Oesophageal and Gastric Cancer

Question 1

What types of cancer affects the oesophagus [2]

Answer 1

Squamous cell

Adenocarcinoma = most common

Question 2

What is TNM staging of oesophageal cancer. Describe ‘T’ [5]

Answer 2

T1A = mucosa
T1b = sub-mucosa
T2 = muscle 
T3 = adventitia (outer layer) 
T4 = attached to organ e.g. aorta / pleura / trachea

Question 3

Why does oesophagus not have serosa

Answer 3

Not covered by peritoneum

Question 4

Morphology squamous cell tumour [4]

Answer 4

Large occluding
Proximal and middle
Dysplasia before
Wart like

Question 5

Morphology adenocarcinoma [3]

Answer 5

Distal oesophagus as due to GORD / Barret
Present late
Fleshy

Question 6

What is the most common presenting symptom [2]

Answer 6

Progressive dysphagia

Solid then liquid

Question 7

What are other symptoms [5]

Answer 7

Weight loss, Anorexia
Vomiting during eating, Haematemesis
Chest pain / heart burn, Odynophagia 
Cough / hoarse, Vocal cord paralysis 
Pneumonia

Question 8

What causes pneumonia

Answer 8

Trachea-oesophageal fistula

Question 9

What causes cough / hoarse / vocal cord paralysis

Answer 9

Damage to L recurrent laryngeal nerve

Question 10

Where does oesophageal cancer spread to [4]

Answer 10

Liver in adenocarcinoma
Brain
Lungs
Bone

Question 11

What are other complications of oesophageal cancer [4]

Answer 11

Ulceration
Perforation
Abscess due to perforation
Stricture

Question 12

What are the RF for oesophageal cancer [3]

Answer 12

Smoking
Alcohol
HPV

Question 13

What is adenocarcinoma associated with [5]

Answer 13

Male 
Caucasian
Obesity - hernia 
GORD 
Barret's

Question 14

What is squamous associated with [3]

Answer 14

Diet
Achalasia
Plummer Vinson Syndrome

Question 15

What is Plummer Vinson Syndrome [3]

Answer 15

Anaemia - iron deficient
Atrophic glossitis
Dysphagia secondary to web

Question 16

What is gold standard for Dx oesophageal cancer [2]

Answer 16

Endoscopy + biopsy

Question 17

What else can you do [2]

Answer 17

Barium swallow - used for motility but may pick up

EUS with CT / MRI

Question 18

Staging investigations [4]

Answer 18

FBC, LFT
CT CAP (chest, abdo, pelvis)
MRI
Laparoscopy if suspicion of peritoneal spread 
Bone scan

Question 19

What do you do if laparotomy -ve

Answer 19

PET

If primary does not light up then no mets will

Question 20

How do you treat dysplasia

Answer 20

Endoscopic ablation

Question 21

Management T1a [3]

Can this be applied to T1b? [2]

Answer 21

Endoscopic mucosal resection - Can’t do for 1b as Mucosa won’t separate from sub-mucosa

Question 22

Management T1b / T2 [3]

Answer 22

Neoadjuvant Chemo
Surgical oesophagostomy
Radical RT / chemo

Question 23

What is only curative for Adenocarcinoma

Answer 23

Surgery

Question 24

What are complications of bariatric surgery [5]

Answer 24

DVT / PE
Infection
Malnutrition 
Vitamin deficinecy
Hair loss

Question 25

Rationale for neoadjuvant chemo

Answer 25

Most upper GI presents with mets

Question 26

What do you do for palliation [6]

Answer 26

``` Stent Laser PEG, Nutrition Intubation Chemo / RT ```

Question 27

What do you do if there's Plummer Vinson [2]

Answer 27

Iron supplement | Dilatation of web

Question 28

What are complications of surgery [6]

Answer 28

``` Chronic volume reflux Anastomotic leak = mediastinitis Arrhythmia Lose LOS - small meals often Perforation General risks ```

Question 29

What do you get after op

Answer 29

Feeding jejunostomy to allow time to heal

Question 30

Pathogenesis of gastric cancer [4]

Answer 30

Gastritis Intestinal metaplasia Dysplasia Cancer

Question 31

What causes

Answer 31

H.ployri | Unknown

Question 32

What are the RF of gastric cancer [9]

Answer 32

``` Male, >55 Smoking H.pylori > atrophic gastritis Gastritis, Reflux, Ulcer Previous gastric resection Blood group A Pernicious anaemia > atrophic gastritis Low SEC, High nitrate diet Familial syndromes eg E cadherin abnormality ```

Question 33

What are the symptoms [7] and signs [5] of gastric cancer

Answer 33

Symptoms - Dyspepsia - Late presentation - Weight loss, anorexia - Dysphagia - N+V, bloating, early satiety - Malaena - Anemic symptoms Signs - Epigastric mass - Jaundice, hepatomegaly - Ascites - Virchow's node - Acanthosis nigricans

Question 34

How does gastric cancer spread [3]

Answer 34

Direct - within stomach, pancreas Lymphatic - Virchow's node Blood to liver Trans-colemic within peritoneal cavity - ovaries, umbilical

Question 35

What is 1st line investigation [2]

Answer 35

Endoscopy + biopsy | +/- Barium swallow

Question 36

How do you stage [4]

Answer 36

EUS for depth CT or MRI laparoscopy for locally advanced / cytology of peritoneal washing PET CT

Question 37

How do you treat [3]

Answer 37

Neo-adjuvant chemo Endoscopic resection if early stage Gastrectomy with Roux-en-Y to prevent bile reflux

Question 38

What do you have to do after surgery [2]

Answer 38

Small meals often | Vitamin supplement

Question 39

What are complications after surgery

Answer 39

``` Infection Bleeding Vomiting Vitamin deficiency: B12 deficiency Iron deficiency, Osteoporosis Impaired protein digestion as lack of pepsin Lack of sterilisation Weight loss Early satiety Dumping syndrome ```

Question 40

What is dumping syndrome [6]

Answer 40

``` Fluid shift and distention Dizzy, Flush, Hypoglycaemia Fast HR N+V, Abdo pain Diarrhoea as increased osmotic pull ```

Question 41

If palliative what is included in management [4]

Answer 41

Analgesia, PPI, secretion control Chemo Pyloric stenting Bypass procedures - connect duodenum to stomach to bypass outlet obstruction

Question 42

``` Zollinger elision syndrome Ax [2] Px [2] Sxs [4] Ix [2] Mx [2] ```

Answer 42

Ax: gastrinoma in small intestine or pancreas, mostly malignant, assoc with MEN1 Px: gastrin increases HCl causing peptic ulceration and chronic diarrhea Sxs: abdo pain, dyspepsia, steatorrhea, refractory ulcers Ix: stomach pH <2, MRI/CT Mx: high dose PPI, surgical resection