Gastric cancer (GI) Flashcards
Define gastric cancer.
Neoplasm that can develop in any portion of the stomach and may spread to the lymph nodes and other organs
What is the most common form of gastric cancer and where is it found?
Usually adenocarcinoma found on the lesser curvature
(Rarely lymphoma or leiomyosarcomas)
Describe the epidemiology of gastric cancer. (2)
- M>F
- > 50 years old
What are some subtypes of gastric cancer? (3)
- tumours that are positive for EBV
- microsatellite unstable tumours
- genomically stable tumours, chromosomal unstable tumours
What is the pathophysiology of gastric cancer? (2)
- loss of tumour suppressor gene - H. pylori increases p53 mutations
- over-expression of proto-oncogenes: RAS, c-MYC and ERB2 (HER2/neu)
What is key to diagnosis of gastric cancer?
Presence of risk factors
What are the clinical features of gastric cancer? (7)
- abdominal pain - vague in early stages, epigastric tenderness, may present as dyspepsia
- weight loss
- lymphadenopathy:
- Virchow’s node: left supraclavicular node
- Sister Mary Joseph’s nodule: periumbilical nodule
- Irish node: left axillary node
- nausea & vomiting
- dysphagia (proximal, GO junction and gastric cardia tumours)
- lower GI bleeding (–> melaena) + haematemesis
- acanthosis nigricans - symmetrical, brown, velvety plaques on neck, axilla or groin
What might you see on examination in gastric cancer? (3)
- anaemia - blood loss, ACD
- lymphadenopathy
- acanthosis nigricans - symmetrical, brown, velvety plaques on neck, axilla or groin
What is Virchow’s node (gastric cancer)?
Lymphadenopathy in left supraclavicular area - sign of lymphatic spread / gastric malignancy
What is a Sister Mary Joseph nodule (gastric cancer)?
Metastatic node on umbilicus (periumbilical nodule)
What is an Irish node (gastric cancer)?
Left axillary node
What is a Krukenberg tumour (gastric cancer)?
Ovarian mass as a result of metastasis from a gastric tumour - rare presentation in women
What are some signs of metastasis of gastric cancer?
Ascites and jaundice
What are the red flag symptoms for gastric cancer? (8)
- new-onset dyspepsia in a patient aged >55
- unexplained persistent vomiting
- unexplained weight loss (>10%)
- progressively worsening dysphagia
- odynophagia
- epigastric pain
- GI bleeding / anaemia
- early satiety
What are some risk factors for gastric cancer? (7)
- pernicious anaemia (antibodies against gastric parietal cells –> reduced IF and B12 deficiency = macrocytic anaemia)
- H. pylori
- N-nitroso compounds (generated after consumption of nitrates - vegetables and cured meat)
- diet: low in fruit and veg, high salt and nitrates
- smoking
- Fx / ethnicity: Japan, China
- blood group A
How can H. pylori increase risk of gastric cancer?
Triggers inflammation of mucosa –> atrophy and intestinal metaplasia –> dysplasia
What is the first-line investigation done for gastric cancer?
Upper GI endoscopy/OGD with biopsy
What might be seen in upper GI endoscopy with biopsy in gastric cancer?
Signet ring cells (contain a large vacuole of mucin which displaces nucleus to one side) - larger numbers = worse prognosis
Ulcer, mass or mucosal changes
What scans are needed after upper GI endoscopy with biopsy, for gastric cancer diagnosis? (5)
- CT CAP for staging in ALL patients
- endoscopic ultrasound with FNA - helps with TNM staging
- MRI helps identify metastatic spread to liver
- PET-CT (staging)
- pre-operative staging laparoscopy
What might FBC show in gastric cancer?
Anaemia
What might LFTs show in gastric cancer?
Deranged LFTs in metastasis
What are some differential diagnoses for gastric cancer? (4)
- peptic ulcer disease (red flags = gastric cancer)
- benign oesophageal stricture (Hx GORD)
- achalasia (suspect malignancy in patients with Sx <6 months, >60y and excessive WL)
- pharyngeal pouch
Who do we refer to OGD on 2WW for gastric cancer? (2)
- dysphagia (any age)
- 55+ with weight loss + upper abdominal pain/reflux/dyspepsia
Who do we refer for non-urgent OGD - gastric cancer? (2)
- haematemesis
- > /=55 + treatment-resistant dyspepsia OR upper abdominal pain with low Hb OR raised platelet count/N&V + weight loss, upper abdominal pain, dyspepsia, reflux
What do we do with patients who do not meet the referral criteria (gastric cancer)?
Do the other if 1 does not work:
Trial full dose PPI for 1 month OR test and treat H. pylori
What surgeries are there for gastric cancer? (3)
- total gastrectomy (proximal tumours)
- partial gastrectomy (distal tumours)
- endoscopic mucosal resection (T1a)
What non-surgical treatment is also available for gastric cancer?
Chemotherapy - increases survival in metastasis
How do we manage gastric cancer if localised + fit for surgery?
- proximal tumours - total gastrectomy
- distal tumours - subtotal/partial gastrectomy
- T1a - endoscopic mucosal resection
- perioperative chemotherapy/postoperative chemoradiation (T2+)
- perioperative: epirubicin + cisplatin + fluorouracil
- postoperative: radiotherapy 5/7 for 5/52 + fluorouracil
How do we manage gastric cancer if localised + UNfit for surgery?
Chemoradiation or radiotherapy (adverse effects: nausea, vomiting, weight loss, diarrhoea)
How do we manage gastric cancer if advanced + metastatic? (2)
- chemoradiation or chemotherapy and/or immunotherapy (e.g. anti-PD1 antibody checkpoint inhibitors - pembrolizumab)
- palliative gastrectomy - may improve Sx like bleeding and obstruction
What parameters do we need to monitor during treatment of gastric cancer? (2)
- monitor FBC during chemotherapy
- monitor vitamin B12 in gastrectomy - can lead to deficiency –> neurological Sx = careful nutrition post-surgery recommended
What are some complications of gastric cancer? (7)
- malnutrition
- paraneoplastic syndrome
- metastases
- gastric obstruction, GI bleeding, gastric perforation
- postoperative: gastroparesis, pneumonia, infection, MI, anastomotic leak
- chemotherapy-related complications: febrile neutropenia, thrombocytopenia, nausea
- radiotherapy-related complications: anorexia, thrombocytopenia, nausea
Describe the prognosis of gastric cancer.
- poor as no early signs - usually diagnosed very late
- if diagnosed at very early stage, 5 year survival = 95%
