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Y3R6: Surgery I 👨‍⚕️ > L7: Gastric Cancer > Flashcards

L7: Gastric Cancer Flashcards

1
Q

Incidence of Gastric Cancer

A
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2
Q

what is decrease in the incidence of Gastric Cancer attributed to?

A
  • advances in food preservation
  • public awareness about healthy diet.
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3
Q

Highest Incidence of Gastric Cancer is in ……

A

In Eastern Asia, Eastern Europe, and South America.

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4
Q

Lowest Incidence of Gastric Cancer is in ……

A

In North America and parts of Africa

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5
Q

what are types of Gastric Cancer?

A

Two biological entities (classified by Lauren) which are different regarding epidemiology, etiology, pathogenesis, and behavior. Which are:

1) The Intestinal type.
2) The Diffuse type.

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6
Q

Compare between Intestinal & Diffuse (Infiltrative) Gastric Cancer

A
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7
Q

Precursor lesions of Intestinal type Gastric Cancer

A
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8
Q

Chronic superficial gastritis

A
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9
Q

Gastric atrophy with loss of parietal cell mass

A
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10
Q

Atrophic gastritis

A
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11
Q

Intestinal metaplasia and dysplasia

A
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12
Q

Incidence of Familial Gastric Cancer

A
  • Most gastric cancers are sporadic but familial pattern is noted in 10% of cases.
  • Hereditary (familial) gastric cancer accounts for 1-3% of gastric cancer and comprises at least three major syndromes
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13
Q

Types of Hereditary (familial) gastric cancer

A

1) Hereditary diffuse gastric cancer (HDGC).

2) Gastric adenocarcinoma and proximal polyposis of the stomach (GAPPS).

3) Familial intestinal gastric cancer (FIGC).

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14
Q

Mode of inheritance of Hereditary diffuse gastric cancer (HDGC)

A

Autosomal dominant (AD) inherited form of diffuse type gastric cancer.

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15
Q

Mutant Gene in Hereditary diffuse gastric cancer (HDGC)

A

It is due to germline truncating mutations in the cadherin 1 (CDH1) gene.

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16
Q

CP of Hereditary diffuse gastric cancer (HDGC)

A
  • Characterized by late presentation.
  • Affected patients generally are diagnosed at an early age.
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17
Q

Prognosis of Hereditary diffuse gastric cancer (HDGC)

A

Poor prognosis.

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18
Q

when to suspect Hereditary diffuse gastric cancer (HDGC)?

A
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19
Q

Prophylactic Therapy in Hereditary diffuse gastric cancer (HDGC)

A
  • The risk of gastric cancer in asymptomatic carriers of a pathogenetic CDH1 mutation is sufficiently high to do prophylactic gastrectomy.
  • Surgery is usually recommended between the age of 20 and 30.
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20
Q

Risk Factors for Gastric Cancer

A
  • Helicobacter pylori
  • Diet
  • Obesity
  • Smoking
  • Occupational Exposure
  • EBV
  • Abdominal Irradiation
  • Gastric Surgery
  • Blood Group A
  • Gastric Ulcer
  • Gastric Diseases
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21
Q

Risk of H. Pylori in Gastric Cancer

A
  • The WHO classified H. pylori as a group 1 or definite carcinogen.
  • H. pylori is potentially modifiable risk factor for gastric cancer.
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22
Q

How does H. Pylori Predispose to Gastric Cancer?

A
  • It triggers inflammation at the mucosa → results in atrophy and metaplasia.
  • It is associated with the risk of intestinal and diffuse types of adenocarcinomas.
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23
Q

CP of H.Pylori

A

The majority of patients with H. pylori infection have no significant clinical symptoms.

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24
Q

Diet as a risk factor for Gastric Cancer

A
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25
Q

Obesity

Risk Factors for Gastric Cancer

A
  • High-level evidence supports of association () obesity and increase risk of gastric cancer.
  • The strength of the association increased with increasing BMI.
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26
Q

Smoking

Risk Factors for Gastric Cancer

A

High-level evidence supports that:

  • Smoking increases the risk of gastric cancer by 1.5-fold.
  • The risk decreased after 10 years of smoking cessation.
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27
Q

Occupational Exposure

Risk Factors for Gastric Cancer

A

Weak evidence suggests that occupations as mining, metal processing (particularly steel and iron), and rubber manufacturing industries increase the risk of gastric cancer.

