Gastric Carcinoma

Question 1

Gastric cancer typically presents with advanced disease due to lack of screening. If you divide the stomach into proximal, middle and distal, list them in order of most likely location.

Answer 1

Distal = middle > proximal

Question 2

A type 2 and 3 GOJ tumour according to the Siewart classification is considered what type of gastric Ca?

Answer 2

Adenocarcinoma at the GOJ

Question 3

What are the types of Gastric Ca?
Which is the most common?

Answer 3

Gastric adenocarcinoma (most common) (at the GOJ)
GIST - Gastro-intestinal stromal tumours (leiomyoma)
Neuroendocrine tumour (carcinoid tumour)
Lymphoma

Question 4

Which type of gastra Ca is associated with H. Pylori?

Answer 4

Lymphoma

Question 5

A neuroendocrine tumour of the stomach is considered a carcinoid tumour. How would a patient present?

Answer 5

Carcinoid tumours secrete serotonin => Facial flushing, diarrhoea, wheezing (brhonchospasm)

Question 6

What are the RFs for a gastric adenocarcinoma?

Answer 6

Same as GORD/PUD (H.pylori, Alcohol, smoking, NSAID use)
+ Family hx of HNPCC and E-cadherin mutation

Question 7

Give 5 symptoms and 5 signs of gastric adenocarcinoma?

Answer 7

Symptoms: Dyspepsia, anorexia, weight loss, fatigue, haematemesis/malaenia, gastric outlet obstruction (+/- Intermittent projectile vomiting, dehydration, malnourished)

Signs:
Anaemia
Palpable epigastric mass
Succusion splash
Palpable virchow’s node
Malignant pleural effusion
Ascites
Hepatomegaly
Jaundice (obstruction of CBD)

Question 8

How does ascites occur as a complication of gastric adenocarcinoma?

Answer 8

Peritoneal involvement, ascites is a common feature among most adenocarcinomas. A few things contribute to it:

Peritoneal metastasis
Liver metastasis (and => LF)
Lymphatic obstruction
Malnutrition (hypoalbuminaemia)

Question 9

What is the diagnostic investigation for Gastric Ca?

How will you stage it?

Answer 9

Dx: OGD + biopsy

Staging is the same as oesophageal Ca
Local staging: Endoluminal US
Regional staging: CT TAP + laparoscopy to assess for peritoneal disease (ascites)
Disseminated disease: PET CT FDG scan

Question 10

What chemotherapy is used to treat gastric adenocarcinoma?

Is it typically neoadjuvant, adjuvant or both?

Is it typically accompanied with radiotherapy?

Answer 10

Neoadjuvant FLOT/MAGIC

Radiotherapy only if R1 or in palliative care

Question 11

What are the surgical management options for gastric adenocarcinoma? Give the indications for each

Answer 11

Surgical tx: Gastrectomy + D2 LN dissection (with R0 margins always):

Distal (antrum/pylorus) - Partial => Gastrojejunostomy
Proximal (cardia) - Total Gastrectomy
Local invasion - Extended Gastrectomy

Question 12

What does a total gastrectomy include? extended gastrectomy?

Answer 12

Total Gastrectomy: Full stomach excised, proximal duodenum sewed up, and distal oesophagus directly anastomosed to jejunum.

Extended: Removal of the Stomach, spleen, part of pancreas and part of small intestine

Question 13

How will patients undergoing a gastrectomy for gastric adenocarcinoma receive nutrition?

Answer 13

Jejunostomy/PEJ (just like oesophagectomy)

Question 14

What is involved in the palliative care of patients with adenocarcinoma with disseminated disease?

Answer 14

Limited radiotherapy + Gastrojejunostomy (partial gastrectomy) for symptom control

Question 15

What is the full management of a gastric adneocarcinoma? (no need for palliative)

Answer 15

1) MDT to determine suitability for surgery based on patient fitness and TNM staging

2) Neoadjuvant chemotherapy (FLOT/MAGIC)

3) Surgical tx: Gastrectomy + D2 LN dissection (with R0 margins always):

Distal (antrum/pylorus) - Partial => Gastrojejunostomy
Proximal (cardia) - Total Gastrectomy
Local invasion - Extended Gastrectomy

Question 16

Give 5 specific complications of a gastrectomy (tx of gastric adenocarcinoma)

Answer 16

Always give general + Specific

1) Acute pancreatitis
2) Anastomotic leak (like oesophagectomy)
3) Duodenal stump disruption
4) Dumping (early vs late)
5) Bile reflux/vomiting
6) Fe and B12 deficiency

Question 17

Explain the concept of dumping (early vs late)

Answer 17

Early = Generalised weakness, light headedness, diaphoresis, confusion.
occurs directly after a meal
Due to rapid emptying of hyperosmolar solutions leading to fluid shift => inappropriate gut hormone secretion causing sx

Late = early + tremor
Occurs 1-3 hrs after eating = glucose surge causing insulin surge = > hypoglycemic sx:

Question 18

What advice would you give a patient post-op to avoid the risk of dumping?

What medications can you provide?

Answer 18

Small, dry meals with restricted carb intake + refer to dietician

Octreotide