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MBBS IV - Junior Clerkship WCS > JC58 (Surgery) - Gastric Cancer > Flashcards

JC58 (Surgery) - Gastric Cancer Flashcards

1
Q

Differentiate esophageal obstruction with gastric obstruction

A

Esophagus

  • Presents with regurgitation, dysphagia
  • Does not present with vomiting due to low volume capacity and lack of musculature to eject vomitus

Stomach
- Presents with vomiting

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2
Q

Compare presentation of upper, middle and lower GIT obstruction

A 
Upper: 
Frequent, early vomiting
Late constipation
No distention 
Intermittent pain 
Middle: 
Moderate vomiting
Late constipation 
Moderate distention 
Intermittent pain 
Late: 
Late vomiting 
Early constipation 
Severe distention 
Variable pain
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3
Q

S/S of upper GI obstruction

A

Vomit:

  • not Bile-stained - obstruction proximal to ampulla of Vater
  • bile stained - obstruction distal to ampulla of Vater

Epigastrium distention

Succussion splashes (pyloric outlet obstruction)

Long-term weight-loss

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4
Q

Gastric cancer

  • Section of Stomach most commonly affected
  • Demographics
A

Proximal stomach/ EGJ more frequently affected than body/ distal stomach

Demographic:

  • Male > Female
  • Increase incidence with aging
  • Median age of onset at 65y
  • High incidence in Asian populations
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5
Q

Gastric cancer

  • Host risk factors
A

Male sex

Old age

Family history of gastric cancer (e.g. hereditary diffuse gastric CA)
Hereditary E-cadherin mutation

Previous gastric pathologies:

  • Old partial gastrectomy with biliary reflux gastropathy (>20 years)
  • Gastric polyps
  • Chronic gastritis and atrophic gastritis: H. pylori, Pernicious anaemia, Menetrier’s disease (Hypertrophic, hypersecretory gastropathy)

Immunodeficiency syndromes e.g. CVID

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6
Q

Gastric cancer

Environmental risk factors
Protective factors:

A 
H.pylori infection 
EBV infection 
Smoking (NOT alcohol)
Obesity 
Diet: 
- N-nitroso compounds, salt and preserved foods, high salt intake 
Low socioeconomic class
Industrial chemical exposure

Protective factors: vitamin C, trace elements and selenium , fibres, fresh fruits and vegetables

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7
Q

Histological types of gastric cancer and cells of origin

A

□ Adenocarcinoma (95%): classified by Lauren’s classification
» Intestinal type vs Diffuse type vs Mixed type

□ Gastric neuroendocrine tumours (carcinoids) from enterochromaffin-like (ECL) cells in mucosa

□ Gastric lymphoma from gastric MALT tissues

□ GI stromal tumours (GIST) from interstitial stromal cells

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8
Q

Compare Intestinal type vs Diffuse type gastric adenocarcinoma

  • Demographics
  • Section of stomach involved
  • Risk factors
  • Pathogenesis
A

Intestinal type:

  • Elderly male
  • Distal stomach
  • Environmental risk factor
  • Series of precursor lesions interact with environmental RFs to cause intestinal metaplasia, dysplasia and carcinoma

Diffuse type:

  • Young, female
  • Proximal stomach
  • Risk factor: CDH-1 expression mutation, not environmental RF driven
  • Hereditary diffuse gastric cancer: infiltrative signet ring cells with early transmural and lymphatic spread
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9
Q

Describe the intestinal type gastric adenocarcinoma pathogenesis

A
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10
Q

Compare Intestinal type vs Diffuse type gastric adenocarcinoma

Histological features
Endoscopic features

A

Intestinal type:
 Histologically subtyped into tubular, papillary and mucinous
 Usually shows expansile growth with haematogenous spread
 Endoscopically appear as a fungating, polypoid or ulcerating mass

