Gastric cancer Flashcards by Ned Jones

RF’s for gastric cancer

H pylori
nitrates 
tobacco/alcohol
GERD
Chronic gastritis

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Protective factors

Diet rich in fruits and vegetables

Vitamin C

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Typical stage at presentation

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

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Frequent preceding medical history in patients with gastric cancer

Ulcers (25%)

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Most common sites of mets

Liver, peritoneum, lymph nodes

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What is Virchow’s node

Left supraclaviuclar lymph node due to mets

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What is a Sister Mary Joseph/s node

Periumbilical nodule due to mets

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Common first indication of peritoneal carcinomatosis

Ascites

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Common lab abnormality with liver mets

Alk phos elevation

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What is sign of Leser-trelat

Sudden appearance of diffuse SK’s (paraneoplastic phenomenon)

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typical appearance of gastric cancer on endoscopy

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

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Distinction between anatomic classification of esophageal and gastric cancers

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

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What is linitis plastica

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)

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Role for laparoscopy and why

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

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Disease burden commonly missed with CT

Peritoneal mets

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Role for EUS

No evidence of M1

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

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Clinical utility of tumor markers for gastric cancer

Limited utility, not usually used for gastric

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Why gastric cancer patients should be tested for h pylori

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

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General prognosis of gastric cancer

High mortality rate (usually presents late)

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Epidemiologic trend of gastric cancer

Has been steadily declining

Preferred neoadjuvant regimen for locally advanced

FLOT

FLOT is

5-fluorouracil
Leucovorin
Oxalaptin
Taxotere

Role for radiation?

Nonsurgical candidate

Poor responders generally means..

Substantial residual tumor burden after neoadjuvant therapy

Molecular profiling

HER2 MSI/MMR PD-L1

Surveillance for gastric cancer

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

Targeted therapies approved for gastric cancer

Trastuzumab | Ramucirumab

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

HER2 positive = FOLFOX + trastuzumab | HER2 negative = FOLFOX + nivolumab

Docetaxel trade name

Taxotere

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

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

What is resected with a D1 resection?

* 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

D2 resection

*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

Adjuvant treatment options for patients not treated neoadjuvantly

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

T1 tumor connotes

invasion of lamina propria

Indication for perioperative chemo

T2 or higher or n+

EMR stands for

endoscopic mucosal resection

Tis or T1a disease management

EMR if no LVI vs. surgery

T1b connotates + management

- invasion of submucosa - gastrectomy with lymphadenectomy | - surgery, not EMR

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

- Greater than 10 - mutations per megabase

Adjuvant therapy for locoregional disease for patient who received preoperative FLOT

R0 resection -- FLOT x 4 cycles | R1 or R2 -- chemoradiation

FISH testing that is considered positive for HER2

Greater than or equal to 2.0

HER2 positive gastric cancer management

Add herceptin AND pembro

What is T1a disease?

Tumor invades the lamina propria or muscularis mucosae

Significance of signet ring features

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

What is FLOT?

Fu oxali docetaxel

Management of germline CDH1 mutation

Prophylactic gastrectomy

Most important prognosticator for early stage gastric cancer

N1 disease

adjuvant therapy after upfront resection

mFOLFOX CapOX NOT FLOT

Management of metastatic HER2 positive gastric

capeOX or FOLFOX + trastuzumab and pembrolizumab