Oesophago-gastric malignancy Flashcards
1
Q
What is the recent trend in incidence of gastric cancer?
A
- overall incidence decreasing
- incidence of tumours arising from cardia increasing
2
Q
What is the peak age of gastric cancer?
A
70-80 years
3
Q
In which regions is gastric cancer more common?
A
Japan, China, Finland and Colombia - more common in these regions than the West
4
Q
What is the gender ratio of gastric cancer?
A
M:F 2:1
5
Q
What is the key histological finding in gastric cancer?
A
signet ring cells
6
Q
What are signet ring cells?
A
may be seen in gastric cancer; contain a large vacuole of mucin which displaces the nucleus to one side
7
Q
What is a higher number of signet ring cells associated with in gastric cancer?
A
worse prognosis
8
Q
What are 6 associations of gastric cancer?
A
- H. pylori infection
- Blood group A (gAstric cAncer)
- gastric adenomatous polyps
- pernicious anaemia
- smoking
- diet: salty, spicy, nitrates
9
Q
What may be a disease that is negatively associated with gastric cancer?
A
duodenal ulcer
10
Q
What are 4 presenting features of gastric cancer?
A
- Dyspepsia
- Nausea and vomiting
- Anorexia and weight loss
- Dysphagia
11
Q
What key investigation is needed to make a diagnosis of gastric cancer?
A
endoscopy with biopsy
12
Q
What are 4 options for investigations for the staging of gastric cancer?
A
- CT-TAP (routine first line in most centres)
- Endoscopic ultrasound (superior to CT)
- PET CT
- Laparoscopy - to identify occult peritoneal disease
13
Q
What is the routine first line staging investigation for gastric cancer in most centres?
A
CT of chest abdomen and pelvis
14
Q
What type of gastric cancer is laparoscopy useful to identify?
A
occult peritoneal disease
15
Q
Which type of gastric cancer is PET CT useful for identifying?
A
junctional tumours
16
Q
What is thought to be the stepwise progression of gastric cancer?
A
intestinal metaplasia to atrophic gastritis to dysplasia, to cance
17
Q
What is the favoured staging system for gastric cancer?
A
TNM
18
Q
What is the risk of lymph node involvement in gastric cancer related to?
A
size and depth of invasion - early cancers confined to submucosa have a 20% incidence of lymph node metastasis
19
Q
What are the 3 classifications of tumours of the gastro-oesophageal junction?
A
- Type 1: true oesophageal cancers, 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 oesophago-gastric junction
- Type 3: sub-cardial cancers that spread across the junction. Involve similar nodal stations to gastric cancer
20
Q
What are 6 aspects of potential management of gastric cancer?
A
- Sub-total gastrectomy
- Total gastrectomy
- Oesophagogastrectomy
- Endoscopic sub-mucosal resection
- Lymphadenectomy
- Chemotherapy
21
Q
What type of gastric cancer is sub-total gastrectomy most likely to be used for?
A
proximally sited disease greater than 5-10cm from the OG junction
22
Q
What type of gastric cancer is total gastrectomy most likely to be used for?
A
tumour <5cm from OG junction
23
Q
What type of gastric cancer is oesophago-gastrectomy most likely to be used for?
A
type 2 junctional tumours (extending into oesophagus)
24
Q
What type of gastric cancer is endoscopic sub-mucosal resection most likely to be used for?
A
early gastric cancer confined to the mucosa and perhaps the sub-mucosa (debated)
25
What type of lymphadenectomy is widely advocated by the Japanese?
D2 lymphadenectomy
26
Which patients with gastric cancer will receive chemotherapy and when?
most patients with gastric cancer, either pre- or post-operatively
27
What is the 5 year survival of early vs stage 3 gastric cancer?
91% vs 18%
28
What type of gastric cancer is associated with signet ring cells?
diffuse gastric cancer
29
What are 4 examples of specific forms or precancerous forms of gastric cancer?
