Stomach Cancer Flashcards by Mario Luna

Stomach Cancer

The stomach begins at ____ and ends at ____.

GE Junction; plyorus

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Stomach Cancer

What divides the stomach into the body and the pyloric portion (antrum)?

A plane passing through the incisura angularis on the lesser curvature

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Stomach Cancer

Which of the following is/are TRUE regarding stomach anatomy?

The anterior surface of the stomach is covered with the peritoneum of the greater sac.

Positive radial margins at GE junction are often “true” positive margins

Posteriorly, the stomach is covered with peritoneum of the lesser sac or omental bursa.

The hepatogastric ligament or lesser omentum is attached to the lesser curvature and contains the left gastric artery and the right gastric branch of the hepatic artery.

All

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Stomach Cancer

What are the five histologic layers of the stomach?

mucosa
submucosa
muscularis
subserosa
serosa

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Stomach Cancer

What are the five layers muscularis layer of the stomach?

OL MC IO

outer longitudinal
middle circular
inner oblique

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Stomach Cancer

Identify the branch of the celiac axis described:

A. supplies the upper
right portion of the stomach

B. gives rise to the
right gastric artery and right gastroepiploic artery

C. gives rise to the left gastroepiploic and short gastric arteries.

A. left gastric
B. common hepatic artery
C. splenic artery

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Stomach Cancer

Modifiable risk factors

H. pylori
Tobacco smoking
Obesity
High-salt diet; low-fruit or -vegetable diet

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Stomach Cancer

Intrinsic risk factors

Ethnicity (East Asian or Pacific Islander)
Male gender
Age
Family history

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Stomach Cancer

Approximately 10% of gastric cancers are linked to genetic syndromes, with the most common being ____, which is characterized by an autosomal dominant inheritance, portending a 60% to 80% increase risk of gastric cancer and 40% to 50% increase in breast cancer.

hereditary diffuse gastric cancer (HDGC)

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Stomach Cancer

The increased association of H. pylori appears to be
confined to patients with ____ gastric cancer and_____histology.

distal; intestinal

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Stomach Cancer

What Lauren classification if prevalent in high-incidence areas?

intestinal

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Stomach Cancer

What Lauren classification is believed to be decreasing in incidence and is primarily well to moderately differentiated?

intestinal

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Stomach Cancer

H. pylori infection has been found to be potentially protective for proximal/cardia cancers.

TRUE or FALSE?

True

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Stomach Cancer

What are the four classifications according to the WHO according to the most common?

chromosomally unstable (50%)
microsatellite-unstable (22%)
genomically stable (20%)
EBV (9%)

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Stomach Cancer

What is the preferred staging modality for T and N (combined)?

EUS

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Stomach Cancer

What are the 5 Borrmann’s type of gastric cancer?

Type I tumors are polypoid or fungating;

type II are ulcerating lesions surrounded by elevated borders;

type III have ulceration with invasion of the gastric wall;

type IV are diffusely infiltrating (linitis plastica); and

type V are unclassifiable.

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Stomach Cancer

How should this patient be staged?
gastric or esophageal?

midpoint in the lower thoracic esophagus

esophageal

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Stomach Cancer

How should this patient be staged?
gastric or esophageal?

midpoint in the GE junction

esophageal

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Stomach Cancer

How should this patient be staged?
gastric or esophageal?

within the proximal 2 cm of stomach (cardia) and extending to esophagus

esophagus

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Stomach Cancer

How should this patient be staged?
gastric or esophageal?

within the proximal 2 cm of stomach (cardia) and extending to GE junction

esophagus

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Stomach Cancer

How should this patient be staged?
gastric or esophageal?

midpoint in the stomach, more than 2 cm distal to and involving the GE junction

gastric

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Stomach Cancer

How should this patient be staged?
gastric or esophageal?

within 2 cm of the GE junction but not involving GE junction or esophagus

gastric

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Stomach Cancer

ToGa trial?

