicate malignant ulcer)

Question 12

Distinction between anatomic classification of esophageal and gastric cancers

Answer 12

IF tumor epicenter is within 2 cm of EGJ, they are classified as esophageal

Question 13

What is linitis plastica

Answer 13

Rare complication of gastric cancer in which broad region of gastric wall or even entire stomach is extensively infiltrated by malignant tissue resulting in rigid, thickened stomach (extremely poor prognosis)

Question 14

Role for laparoscopy and why

Answer 14

IF no evidence of mets + resectable –> recommended preoperatively (peritoneal mets commonly missed on CT)

Question 15

Disease burden commonly missed with CT

Answer 15

Peritoneal mets

Question 16

Role for EUS

Answer 16

No evidence of M1

- necessary for staging because CT can’t determine depth of invasion

Question 17

Clinical utility of tumor markers for gastric cancer

Answer 17

Limited utility, not usually used for gastric

Question 18

Why gastric cancer patients should be tested for h pylori

Answer 18

• associated with development of metachronous gastric cancer so testing and eradication reduces risk of metachronous cancer

Question 19

General prognosis of gastric cancer

Answer 19

High mortality rate (usually presents late)

Question 20

Epidemiologic trend of gastric cancer

Answer 20

Has been steadily declining

Question 21

Preferred neoadjuvant regimen for locally advanced

Answer 21

FLOT

Question 22

FLOT is

Answer 22

5-fluorouracil
Leucovorin
Oxalaptin
Taxotere

Question 23

Role for radiation?

Answer 23

Nonsurgical candidate

Question 24

Poor responders generally means..

Answer 24

Substantial residual tumor burden after neoadjuvant therapy

Question 25

Molecular profiling

Answer 25

HER2
MSI/MMR
PD-L1

Question 26

Surveillance for gastric cancer

Answer 26

IF stage I –> CT chest, abdomen,pelvis with oral and IV contrast “as clinically indicated”
IF stage II or higher

Question 27

Targeted therapies approved for gastric cancer

Answer 27

Trastuzumab

Ramucirumab

Question 28

Systemic therapy for unresectable, locally advanced, recurrent or metastatic disease

Answer 28

HER2 positive = FOLFOX + trastuzumab

HER2 negative = FOLFOX + nivolumab

Question 29

Docetaxel trade name

Answer 29

Taxotere

Question 30

of lymph nodes required for dissection in patients with gastric cancer for staging

Answer 30

15 (extended lymph node retrieval is recommended to avoid stage migration and positively influences survival)

Question 31

What is resected with a D1 resection?

Answer 31

• Just N1
• gastrectomy, resection of greater/lesser omentum, right/left cardiac LN, lesser/greater curvature LN, suprapyloric LN, right gastric artery LN, and infrapyloric nodes

Question 32

D2 resection

Answer 32

*N1 + N2
D1 resection + lymph node removal of left gastric artery, common hepatic artery, celiac artery, splenic hilum, and splenic artery
**basically D1 + dissection of vessels along celiac axis

Question 33

Adjuvant treatment options for patients not treated neoadjuvantly

Answer 33

IF D1 dissection → 5-FU or capecitabine then 5-FU based chemoradiation then Fluoropyrmidine (INT-0116 Study)
IF D2 dissection → XELOX

Question 34

T1 tumor connotes

Answer 34

invasion of lamina propria

Question 35

Indication for perioperative chemo

Answer 35

T2 or higher or n+

Question 36

EMR stands for

Answer 36

endoscopic mucosal resection

Question 37

Tis or T1a disease management

Answer 37

EMR if no LVI vs. surgery

Question 38

T1b connotates + management

Answer 38

• invasion of submucosa
• gastrectomy with lymphadenectomy

- surgery, not EMR

Question 39

What is a high tumor mutation burden? What is the unit?

Answer 39

• Greater than 10
• mutations per megabase

Question 40

Adjuvant therapy for locoregional disease for patient who received preoperative FLOT

Answer 40

R0 resection – FLOT x 4 cycles

R1 or R2 – chemoradiation

Question 41

FISH testing that is considered positive for HER2

Answer 41

Greater than or equal to 2.0

Question 42

HER2 positive gastric cancer management

Answer 42

Add herceptin AND pembro

Question 43

What is T1a disease?

Answer 43

Tumor invades the lamina propria or muscularis mucosae

Question 44

Significance of signet ring features

Answer 44

1) Not FDG avid, PET less useful
2) poor prognosticator

Question 45

What is FLOT?

Answer 45

Fu oxali docetaxel

Question 46

Management of germline CDH1 mutation

Answer 46

Prophylactic gastrectomy

Question 47

Most important prognosticator for early stage gastric cancer

Answer 47

N1 disease

Question 48

adjuvant therapy after upfront resection

Answer 48

mFOLFOX
CapOX
NOT FLOT

Question 49

Management of metastatic HER2 positive gastric

Answer 49

capeOX or FOLFOX + trastuzumab and pembrolizumab