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28
Q

EBV

Risk Factors for Gastric Cancer

A

It is that about 5-10% of gastric cancers worldwide are associated with EBV.

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29
Q

Abdominal Irradiation

Risk Factors for Gastric Cancer

A

…

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30
Q

Gastric Surgery

Risk Factors for Gastric Cancer

A
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31
Q

Gastric Ulcer

Risk Factors for Gastric Cancer

A
  • An association between benign gastric ulcers and gastric cancers probably reflects common risk factors (ie, mainly H. pylori infection).
  • The risk of gastric cancer was increased among patients with benign gastric ulcers (incidence ratio 1.8).
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31
Q

Blood Group A

Risk Factors for Gastric Cancer

A

It is possible that the observed associations are not due to the blood group antigens themselves but to the effects of genes closely associated with them.

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32
Q

Gastric Diseases

Risk Factors for Gastric Cancer

A

Hypertrophic gastropathy (including Ménétrier’s disease) and immunodeficiency syndromes → weak evidence suggests the link to gastric cancer.

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33
Q

Does Iatrogenic Achlohydria predispose to Gastric Cancer?

A
  • Iatrogenic achlorhydria induced by long-term use of histamine 2 receptor antagonists or proton pump inhibitors has not been associated with an increased risk of either gastric adenocarcinomas or neuroendocrine tumors.
  • An association between maintenance therapy with omeprazole and the development of atrophic gastritis in individuals with H. pylori infection has been suggested, but the data are inconclusive.
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34
Q

what are possible protetictive factors from Gastric Cancer?

A
  • Fruits, vegetables, and fiber
  • NSAIDs
  • Reproductive hormones
  • Helicobacter pylori eradication
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35
Q

Fruits, veges & Fibers

possible protetictive factors from Gastric Cancer

A

It is most likely due to vitamin C content → ↓ the formation of carcinogenic N- nitroso compounds inside the stomach.

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36
Q

NSAIDs

possible protetictive factors from Gastric Cancer

A

Regular use has been inversely associated with the risk of distal gastric adenocarcinoma

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37
Q

H.Pylori Eradication

possible protetictive factors from Gastric Cancer

A
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38
Q

Reproductive Hormones

possible protetictive factors from Gastric Cancer

A
  • Gastric cancer incidence rates are consistently lower in women.
  • This supports that reproductive hormones may have a protective role in gastric cancer risk in women.
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39
Q

Intro to screening of Gastric Cancer

A

Screening for gastric cancer is controversial, and recommendations for screening differ based on the incidence of gastric cancer.

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40
Q

Screening for Gastric Cancer in High Incidence Countries

A
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41
Q

what are individuals at high risk for Gastric Cancer?

A
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42
Q

Screening for Gastric Cancer in low incidence Countries

A

Selective screening of high-risk subgroups is recommended.

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43
Q

Screening in High-risk patients from families with hereditary diffuse gastric cancer

A
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44
Q

Presentation of Gastric Cancer

A
  • Most patients with gastric cancer are symptomatic.
  • Weight loss and persistent abdominal pain are the most common symptoms at initial diagnosis.
  • Approximately 25% of patients with gastric cancer have a history of gastric ulcer.
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45
Q

CP of Gastric Cancer

A
  • Weight loss
  • Abdominal pain
  • Nausea or early satiety
  • Dysphagia
  • Gastric outlet obstruction
  • Bleeding
  • Palpable abdominal mass
  • Distant Metastasis
  • Local Infiltration
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46
Q

Weight Loss in Gastric Cancer

A

results from:

  • Insufficient caloric intake
  • Attributable to anorexia, nausea, abdominal pain, early satiety, and/or dysphagia.
47
Q

Abdominal Pain in Gastric Cancer

A
  • Early in the disease → tends to be epigastric, vague, and mild.
  • When the disease progresses → more severe and constant.
48
Q

Nausea & Early Satiety in Gastric Cancer

A

Due to tumor mass and in cases of linitis plastica (aggressive form of diffuse type gastric cancer), these symptoms arise from the inability of the stomach to distend.

