Stomach Cancer Flashcards
Stomach Cancer
The stomach begins at ____ and ends at ____.
GE Junction; plyorus
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
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
Stomach Cancer
What are the five histologic layers of the stomach?
mucosa submucosa muscularis subserosa serosa
Stomach Cancer
What are the five layers muscularis layer of the stomach?
OL MC IO
outer longitudinal
middle circular
inner oblique
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
Stomach Cancer
Modifiable risk factors
H. pylori
Tobacco smoking
Obesity
High-salt diet; low-fruit or -vegetable diet
Stomach Cancer
Intrinsic risk factors
Ethnicity (East Asian or Pacific Islander)
Male gender
Age
Family history
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)
Stomach Cancer
The increased association of H. pylori appears to be
confined to patients with ____ gastric cancer and_____histology.
distal; intestinal
Stomach Cancer
What Lauren classification if prevalent in high-incidence areas?
intestinal
Stomach Cancer
What Lauren classification is believed to be decreasing in incidence and is primarily well to moderately differentiated?
intestinal
Stomach Cancer
H. pylori infection has been found to be potentially protective for proximal/cardia cancers.
TRUE or FALSE?
True
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%)
Stomach Cancer
What is the preferred staging modality for T and N (combined)?
EUS
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.
Stomach Cancer
How should this patient be staged?
gastric or esophageal?
midpoint in the lower thoracic esophagus
esophageal
Stomach Cancer
How should this patient be staged?
gastric or esophageal?
midpoint in the GE junction
esophageal
Stomach Cancer
How should this patient be staged?
gastric or esophageal?
within the proximal 2 cm of stomach (cardia) and extending to esophagus
esophagus
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
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
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
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
Stomach Cancer
AJCC staging 8th edition.
Identify the T-stage:
invasion of the lamina propria
T1a
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
T3
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
T2
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
A
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
B
Stomach Cancer
(from in-service bank)
- 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
C
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
A
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
C
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
9
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
10
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
20
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)
