Gastric carcinoma

Question 1

Define a gastric carcinoma.

Answer 1

Neoplasm that can develop in any portion of the stomach and may spread to the lymph nodes and other organs.

Question 2

Most tumours are what?

Answer 2

Adenocarcinomas.

Question 3

What investigation is required to confirm the diagnoses?

Answer 3

Upper GI endoscopy.

Question 4

Which gender is most affected?

Answer 4

Men.

Question 5

What happens with age?

Answer 5

Incidence increases with age (commonest >50).

Question 6

What is the pathophysiology of a gastric carcinoma?

Answer 6

· Loss of the tumour suppressor gene, p53.

· Overexpression of some proto-oncogenes:
- Several proto-onocgenes such as rac, c-myc and erbB2 (HER2/neu) have been shown to be over-expressed in gastric cancers.

· H. pylori has been associated with molecular events that could lead to gastric cancer such as an increase in p53 mutations.

Question 7

What risk factors are associated with gastric carcinomas?

Answer 7

· Pernicious anaemia. 
· H pylori.
· N-nitroso compounds. Generated after consumption of nitrates. 
· Diet low in fruits and vegetables. 
· Smoking.
· Family history.

Question 8

What signs and symptoms are common with gastric carcinomas?

Answer 8

· Abdominal pain - tends to be epigastric and vague in early stage disease. 
· Weight loss. Most common PC. 
· Aged 50-70 years.
· Male.
· Smoking.
· FH. 
· Dysphagia. For proximal and GOJ tumours. 
· Presence of RFs.

Question 9

What investigations can be done to help confirm a gastric carcinoma?

Answer 9

· Upper GI endoscopy with biopsy.
· Endoscopic USS. For patients with confirmed cancer, to determine the clinical T and N stage.
· CT abdomen/pelvis/chest, PET, CXR. For metastatic lesions.

Question 10

Suggest some differential diagnoses.

Answer 10

· Peptic ulcer disease.
· Benign oesophageal stricture.
· Achalasia.

Question 11

What is the treatment option for a patient with a localised tumour who is a surgical candidate?

Answer 11

· 1st line - Surgery.

· Adjunct - Peri-operative chemotherapy or post-operative chemoradiation.

Question 12

What is the treatment option for a patient with a localised tumour who is not a surgical candidate?

Answer 12

1st line - Chemoradiation / radiotherapy.

Question 13

What is the treatment option for a patient with an advanced / metastatic tumour?

Answer 13

· 1st line - Chemoradiation or chemotherapy and/or immunotherapy.

· Adjunct - Palliative gastrectomy.

· 2nd line - Pembrolizumab.

· Adjunct - Palliative gastrectomy.

Question 14

What complications can arise?

Answer 14

· Malnutrition. 
· Gastric obstruction. 
· GI bleeding. 
· Post-operative gastroparesis. 
· General post-operative complications.