49
Q

Dysphagia in Gastric Cancer

A

It is common in patients with proximal gastric cancer.

50
Q

Gastric Outlet Obstruction in Gastric Cancer

A

In advanced distal tumor.

51
Q

Bleeding in Gastric Cancer

A
  • Occult gastrointestinal bleeding, with or without iron deficiency anemia.
  • Overt bleeding (i.e., melena or hematemesis) is seen in fewer than 20% of cases.
51
Q

Palpable Abdominal Mass in Gastric Cancer

A

It is uncommon but it is the most common physical finding and generally indicates long-standing & advanced disease.

52
Q

Manifestation of Distant Metastasis in Gastric Cancer

53
Q

Def of Linitis plastica

A

Linitis plastica is a particularly aggressive form (5%) of diffuse-type gastric cancer.

54
Q

Manifestation of Local Infiltration in Gastric Cancer

55
Q

Spread of Linitis plastica

56
Q

Investigations in Linitis plastica

A
  • Barium study,
  • Abdominal computerized tomography (CT),
  • Endoscopic ultrasound (EUS).
57
Q

Prognosis of Linitis plastica

A

It has an extremely poor prognosis.

58
Q

TTT of Linitis plastica

A

Some surgeons consider it a potentially curative resection.

59
Q

Investigations in Gastric Cancer

A
  • Routine laboratory investigation
  • Serum tumor markers
  • Barium studies
  • Upper endoscopy with biopsy
  • Contrast-enhanced CT of chest, abdomen, and pelvis
  • Endoscopic ultrasound (EUS)
  • Staging laparoscopy
60
Q

What are tumor Markers used in Gastric Cancer?

A

CEA and CA 125.

60
Q

Routine Lab Investigations in Gastric Cancer

61
Q

Advantages of tumor Markers used in Gastric Cancer

A

Useful in the evaluation of the response to neoadjuvant therapy.

62
Q

Disadvantages of tumor Markers used in Gastric Cancer

A

Low sensitivity and specificity → low diagnostic value.

63
Q

Barium Studies in Gastric Cancer

64
Q

Importance of Upper endoscopy with biopsy in Gastric Cancer

A

Mandatory for tissue diagnosis by biopsy and anatomic localization of the primary tumor.

65
Q

Findings of Upper endoscopy with biopsy in Gastric Cancer

66
Q

The typical appearance of gastric cancer is …….

A

friable, ulcerated mass

67
Q

Up to 5% of malignant ulcers appear benign grossly → Histologic examination of tissue is required to establish the diagnosis.

68
Q

Performing seven biopsies from the ulcer margin, edge, and base increases the …….

A

sensitivity to greater than 98%.

69
Q

Uses of Contrast-enhanced CT of chest, abdomen, and pelvis in gastric Cancer

70
Q

Disadvantages of Contrast-enhanced CT of chest, abdomen, and pelvis in gastric Cancer

A

It has a limited value in assessment of depth of tumor invasion and LN metastasis.

71
Q

Advantages of Endoscopic ultrasound (EUS) in Gastric Cancer

A
  • It is the most reliable nonsurgical method for evaluating the depth of invasion.
  • Superior to CT in assessment of tumor depth (T stage) and LN involvement (N stage), particularly if fine-needle aspiration (FNA) is performed.
72
Q

When to do Endoscopic ultrasound (EUS) in Gastric Cancer?

A

It is better to be done when it is anticipated to change the plan of management.

73
Q

Disadvantages of Endoscopic ultrasound (EUS) in Gastric Cancer

A
  • More invasive than CT
  • Not easily available
  • Requires special experience.
74
Q

Advantages of Staging laparoscopy in Gastric Cancer

75
Q

Staging of gastric cancer is important to: ……

A

1) Determine the plan of management.
2) Minimize unnecessary surgery, and
3) Maximize the value of the treatment for the patient.