1. Menetrier's disease (pre-cancerous)
2. Krukenberg tumour
3. Sister Mary Joseph nodule
4. Linitis plastica
30
What is Menetrier's disease?
pre-cancerous condition in which there is hyperplasia of the gastric mucosa (cause unknown)
there are large, gastric folds on body and stomach associated with increased mucus production
associated with parietal cell atrophy and hence reduced acid production
31
What is a Krukenberg tumour?
type of gastric cancer, also known as signet ring tumour due to pathological appearance of these cells which readily secrete mucin
32
Where do Krukenberg or signet ring tumours readily metastasise to?
ovaries
33
What are 3 aspects of the presentation of Krukenberg tumour?
1. Bloating
2. Ascites
3. Pain during intercourse
34
What is the most common primary site of Krukenberg tumours and where else can they occur?
stomach most common primary
colon, breast, lung and contralateral ovary less common sites
35
What is a Sister Mary Joseph nodule?
subcutaneous peri-umbilical metastasis associated with intestinal type of gastric cancer
36
What is linitis plastica?
muscles of stomach wall become thicker and more rigid
stomach holds less food as cannot stretch and transition of food slower due to decreased relaxation of the stomach
sometimes known as leather bottle stomach
associated with diffuse type of stomach cancer
37
Does GORD increase the risk of gastric cancer?
no but does increase risk of oesopahgeal adenocarcinoma via Barrett's oesophagus
38
What are the 2 indicatoins for urgent referral (within 2 weeks) for OGD for suspected gastric cancer?
1. **Dysphagia** at any age
2. Aged 55 and over with **weight** **loss** AND:
* upper abdominal pain
* OR reflux
* OR dyspepsia
* OR upper abdo mass consistent with stomach cancer
39
Within what time frame is a non-urgent OGD?
within 6 weeks
40
What are the indications for a non-urgent OGD for potential gastric cancer?
1. Haematemesis (any age)
2. Age 55 and over with either:
* treatment-resistant dyspepsia
* upper abdo pain and low haemoglobin
* raised platelet count AND any of the following -
* nausea, vomiting, reflux, weight loss, dyspepsia, epigastric pain
* nausea or vomiting AND any of the following:
* weight loss, reflux, dyspepsia, epigastric pain
41
What must be done following endoscopy for gastric cancer?
tumour must be staged with CT-TAP / MRI / endoscopic ultrasound
42
When is MRI a useful investigation for gastric cancer staging?
accurate for identifying metastatic spread to the liver and if there is advanced local disease
43
When is MRI a less useful investigation for staging gastric cancer?
less accurate for early localised spread; CT scan preferred for this so is first-line
44
What is a limitation of endoscopic ultrasound for staging of gastric cancer?
limited penetration fo ultrasound waves means it will not inform us about metastatic spread
45
Which tend to be the operative gastric tumours that can be cured?
those that have only locally invaded which usually include stages T0-3
46
What does T4 indicate about a gastric tumour and what are the management option?
tumour that has invaded local structures, meaning operative intervention is needed (but not likely to be cured)
47
What is the approach to management of gastric tumours with nodal spread?
can be treated surgically but depends on site of spread
48
What is the approach to management of gastric cancer with metastatic spread?
usually inoperable
49
What is Barrett's oesophagus?
condition seen in patients with long-standing GORD
describes when chronic acid exposure leads to a change in the distal oesophagus from the usual squamous epithelium to metaplastic columnar epithelium
50
Why is Barrett's oesophagus an important condition to identify?
carries a risk of progression to oesophageal **adenocarcinoma**
51
What is the risk of developing Barrett's oesophagus related to?
the length and severity of reflux symptoms
52
What is the management of Barrett's oesophagus with low-grade dysplasia?
high dose PPI and follow up with endoscopic surveillance at **six monthly interavals**
53
How frequent is endoscopic surveillance for Barrett's oeosphagus?
