Gastric carcinoma

Question 1

what kinds of cancers develop in the stomach and which is the most common?

Answer 1

majority >90% = adenocarcinomas

lymphoid and neuroendocrine tumours also develop

Question 2

what two histopathological groups are recognised in bowel carcinomas?
which has a better prognosis?

Answer 2

• intestinal type carcinoma –> better prognosis

- mucin-producing signet ring carcinoma

Question 3

what are the three morphological forms of gastric carcinomas?

Answer 3

• fungating tumour: polypoid lesions
• malignant ulcer: necrosis in broad-based solid tumour (larger than peptic), with heaped up indurated margin
• infiltrating carcinomas: apreads widely below mucose invading tissue –> thikening and rigidity

Question 4

what is defined as an early gastric cancer and what is its relevance?

Answer 4

cancer only spreading in mucosa and sub-mucosa –> very good prognosis on resection

Question 5

what are the risk factors for gastric carcinomas?

Answer 5

• male
• H.pylori infection
• increasing age
• smoking
• alcohol consumption

Question 6

what are the clinical features of gastric carcinomas?

Answer 6

usually vague and non-specific 
common presenting symptoms:
- dyspepsia
- dysphagia 
- early satiety, vomiting or melena

Question 7

what investigations are performed in suspected gastric carcinoma

Answer 7

lab tests:
routine bloods: anaemia

imaging:
urgent upper GI endoscopy with biopsy: 
- histology: classification and grading
- CLO test: h-pylori 
- HER2 protein expression:  allow for targeted monoclonal therapy

Question 8

how are gastric carcinomas staged?

Answer 8

CT CAP
laparoscopy to assess for serosal metastases
EUS determining the depth of penetration

Question 9

what are the curative treatments for gastric carcinomas?

Answer 9

surgery: removal stomach along with relevant lymph nodes

peri-op chemotherapy for patients who are healthy enough (3 cycles before and after)

proximal gastric cancer: total gastrectomy

distal gastric cancers (antrum/pylorus) - subtotal gastrectomy

may offer endoscopic mucosal resection (EMR) - T1a cancers (confined to muscularis mucosa)

Question 10

what’s the most common method of reconstruction of the alimentary canal after gastrectomy?

Answer 10

Roux-en-Y reconstruction - less bile reflux and best functional result (look at diagram)

Question 11

what is the use of chemo and radiotherapy in the management of gastric cancer?

Answer 11

used as peri-op treatment (3 cycles before and after)

Question 12

what is the palliative management of gastric carcinoma?

Answer 12

• chemotherapy
• supportive care
• stenting (for those with gastric outlet obstruction)
• rarely palliative surgery - in bleeding gastric tumour/stents are failing

Question 13

what are the complications of gastrectomy?

Answer 13

• anastomotic leak
• death
• dumping syndrome (early - hypertonic solution in intestines –> intraluminal fluid shift –> intestinal distension –> N&V, diarrhoea and hypovolemia)
  (late - a surge in insulin production following of dumping of food –> hypoglycemia )
• b12 deficiency

Question 14

what are the complications of gastric cancers?

Answer 14

• gastric outlet obstruction
• iron deficiency anaemia
• perforation
• malnutrition

Question 15

what are gastric polyps?

Answer 15

mostly - benign hyperplastic nodules of mucosa

• adenomatous polyps

Question 16

how are gastric polyps treated?

Answer 16

adenomatous - genuine neoplasms therefore endoscopically excised

hyperplastic nodules - never malignant therefore left alone

Question 17

explain the signet ring sign in mucin secreting carcinomas

Answer 17

mucin accumulates in cells –> pushes nucleus to the edge of the cell –> signet ring