76
Q

There are two main classification systems for staging of gastric cancer:

77
Q

TNM Staging of Gastric Cancer

  • T
78
Q

TNM Staging of Gastric Cancer

  • M
79
Q

TNM Staging of Gastric Cancer

  • N
80
Q

Clinical Staging of Gastric Cancer

A
  • Locoregional, potentially resectable (stage I to III)
  • Locally advanced, unresectable or metastatic (stage IV)
81
Q

Locoregional, potentially resectable (stage I to III)

A

These are potentially curable, and the decision can be neoadjuvant therapy then surgery or upfront surgery based on a multidisciplinary evaluation.

82
Q

Locally advanced, unresectable or metastatic (stage IV)

A

Palliative therapy depending on their symptoms and functional status.

83
Q

Stage 0 in Gastric Cancer TNM

84
Q

Stage 1 in Gastric Cancer TNM

85
Q

Stage 2A in Gastric Cancer TNM

86
Q

Stage 2B in Gastric Cancer TNM

87
Q

Stage 3 in Gastric Cancer TNM

88
Q

Stage 4A in Gastric Cancer TNM

89
Q

Stage 4B in Gastric Cancer TNM

90
Q

Prognosis of Gastric Cancer

A

The prognosis of gastric cancer is generally poor

91
Q

Why is the prognosis of gastric cancer poor?

A

1) The tumor has often metastasized by the time of discovery.

2) Most people with the condition are elderly at presentation.

92
Q

5-year survival rate of:

  • Locoregional disease
  • Locally advanced or metastatic disease
93
Q

TTT of Early gastric cancer

A

Treatment includes:

1) Gastrectomy

2) Endoscopicresection,

3) Antibiotic treatment for eradication of Helicobacter pylori

4) Adjuvant therapies.

Gastrectomy remains the main treatment modality used for early gastric cancer worldwide

94
Q

Indications of Endoscopic resection in Gastric Cx

95
Q
  • CI of Endoscopic resectio. in Gastric Cx
  • Indications of Gastrectomy in Gastric Cx
96
Q

Procedure in Surgical Resection in Gastric Cancer

A
  • Complete surgical eradication with adequate safety margin and proper lymphadenectomy is the treatment of choice for gastric cancer.
97
Q

Indications of Surgical Resection in Gastric Cancer

A
  • Radical resection of early or localized gastric cancer.
  • Palliative resection for advanced cancer for management of bleeding or obstruction.
98
Q

Types of Surgical Resection in Gastric Cancer

99
Q

CI of Surgical Resection in Gastric Cancer

A

Anesthetic unfitness and suspected metastasis.

100
Q

The choice of operation for gastric cancer depends on:

A

1) The location of the tumor within the stomach,
2) The clinical stage,
3) The histologic type.

100
Q

SOC in Proximal tumors away from the cardia

A

Can be managed by proximal or total gastrectomy.

101
Q

SOC in Distal gastric tumors

A

Can be managed by partial, subtotal, or total gastrectomy

102
Q

SOC in Large tumors or linitis plastica

A

Better managed by total gastrectomy.

103
Q

extent of lymphadenectomy in Gastric Surgery

104
Q

Neoadjuvant therapy in gastric cancer

105
Q

Palliative gastrectomy in gastric surgery

A

Surgical intervention can be performed in patients with metastatic cancer for palliation of symptoms such as bleeding, or obstruction.

106
Q

Managment of Obstructing gastric tumors

A

Can be managed by
1) Endoscopic laser canalization,
2) Endoscopic stent,
3) Gastrojejunostomy.

107
Q

Managment of Unresectable, progressive, and metastatic disease

A

Systemic therapy and supportive care

108
Q

Clinical Surveillance in Gastric Cancer

A
  • History and physical examination → Every 3-6 months for 1-2 years
  • then every 6 to 12 months for 3-5 years
  • then annually.
109
Q

Lab Surveillance in gastric Cancer

A

Patients are evaluated by:

1) CBC and chemistry profile, nutritional assessment,

2) Upperendoscopy,

3) Computed tomography (CT) of the chest / abdomen / pelvis with oral and intravenous contrast as clinically indicated.

110
Q

Algorithm in TTT of Gastric Cancer

111
Q

Done

Y3R6: Surgery I 👨‍⚕️ (36 decks)

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