6 monthly
54
What is the management of Barrett's oesophagus with high-grade dysplasia or early adenocarcinoma?
undergo endoscopic resection of the abnormal areas - radiofrequency ablation, photodynamic ablation, or laser
if fit for surgery - oesophagectomy
55
What is the change in cell type in Barrett's oesophagus?
lower oesophageal mucosa changes from squamous epithelium to columnar epithelium
may resemble either the cardiac region of stomach of that of small intestine (i.e. with goblet cells, brush border)
56
What 2 classes can cases of Barrett's metaplasia be divided into?
short (\<3cm) and long (\>3cm)
57
What is the evidence for the use of high-dose PPIs in Barrett's oesophagus?
limited evidence that it reduces change of progression to dysplasia or induces regression of lesion
58
At what point in Barrett's oesophagus is endoscopic intervention always offered?
dysplasia (As opposed to just metaplasia) of any grade
59
What are the 2 key endoscopic therapies offered for Barrett's oesophagus with dysplasia?
1. endoscopic mucosal resection
2. Radiofrequency ablation
60
What is the most common type of cancer of the oesophagus?
it is now adenocarcinoma (previously was squamous cell carcinoma, as it still is worldwide)
61
What is the key risk factor for adenocarcinoma of the oesophagus?
GORD/Barrett's
62
Where are adenocarcinomas of the oesophagus most commonly located?
near gastro-oesophageal junction
63
Where are squamous cell carcinomas most commonly found?
upper two thirds of the oesopahgus
64
What are 5 risk factors for oesophageal adenocarcinoma?
1. GORD
2. Barrett's oesophagus
3. Smoking
4. Achalasia
5. Obesity
65
What are 5 risk factors for squamous cell carcinoma of the oesophagus?
1. Smoking
2. Alcohol
3. Achalasia
4. Plummer-Vinson syndrome
5. Diets rich in nitrosamines
66
What are 7 possible presenting features of oesophageal cancer?
1. Dysphagia (most common)
2. Anorexia and weight loss
3. Vomiting
4. Odynophagia
5. Hoarseness
6. Melaena
7. Cough
67
What is the first line test for oesophageal cancer?
upper GI endoscopy
68
What is the role of contrast swallow for assessing oesophageal cancer?
may be of benefit for classifying benign motility disorders, but no place in assessment of tumours
69
What are 2 aspects of the initial staging of oesophageal cancer?
1. CT-TAP
2. If overt metastatic disease identified: further complex imaging unnecessary
70
How can local stage of oesophageal cancer be more accurately assessed following initial CT?
endoscopic ultrasound
71
What investigation can be used to detect occult peritoneal disease for oesophageal cancer?
staging laparoscopy
72
What investigation can be performed for staging of oesophageal cancer if laparoscopy is negative?
PET-CT
73
What is the best kind of management of oesophageal cancer which is operable?
surgical resection - Ivor-Lewis type oesophagectomy
74
What is the most standard procedure used for operable oesopahgeal cancer?
* **Ivor-Lewis type oesophagetomy:**
* mobilisation of stomach and division of oesophageal hiatus
* abdomen closed and right-sided thoractomy performed
* stomach brough into chest and oesophagus mobilised further
* intrathoracic oesopahgogastric anatomosis constructed
75
What are 3 types of surgical resections for oesophageal cancer that are alternatives to the Ivor-Lewis type oesophagectomy?
1. Transhiatal resection (for distal lesions)
2. Left thoracoabdominal resection (difficult access due to thoracic aorta)
3. Total oesophagectomy (McKeown) with cervical oesophagogastric anastomosis
76
What is the biggest challenge of surgical resection of oesophageal cancer?
anastomotic leak - intrathoracic anastomosis will result in mediastinitis, high mortality
77
Which type of surgical resection technique for oesophageal cancer has an intrinsically lower systemic insult in the event of anastomotic leakage?
McKeown - total oesophagectomy with cervical oesophagogastric anastomosis
78
What adjuvant treatment will many patients with oesophageal cancer be treated with, in addition to surgical resection?
adjuvant chemotherapy
79
How does the dysphagia of oesophageal carcinoma differ from that of motility disorders (e.g. oesophageal spasm and achalasia)?
oesophageal carcinoma = progressive dysphagia from liquids to solid
motlility disorder = dysphagia to solids and liquids from start
80
Why can hoarseness develop in oesophageal cancer?
if local invasion of recurrent laryngeal nerve