Patients with locally advanced or metastatic gastric or GE
cancer (the ToGA trial) were randomized to determine whether trastuzumab (an
antibody against the HER2 gene product/receptor) enhanced treatment efficacy
when added to cisplatin and 5-fluorouracil (5-FU)/capecitabine therapy

OS and PFS benefit

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Stomach Cancer

AJCC staging 8th edition.
Identify the T-stage:

invasion of the lamina propria

T1a

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Stomach Cancer AJCC staging 8th edition. Identify the T-stage: invasion of the submucosa

T1b

Stomach Cancer AJCC staging 8th edition. Identify the T-stage: penetration into the subserosa

Stomach Cancer AJCC staging 8th edition. Identify the T-stage: invasion of the muscularis mucosa

T1a

Stomach Cancer AJCC staging 8th edition. Identify the T-stage: invasion of the muscularis propria

Stomach Cancer AJCC staging 8th edition. Identify the T-stage: intramural extension to the submucosa duodenum

T1b *** Intramural extension to the duodenum or esophagus is not considered invasion of an adjacent structure, but is classified using the depth of the greatest invasion in any of these sites.

Stomach Cancer AJCC staging 8th edition. Identify the T-stage: extension to the spleen

T4b other adjacent organs

Stomach Cancer AJCC staging 8th edition. Identify the T-stage: extension to visceral peritoneum

T4a

Stomach Cancer AJCC staging 8th edition. Identify the N-stage: 8 lymph nodes

N3a (7-15)

Stomach Cancer AJCC staging 8th edition. Identify the N-stage: 5 lymph nodes

N2 (3 to 6)

Stomach Cancer AJCC staging 8th edition. Identify the N-stage: 16 lymph nodes

N3b (>15)

Stomach Cancer In high-volume centers, very early gastric cancer (Tis and T1a) can be treated with what approach?

endoscopic (mucosal/submucosal) resection

Stomach Cancer Conditions that render stomach cancers unresectable.

evidence of peritoneal involvement, distant metastases, locally advanced (encasement of major blood vessels)

Stomach Cancer Palliative D1 gastrectomy is hard to justify even in the setting of a solitary metastasis TRUE or FALSE?

TRUE. A recent randomized trial from Asia (the REGATTA trial) enrolled 175 gastric cancer patients. Patients were randomized to receive either chemotherapy (oral S1 + cisplatin) or palliative D1 gastrectomy followed by the same regimen. At interim analysis, no significant difference was seen in 2-year survival between the arms. The authors concluded that palliative gastrectomy could not be justified even in the setting of a solitary metastasis

Stomach Cancer What is D1, D2, D3 resection/dissection?

D1 - removal of perigastric nodes (stations 1-6) D2 - nodes along the main vessels of the celiac trunk (common hepatic, left gastric, celiac, and splenic arteries) (stations 7-11) D3 - adjacent to the porta hepatis/aorta (stations 12-16)

Stomach Cancer How many lymph nodes are considered adequate?

≥16

Stomach Cancer Which of the following statements regarding surgical approach in distal gastric cancers is/are FALSE? I. Distal gastrectomy is preferred if adequate margins can be obtained. Larger lesions may require total gastrectomy. II. Generally, the distal margin in subtotal gastrectomy needs to be approximately 1 cm. III. Subtotal gastrectomy for distal cancers removes approximately 80% of the stomach along with the node-bearing tissue, the gastrohepatic and gastrocolic omenta, and the first portion of the duodenum. IV. Total gastrectomy is not recommended where 4- to 6-cm margins can be achieved with partial gastrectomy given improved safety and long-term functional outcome improvements in the latter.

II. 2 cm

Stomach Cancer Prophylactic splenectomy improves the overall survival in patients with proximal gastric cancers. TRUE or FALSE?

May be true, but generally FALSE. The value of splenectomy has not been addressed in prospective randomized trials; however, retrospective Japanese data do not support a survival benefit

Stomach Cancer Vitamin __ supplementation is generally required following total gastrectomy.

B because of lack of intrinsic factor production from the stomach.

Stomach Cancer How many lymph nodes stations are there according to the Japanese Research Society for gastric cancer?