Diffuse type:
 Histologically characterized by individual cells infiltrating surrounding tissues with signet ring cell formation
 Usually shows infiltrative growth with transmural and lymphatic spread
 Endoscopy may not show a mass: Linitis plastica (leather bottle stomach)

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11
Q

Linitis plastica

  • Pathogenesis
  • Investigations for diagnosis
A

Desmoplastic reaction vs rapid submucosal infiltration of tumour

□ Rigid wall w/ difficulty in insufflating stomach on OGD
□ Submucosal biopsy
□ Barium studies or CT

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12
Q

Common presenting features of gastric cancer (by %)

A 
weight loss (62%), 
abd pain (52%), 
nausea (34%), 
dysphagia (26%), 
melena (20%), 
early satiety (18%), 
ulcer-like pain (17%)
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13
Q

Local clinical features of gastric cancer

A

Non-specific dyspepsia

Epigastric tenderness, mass

Epigastric distension, visible peristalsis

Early satiety, bloating, distension esp in linitis plastica

UGIB: majority occult (anaemia)

Obstruction:
□ Dysphagia in cardia tumours
□ Gastric outlet obstuction (vomiting >1h after eating, epigastric distension) for distal tumours

Fistula, eg. feculent vomiting if gastrocolic

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14
Q

Systemic and metastatic features of gastric cancer

A

Constitutional symptoms: LOW, LOA, cachexia, malaise

Metastatic S/S:
□ LN spread:
→ Virchow’s node or Troisier’s sign (Lt supraclavicular node)
→ Irish’s node (Lt axillary node)

□ Liver mets: jaundice, ascites, irregular hepatomegaly

□ Lung mets: dyspnoea (due to pleural effusion or lymphangitis carcinomatosis)

□ Peritoneal mets: ascites, Sister Joseph nodule, IO, Krukenberg’s tumour

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15
Q

Paraneoplastic features of gastric cancer

A

□ Trouseau’s sign (migratory phlebitis)

□ Leser-Trelat sign: sudden appearance of diffuse seborrheic keratosis

□ Acanthosis nigricans

□ Others: MAHA, membraneous nephropathy

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16
Q

Modes of gastric cancer spread

A

Direct invasion to pancreas, transverse colon, duodenum, Colon extension

Lymphatic spread: perigastric → coeliac → pre-aortic → Virchow’s node

Haematogenous spread: liver (most common), lungs, bones

Transcoelomic spread: indicated incurability

17
Q

Features of transcoelomic spread pf gastric cancer

A

→ Peritoneal carcinomatosis: may be a/w ascites, palpable nodules or IO

→ Sister Mary Joseph nodule

→ Krukenberg tumour: metastatic ovarian tumour from GI primary

→ Blumer’s shelf: ‘shelf-like’ POD tumour deposit felt at anterior rectal wall on PR

18
Q

4 molecular subtypes of gastric cancer

A

EBV - Male predominant

MSI - Female predominant, old age

GS - Diffuse histology enrichment, recurrent CDH1 and RHOA mutation, inactivating ARID1A mutation

CIN (most common) - Intestinal histology, with RTK-Ras amplification, phosphorylation of EGFR

19
Q

Diagnostic investigations for suspected gastric cancer

A

Gold standard: OGD + mucosal/ submucosal biopsy at 4 quadrants of ulcer edge
Supportive tests: CBP, LFT, RFT, CXR

(Double contrast barium study (poor false negative rate): visualize ulcers, infiltrating lesions)

20
Q

Name one staging system for gastric cancer

Function of staging

A

Staging: AJCC8 TNM staging
□ Early CA stomach, i.e. T1N0 → endoscopic Tx
□ Resectable locoregional → gastrectomy
□ Unresectable locoregional or metastatic → palliative Tx

