STOMACH CANCERS AND NEOPLASIAS

Question 1

What are the two types of gastric polyp and which is more common?

Answer 1

Adenomatous polyps - 5%

Hyperplastic or cystic fundal polyps - very common

Question 2

How are most gastric polyps discovered?

Answer 2

Through endoscopy. Most of them are asymptomatic so will not be picked up until they develop into something more sinister.

Question 3

Which group of patients might develop polyps in the stomach fundus which turn out to be carcinoid tumours?

Answer 3

Pernicious anaemia patients

Question 4

What are the complications of gastric polyps?

Answer 4

Bleeding

Malignant change

Question 5

What are the treatment options for someone found to have a gastric polyp?

Answer 5

Surgical resection

Hyperplastic polyps are often left alone unless symptomatic

Question 6

What are gastrointestinal stromal tumours (GIST)?

Answer 6

Most common mesenchymal neoplasms of the gastrointestinal tract. GISTs arise in the smooth muscle pacemaker interstitial cell of Cajal, or similar cells. They are in the walls of the stomach and therefore the overlying mucosa can be intact.

Question 7

What proportion of GI tract malignancies are made up of gastrointestinal stromal tumours (GIST)?

Answer 7

Rare - only 3%

Question 8

What are the clinical features of gastrointestinal stromal tumours (GIST)?

Answer 8

Asymptomatic if small
GI blood loss if they ulcerate and bleed
Abdominal pain
Palpable mass

Question 9

What drug can be used in patients with a gastrointestinal stromal tumour that is not resectable?

Answer 9

Imatinib - anti-tyrosine kinase receptor monoclonal antibody

Question 10

What is Menetrier’s disease?

Answer 10

Normal gastric mucosa is replaced by hypertrophied epithelium producing a characteristic appearance of thickened mucosal folds. There is excessive protein loss through the gastric mucosa. It is not a true neoplasia. Possibly pre-malignant but risk is poorly characterised.

Question 11

How is Menetrier’s disease (thickening of the mucosal folds) treated?

Answer 11

Antisecretory medication - PPI

Partial gastrectomy - may be required to reduce protein loss

Question 12

What type of carcinoma are most gastric cancers?

Answer 12

Glandular adenocarcinomas (90%)

Question 13

Where is the world has a 5 times greater incidence of gastric cancer than the UK?

Answer 13

Japan

China also increased but not quite as high

Question 14

What types of food increase the risk of developing gastric cancer?

Answer 14

Nitrates from salted or smoked foods

Question 15

What are the risk factors for developing gastric carcinoma?

Answer 15

Chronic H. pylori infection
Diet - neutral/high pH
Pernicious anaemia
Blood group A
Previous partial gastrectomy
Lower SEC
Adenomatous gastric polyps

Question 16

How might someone with gastric carcinoma present?

Answer 16

Epigastric pain (similar to peptic ulcers)
Weight loss
Nausea, vomiting
Loss of apetite
Fatigue
Malaise
Symptoms of metastases

Question 17

On examination, what signs might you pick up in someone with suspected gastric carcinoma?

Answer 17

Conjunctival pallor
Palpable mass
Lymphadenopathy (Virchow's node)
Jaundice - mets
Ascites

Question 18

What investigations would you do in someone with suspected gastric carcinoma?

Answer 18

Endoscopy
Barium meal
CT
PET
LFTs, U&Es

Question 19

What might you expect to find during endoscopy of someone with gastric carcinoma?

Answer 19

You could find a tumour, but more likely you would find an ulcer which would need biopsy and further investigation to check that it wasn’t malignant

Question 20

What might a barium meal reveal in someone with gastric carcinoma?

Answer 20

May show gastric ulcer

If diffuse infiltrative type of gastric cancer then barium meal may reveal a rigid, contracted stomach.

Question 21

What are the most common sites for gastric cancer?

Answer 21

Antrum - 50%
Body/Fundus - 25%
Cardia (oesophageal opening) - 25%

Question 22

Why would you do LFTs and U&Es in someone with gastric cancer?

Answer 22

This is to look for signs of metastases ie liver and bone (hypercalcaemia).

Question 23

What is the prognosis for someone diagnosed with gastric carcinoma?

Answer 23

Those confined to the mucosa have a 90% 5 year survival rate
However, those with invasive lesions have more like 10% 5 year survival rate.
Screening programs have now been set up in Japan due to high rates.

Question 24

How is someone diagnosed with gastric carcinoma managed?

Answer 24

MDT
Options include:
Surgery - only curative option
Chemo and radiotherapy are actually rarely used but may help with control of symptoms due to tumour bulk.
Symptom control with analgesia and antiemetics

Question 25

What percentage of gastric malignancies does gastric lymphoma make up?

Answer 25

5-10%

Question 26

What type of lymphoma are gastric lymphomas?

Answer 26

Non-Hodgkin B cell type arising from MALT (mucosal-associated lymphoid tissue), rather than primary lymph nodes.

Question 27

Are gastric lymphomas associated with H. pylori infection?

Answer 27

Yes

Question 28

What are the clinical features of gastric lymphoma?

Answer 28

``` Epigastric pain (similar to peptic ulcers) Weight loss Night sweats Nausea, vomiting Loss of apetite Fatigue Malaise Symptoms of metastases ```

Question 29

What are the treatment options for someone diagnosed with gastric lymphoma?

Answer 29

``` MDT Eradication of H. pylori Chemotherapy and radiotherapy Surgical resection of the tumour Endoscopic surveillance ```

Question 30

What is the prognosis for someone diagnosed with gastric lymphoma?

Answer 30

Very good | 80-90% survival depending on the type of lymphoma. Complete excision can be curative.

Question 31

What are the two main types of gastric adenocarcinoma as defined by the Lauren Classification?

Answer 31

``` Intestinal type (58%) Diffuse type (33%) ```

Question 32

What is the different between intestinal type and diffuse type of gastric adenocarcinoma?

Answer 32

Intestinal type gastric carcinomas are associated with Helicobacter pylori associated chronic gastritis, atrophy, and intestinal metaplasia, which are thought to be precursors of the dysplastic changes that evolve into this type of carcinoma. Gastric carcinomas of the diffuse type are also associated with H pylori infection, but not with atrophy and intestinal metaplasia; they are usually less well differentiated, characterised by sheets of cells without gland formation, with the occasional presence of signet ring cells and mucin, and are associated with a poor prognosis compared with the intestinal type of tumour.