stomach

Question 1

What are risk factors for stomach cancer

Answer 1

Smoking
obesity
H. pylori - increases risk by 3-6x
Barrett’s oesophagitis - for proximal tumours
Pernicious anaemia
CDH1 mutation - causes hereditary diffuse gastric cancer

Question 2

What is the commonest histology for gastric cancer

Answer 2

Adenocarcinoma, but also the commonest site of GI lymphoma
Rarely can have lobular breast mets to the stomach

Question 3

How should a potential gastric cancer be investigated

Answer 3

OGD and biopsy
HER2 status in metastatic disease
Staging CT
EUS if GOJ lesion
Laparoscopy to exclude peritoneal mets

Question 4

When is surgery only an appropriate management for gastric cancer

Answer 4

Stage 1A (T1N0), and grade 1-2, <2cm, non-ulcerated

Question 5

When is Neo-adjuvant chemotherapy indicated for gastric cancer
And what regimen

Answer 5

≥T2 or node positive

4x FLOT followed by surgery and 4x FLOT adjuvant chemoW

Question 6

What chemo regimen is used for those who did not receive NACT

Answer 6

doublet with fluoropyrimidine and oxali/docetaxel
FolFox / CapOx, or 5-FU/capecitabine with docetaxel
Treatment for 6mths - 6% survival benefit

Question 7

When is there no benefit to adjuvant chemotherapy

Answer 7

MSI-H disease, post radical resection

Question 8

When is chemoRT indicated for gastric cancer
And at what dose

Answer 8

In those who haven’t received NACT, and have an R1 resection or non-D2 resection, can consider adjuvant CRT

45Gy/25# with concurrent 5FU or cape

Question 9

What is the management of metastatic gastric cancer

Answer 9

Doublet chemotherapy with Pt and fluoropyridime - cisplatin/capecitabine (5FU-irini if Pt-intolerant)
+ trastuzumab if HER2+
+ nivolumab if PDL1+

Question 10

What is used 2nd line metastatic gastric cancer

Answer 10

Ramicurimab-paclitaxel if no contraindications to either
MSI-H or dMMR - single agent pembro (2nd line only)

Question 11

What is the prognosis for stomach cancer

Answer 11

5 year OS for all stages = 22% (but for T1 patients = 70%)

Question 12

When does staging affect management for stomach cancer

Answer 12

Stage 1A - T1N0 - can be managed by endoscopic or surgical resection only

stage 1B (T1N1 or T2N0) - stage 3 (all except M1) - multimodality treatment

Question 13

What are the numbers for stomach cancer staging

Answer 13

3,6,15,16
N1 - 1-2LNs
N2 - 3-6
N3a - 7-15
N3b - ≥16

Question 14

what is the mOS for gastric cancer treated with NA and adj FLOT and radical surgery

Answer 14

50mths

Question 15

What is the recurrence rate of a gastric cancer treated radically

Answer 15

54%

Question 16

What is not a risk factor for stomach cancer but is for oesophageal

Answer 16

alcohol

Question 17

what markers should be tested for in the metastatic setting and how are they acted on

Answer 17

HER2 & MMR
If HER2+ - add trastuzumab to doublet chemo
PDL1 - add nivolumab to doublet chemo if CPS >5%

Question 18

what is the mOS of metastatic disease
And if HER2+ met gastric cancer

Answer 18

11mths
HER2+ - 14mths