21
Q

Staging investigations for gastric cancer

A

Staging evaluation: r/o metastasis before proceeding to other Ix

  • Ultrasound or CT abdomen
  • Liver function test: hepatic metastasis
  • Chest X-ray: thoracic metastasis
  • PET/CT scan: distant metastasis
  • Endoscopic ultrasound: T/N staging
  • Staging Laparoscopy: peritoneal metastasis
22
Q

Serum tumor markers for gastric cancer

Function and limitations

A

Serum tumour markers: CEA, CA 19-9, CA72-4
→ Low Sens/Spec, NOT diagnostically useful
→ May be useful as serial monitoring for Tx response

23
Q

Treatment options for gastric cancer based on resectability

A

Curative treatment for resectable tumours
→ Endoscopic resection for early CA stomach (T1, any N)
→ Gastrectomy ± adjuvant for resectable invasive CA stomach

Palliative treatment for unresectable tumours
→ Chemotherapy for systemic disease control
→ Local palliation for local complications

24
Q

Criteria for Unresectable gastric cancers

A

□ Presence of distant metastasis, including LNs outside surgical field (eg. retropancreatic LNs)

□ Invasion of major vascular structures, eg. aorta

□ Encasement/occlusion of coeliac axis, proximal splenic a. or hepatic a.
(Distal splenic artery involvement is NOT an indicator of unresectability)

25
Q

Treatment options of early, limited, Resectable gastric cancer

A

□ Endoscopic mucosal resection (EMR): snare resection of lesion after saline injection to elevate lesion

□ Endoscopic submucosal dissection (ESD): region of mucosa dissected away at submucosa level after saline injection
→ Allow en-bloc resection with risk of perforation
→ Used for polypoid or large lesions

26
Q

Treatment options for resectable, invasive gastric cancer

A

Surgery:

  • radical gastrectomy (open/lap gastrectomy + LN)
  • reconstruction (laparoscopic assisted or total laparoscopic; hand sewn or stabled)

Systemic:

  • Neoadjuvant chemo: considered for all potentially resectable tumours ≥T2
  • Adjuvant chemo-RT: indicated for T3N0 or N1, chemo (FOLFOX) followed by chemo/RT (capecitabine or FU)
27
Q

Post- gastrectomy management for gastric cancer

A

Regular F/U w/ monitoring by CEA/CA-125 and imaging studies

Postgastrectomy diet: small frequent meals, avoid high carbohydrate meals (dumping)

Nutritional supplementation:
- B12, Iron, Calcium, Fat soluble vitamin

28
Q

Gastrectomy for gastric cancer removal

  • Extent of excisions
  • Extent of LN dissection
  • Reconstruction methods
A

Extent of excision: ligate Lt/Rt gastric, Lt/Rt gastroepiploic vessels
→ Distal gastrectomy for distal lesions
→ Total gastrectomy for proximal lesions

Extent of LN dissection: D2 (extended) dissection
→ i.e. clearance of major arterial trunks

Reconstruction: 1 limb for B1, 2 limbs for B2
Billroth I = end-to-end gastroduodenostomy for distal gastrectomy
Billroth II = gastrojejunostomy for distal gastrectomy
Roux-en-Y = esophago- or gastrojejunostomy + jejunojejunostomy (Bohn anastomosis) for total gastrectomy

29
Q

Treatment options for unresectable gastric cancer

A

Supportive: pain control, feeding care

Systemic: only if functional status satisfactory
→ 1st line: chemotherapy ± trastuzumab (if HER2 +ve)
→ Other options: targeted therapy, immunotherapy

Local: to palliate complications
→ Obstruction: EBRT, endoscopic stenting or ablation (for dysphagia), surgical bypass (GJ)
→ Haemorrhage: endoscopic therapy, transcatheter embolization, EBRT
→ Regional intra-arterial chemotherapy
→ Palliative gastrectomy if less-invasive strategies fail

30
Q

Compare endoscopic stenting vs surgical bypass for Gastric cancer palliation

A

MBBS IV - Junior Clerkship WCS (131 decks)

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