16 (1-6 perigastric) (10 regional)

Stomach Cancer Based on the Japanese Gastric Cancer association, how do you delineate the primary tumor CTV based on location?

proximal -stomach, exclude pylorus and antrum (keeping a 5 cm margin from the GTV) middle -entire stomach, cardia to plyorus distal -stomach, exclude cardia/fundus (keeping a 5 cm margin from the GTV)

Stomach Cancer Based on the Japanese Gastric Cancer association, how do you delineate the primary tumor CTV if there is involvement of the duoednum

include the entire duodenum + 3 cm margin from the tumor

Stomach Cancer If no respiratory motion techniques were used during RT planning, what is the margin recommended to account for respiration to obtain an ITV?

1.5 cm 3-D margins to the CTV

Stomach Cancer What lymph node groups are usually included in the CTV for proximal tumors?

1-4 (R&L paracardiac, lesser curvature, short gastric&LGEV) 7 (LN along LGA) 9-11 (celiac, splenic hilum, splenic) 12-13 pancreatic

Stomach Cancer What lymph node groups are usually added to the CTV for proximal tumors with GE junction involvement?

20 (esophageal hiatus) 110 (paraesophageal) 111 (supradiaphragmatic)

Stomach Cancer What lymph node groups are usually added to the CTV for proximal tumors extending to the middle stomach?

5-6 (supra and infrapyloric) 8 CHA

Stomach Cancer What lymph node groups are usually included to the CTV for tumors of the middle third undergoing TG+Roux-en-Y?

3 to 11 (+/- 12-13) (+1-2 if with proximal involvement)

Stomach Cancer In PORT, irradiation of the regional nodes may be omitted for N0 patients with more than 16 evaluated lymph nodes. TRUE or FALSE?

True

Stomach Cancer In PORT, irradiation of the residual stomach may be omitted for T1 N0 patients. TRUE or FALSE?

True

Stomach Cancer Dose constraints: Lungs

V20 <20% (EORTC) V20 ≤30%; mean ≤20 Gy (NCCN)

Stomach Cancer Dose constraints: Heart

V40 <30%, V25 < 50% (EORTC) V30 ≤30%, mean 30 Gy (NCCN)

Stomach Cancer Dose constraints: Kidneys

V20 <50% (at least one kidney V20 <30%) (EORTC) individual kidney: V20 ≤33%; mean <18 Gy (NCCN)

Stomach Cancer Dose constraints: Liver

V30 <30% (EORTC) V30 ≤33%; mean <25 Gy (NCCN)

Stomach Cancer Dose constraints: V45 Bowel

<195 cm3

Stomach Cancer General RT prescription

45-50/1.8/25-28

Stomach Cancer What are the treatment arms and results of the Mayo Clinic's experience in unresectable or residual gastric cancer? (Moertel et al.)

EBRT+Chemo vs. EBRT alone 35–40 Gy 5-FU increased survival for EBRT + 5-FU with mean survival 13 vs. 5.9 mo and 3/25 (12%) vs. 0/23 5-y survival

Stomach Cancer What are the treatment arms and results of the GITSG's experience in unresectable or residual gastric cancer?

EBRT+chemo vs. chemo alone 50 Gy (split course) 5-FU+semustine Advantage in long-term survival with EBRT + ChT at 18% vs. 7% (P < .05)

Stomach Cancer This trial compared surgery alone wersus 5-FU based chemotherapy (1 cycle) + concurrent 5-FU based CRT, + adjuvant 5-FU. The results of this large study demonstrate a clear survival advantage for the use of postoperative chemoradiation and strongly support its integration into the routine care of patients with curatively resected high-risk carcinoma of the stomach and GE junction

Int 0116

Stomach Cancer What study concluded that the addition of RT to capecitabine+cisplatin chemotherapy did not significantly reduce recurrence after curative resection and D2 lymph node dissection in gastric cancer. However, DFS benefit was seen in those who were pathologically node positive at the time of surgery, and those with intestinal-type cancers.

