Gastric carcinoma

Question 1

what is defined as ‘early’ gastric carcinoma?

Answer 1

confined to mucosa and submucosa.

carries better prognosis with endoscopic resection

Question 2

what are the symptoms (6)

Answer 2

•	Often non-specifc
•	Dyspepsia (age more than 55years with treatment refractory symtpoms demands investigation) 
•	Weight loss 
•	Vomiting 
•	Dysphagia 
Anaemia

Question 3

what are the signs?

Answer 3

• Suggesting incurable disease
• Epigastric mass
• Hepatomegaly
• Jaundice
• Ascites
• Large left supraclavicular (Virchow’s node) = Troisiers sign
• Acanthosis nigrans
• Most patients In West present with locally advanced (inoperable) or metastatic disease

Question 4

how does it spread?

Answer 4

local lymphatic, bloode borne and transcoelemic (e.g. to ovaries = Krukenberg tumours)

Question 5

how do you investigate it?

Answer 5

• Gastroscopy + multiple ulcer edge biopsies.
• Aim to biopsy all gastric ulcers as even malignant ulcers may appear to heal on drug treatment.
• Endoscopic ultrasound (EUS) can evaluate depth of invasion
• CT/MRI helps staging
• Staging laparoscopy is recommended for locally advanced tumours
• Cytology or peritoneal washings can help identify peritoneal metastases • Gastroscopy + multiple ulcer edge biopsies.
• Aim to biopsy all gastric ulcers as even malignant ulcers may appear to heal on drug treatment.
• Endoscopic ultrasound (EUS) can evaluate depth of invasion
• CT/MRI helps staging
• Staging laparoscopy is recommended for locally advanced tumours
• Cytology or peritoneal washings can help identify peritoneal metastases

Question 6

what is the treatment?

Answer 6

See for a description of surgical resections. Early gastric cancers may be respectable endospiclaly (endoscopic mucosal resection). Partial gastrectomy may suffice for more advanced distal tumours.

If proximal, total gastrectomy may be needed. Combination chemotherapy (e.g. epirubicin, cisplatin and flurorouracil) appears to increase survival in advanced disease.

If given preoperatively in operable disease it improves survival compared to surgery alone.

Surgery palliation is often needed for obstruction, pain, or haemorrhage. In locally advanced and metastatic disease, chemotherapy increases quality of life and survival. Target therapies are likely to have an increasing role, e.g. trastuzumab for HER-2 positive tumours.

Question 7

what do you see in the histology?

Answer 7

Signet ring cells may be seen in gastric cancer. They contain a large vacuole of mucin which displaces the nucleus to one side.
Higher numbers of signet ring cells as associated with a worse prognosis

Question 8

what are associations of gastric ulcers?

Answer 8

• H.Pylori infection
• Blood group A: gAstric cAncer
• Gastric adenomatous polyps
• Pernicious anaemia
• Smoking
• Diet: salty, spicy, nitrates
• May be negatively associated with duodenal ulcer

Question 9

what are features of gastric ulcers?

Answer 9

• Dyspepsia
• Nausea and vomiting
• Anorexia and weight loss
Dysphagia

Question 10

what is the favoured staging?

Answer 10

TNM

Question 11

what investigation is used for staging?

Answer 11

CT/endoscopic ultrasound CT scanning of the chest abdomen and pelvis is the routine first line staging investigation in most centresLaparoscopy to identify occult peritoneal disease 
PET CT (particularly for junctional tumours)

Question 12

how are tumours of the gastro-oesophageal junction classified.

Answer 12

Type 1 = true oesophageal cancers and may be associated with Barrett’s oesophagus

Type 2 = carcinoma of the cardia, arising from cardiac type epithelium or short segments with intestinal metaplasia at the oesophagogastric junction

Type 3 = sub cardial cancers that spread across the junction. Involve similar nodal stations to gastric cancers.

Question 13

what are the treatments

Answer 13

• Proximally sited disease greater than 5-10cm from the OG junction may be treated by subtotal gastrectomy
• Total gastrectomy if tumour is <5cm from OG junction
• For type 2 junctional tumours (extending into oesophagus) oesophagogasterectomy is usual
• Endoscopic sub mucosal resection may play a role in early gastric cancer confined to the mucosa and perhaps the sub mucosa (this is debated)
• Lymphadenectomy should be performed. A D2 lymphadenectomy is widely advocated by the Japanese, the survival advantages of extended lymphadenopathy have been debated. However, the overall recommendation is that a D2 nodal dissection be undertaken.
• Most patients will receive chemotherapy either pre-or post operatively.