Gastric Carcinoma (15)

Question 1

What are the major risk factors for gastric cancer?

Answer 1

• H. pylori infection
• Chronic atrophic gastritis

Question 2

What is the pathogenesis of gastric cancer?

Answer 2

Normal mucosa → Chronic gastritis → Intestinal metaplasia → Dysplasia → Intramucosal carcinoma → Invasive gastric carcinoma

Question 3

How would you discuss the pathology report with the family?

Patient with left iliac fossa pain and gastric cancer underwent gastrectomy with splenectomy. Pathology report available.

Answer 3

• This is cancer of the stomach
• With incomplete resection
• With high possibility of recurrence
• The patient will require further resection and chemotherapy

Question 4

What is the commonest histological type of gastric cancer?

Answer 4

Adenocarcinoma (95%)

Question 5

What are the procedure-specific complications of total gastrectomy?

Answer 5

• Early: Anastomotic leak, pancreatitis, cholecystitis, hemorrhage, infection
• Late: Dumping syndrome, vitamin B12 deficiency (lack of intrinsic factor), metabolic bone disease, recurrence of malignancy

Question 5

What are the types of adenocarcinomas of the stomach?

Answer 5

• Tubular adenocarcinoma
• Papillary adenocarcinoma
• Mucinous adenocarcinoma
• Poorly cohesive carcinomas (including signet ring cell carcinoma and others)
• Mixed carcinoma

Question 6

What are the two main types of adenocarcinoma of the stomach according to the Lauren classification?

Answer 6

• Intestinal type
• Diffuse type

Question 7

What can predispose a gastric cancer patient to axillary vein thrombosis?

Answer 7

• Hypercoagulable state in malignancy
• Venous stasis from Virchow lymph node

Question 8

What are the treatment options for a patient with gastric carcinoma?

Answer 8

• Feeding jejunostomy
• Palliation of ascites by repeated tapping
• Pain relief using opioids
• Palliative chemotherapy

Question 9

What pathological tests can be done in a patient with gastric cancer, who now has suspicious hepatic lesions and ascites?

Answer 9

• Ascites tap and cytology
• Liver biopsy from metastasis

Question 10

What is the mechanism of malignant ascites?
Difference compared to mechanism for ascites in cirrhotic liver (hepatic ascites)?

Answer 10

Malignant ascites:
- Either due to Direct invasion of peritoneum (peritoneal carcinomatosis) or a result of venous or lymphatic obstruction
- Advanced and usually terminal stage of cancer
- SAAG less than 1.1 (excludes portal hypertension)

Hepatic ascites:
- Portal hypertension
- SAAG (serum ascites albumin ratio) greater than 1.1
- Increased hydrostatic pressure within blood vessels of hepatic portal system, which forces water into the peritoneal cavity but leaves proteins such as albumin within vasculature

*note extensive liver metastasis can cause functional cirrhosis and portal hypertension resulting in ascites which is malignant-related ascites

Question 11

What is the Borrmann classification system for gastric cancer?

Answer 11

• Type 1: Polypoid growth
• Type 2: Fungating growth
• Type 3: Ulcerating growth
• Type 4: Diffusely infiltrating growth (linitis plastica)

Question 12

What are the para-neoplastic conditions associated with gastric cancer?

Answer 12

• Acanthosis nigricans
• Dermatomyositis

Question 13

What is dumping syndrome?

Answer 13

• Gastrectomy can cause ‘dumping syndrome’
• Early dumping occurs 30-60 minutes after a meal and causes abdominal pain, diarrhea, and vasomotor symptoms
• Late dumping occurs 1-3 hours after a meal and results in hypoglycemia due to sudden absorption of high levels of glucose