ARTIST A Korean phase III trial (the Adjuvant Chemoradiation Therapy in Stomach Cancer [ARTIST] study)

Stomach Cancer This trial showed that perioperative chemotherapy with ECF had statistically improved progression-free and overall survival rates.

MAGIC - Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MRC)

Stomach Cancer (from in-service bank) ``` 7. The stomach’s main vascular supply is derived from _______. A. Celiac axis B. Mesenteric artery C. Left Gastric artery D. Right Gastric artery ```

Stomach Cancer (from in-service bank) ``` 8. According to geography, the most common location of Gastric CA observed in the Far East is at _______. A. cardia B. distal region C. GE junction D. proximal lesser curvature ```

Stomach Cancer (from in-service bank) 9. TRUE of patterns of spread of Gastric CA A. The initial lymphatic drainage is to the paraaortic area. B. Peritoneal carcinomatosis is possible when lesion is located in the mucosa layer. C. The relative risks for nodal involvement depends on the location of the primary tumor and extent of gastric wall involvement. D. It is the submucosal plexus in the esophagus which allows the distant spread

Stomach Cancer (from in-service bank) ``` 10. Most frequent site of origin of Gastric CA is the ______. A. antrum B. fundus C. body D. GE junction ```

Stomach Cancer (from in-service bank) ``` 11. Roux-en-Y procedure is the anastomosis of ______. A. esophagus and stomach B. esophagus and small bowel C. stomach and small bowel D. small bowel and large bowel ```

Stomach Cancer Bonus: Identify the lymph node station #/#s: Infrapyloric LN Suprapyloric LN

6 5 clue* top to bottom supra(five)loric supra comes first

Stomach Cancer Bonus: Identify the lymph node station #/#s: Left paracardial LN Right paracardial LN

2 1 be right first

Stomach Cancer Bonus: Identify the lymph node station #/#s: LN along lesser curvature

3 L3ss3r curvature

Stomach Cancer Bonus: Identify the lymph node station #/#s: LN along the short gastric vessels LN along the left gastroepiploic vessels

4sa 4sb (4"s", branches of the splenic artery)

Stomach Cancer Bonus: Identify the lymph node station #/#s: LN along the left gastric artery

7 *7eft gastric LGA

Stomach Cancer Bonus: Identify the lymph node station #/#s: LN along the common hepatic artery

8a and 8p it is the 2nd branch of the celiac so it follows the 7eft gastric CHA-8

Stomach Cancer Bonus: Identify the lymph node station #/#s: LN around the celiac artery

Stomach Cancer Bonus: Identify the lymph node station #/#s: LN along the splenic artery

11 (p and d) proximal/distal

Stomach Cancer Bonus: Identify the lymph node station #/#s: LN in the hepatoduodenal ligament

12 a-hepatic artery b-bile duct p-portal vein

Stomach Cancer Bonus: Identify the lymph node station #/#s: LN at the splenic hilum

Stomach Cancer Bonus: Identify the lymph node station #/#s: LN on the posterior surface of the pancreatic head LN along the inferior margin of the pancreas LN along the anterior surface of the pancreatic head

13 (remember, pancreas is poor prognosis, 13 is unlucky) 18 - inferior 17 - anterior

Stomach Cancer Bonus: Identify the lymph node station #/#s: Supradiaphragmatic LN

111

Stomach Cancer Bonus: Identify the lymph node station #/#s: Paraesophageal LN (lower thorax)

110

Stomach Cancer Bonus: Identify the lymph node station #/#s: LN in the esophageal hiatus of the diaphragm

Stomach Cancer Bonus: Identify the lymph node station #/#s: Infradiaphragmatic LN

19 hiatus is at 20. so below it, you subtract 1 = 19

Stomach Cancer Bonus: Identify the lymph node station #/#s: aortic hiatus aorta (celiac to LRV) aorta (LRV to IMA) aorta (IMA to bifurcation)

16a1 16a2 16b1 16b2 - bifurcation "B" to two... bi

Stomach Cancer Bonus: Identify the lymph node station #/#s: LN along middle colic vessels LN along he superior mesenteric vessels

15 | 14 (v for vein, a for artery)