Upper GI Oncology - Stomach

Question 1

What major organs make up the upper gastrointestinal tract?

Answer 1

Stomach
Liver
Pancreas 
Oesophagus
Gallbladder

Question 2

Where is the stomach located?

Answer 2

Left hypochondriac region, epigastric region,

Left upper quadrant
Lies directly inferior to the diaphragm

Question 3

What is the stomachs function?

Answer 3

secretes mixture of acid, mucus and digestive enzymes.

Functions as a mixing chamber and holding reservoir

Question 4

What are the regions of the stomach

Answer 4

cardia, body and pyloric antrum

Question 5

What are the major regional nodes of the stomach?

Answer 5

coeliac axis nodes, splenic hilar, porta hepatis, gastroduodenal & suprapancreatic nodal groups

(venous drainage is primarily through the portal venous system into liver)

Question 6

What organs are in close proximity to the stomach?

Answer 6

liver, spleen, kidney and inferior vena cava

Question 7

What are the diet risk factors of stomach cancer?

Answer 7

Low intake of animal fats and proteins

High intake of carbs
(grains and starchy roots)
High salt intake

Low intake of fruits and vegetables

Diet rich in smoked foodstuffs

Diet high in nitrates

Question 8

What are the lifestyle risk factors of stomach cancer?

Answer 8

?Alcohol & tobacco

Poor nutrition

Low socioeconomic status

(also working in an area with industrial dust exposure)

Question 9

What are the biological risk factors of stomach cancer?

Answer 9

Helicobacter pylori infection (they secrete ammonia which can lead to gastric cancer)

Anaemia due to B12 def (6x risk)

Genetic – Blood group A

Question 10

What are common presenting symptoms of stomach cancer?

Answer 10

Vague epigastric discomfort

Loss of appetite

Weight loss

Nausea, vomiting

Palpable epigastric mass

Ascites (fluid in peritoneal cavity)

Left supraclavicular adenopathy

Jaundice

Left axillary and supraclavicular adenopathy

haematemesis (vomiting blood)

Question 11

What are common patterns of spread of disease?

Answer 11

(1/3 of all cases are metastatic)
Local spread:
- omentum, pancreas
- regional lymph and blood channels in submucosa, subserosa

Blood:
- Liver and lung via portal venous system

Lymphatics:

• Nodes in the left gastric chain
• Then splenic, coeliac plexus (axis), & hepatic

Question 12

What is the pathology of stomach cancers?

Answer 12

90-95% are Adenocarcinoma
5% are Lymphoma

Gastrointestinal stromal tumours (GISTS)

Carcinoids

Question 13

What is the common staging technique for stomach cancer

Answer 13

TNM

Question 14

Read Walter and Millers Cancer and its management - pg 403 AND 264

Answer 14

READ IT

Question 15

How is stomach cancer managed clinically

Answer 15

There is a multidisciplinary approach

Surgery, neoadjuvant & adjuvant chemo, palliative chemotherapy and radiation

primarily resection
- Only 25-30% suitable for curative surgery

Question 16

What is classified as ‘upper GI’

Answer 16

digestives above the small bowel (small intestine)

Question 17

What is classified as ‘lower GI’

Answer 17

digestives below the small bowel

Question 18

What types of adjuvant treatments are available

Answer 18

Chemo and RT
For RT the high toxicity to organs at risk (as the stomach is surrounded by many radiosensitive organs) is what limits the dose prescribed.

(E.G. abdomen small intestine, liver, spinal cord and kidneys)

post operative chmo/RT is for good performance and helps improve survival/

Question 19

What are palliative therapies for stomach cancer?

Answer 19

RT and chemo

RT - Inoperable local control for symptoms, Dysphagia, haemorrhage, pain

Chemo- Inoperable metastatic disease

Question 20

What areas should be included in the CTV for gastric cancers

Answer 20

the gastric/tumour bed, gastric remnant, nodal stations along the lesser & greater curvature of the stomach, coeliac axis, suprapancreatic, porta hepatis & splenic groups

Question 21

What OAR should be contoured?

Answer 21

The liver, kidneys, lungs and heart are contoured as OAR.

Question 22

What is the conventional dose given to treat gastric cancer?

Answer 22

Adjuvant radiotherapy - 45 Gy in 25 daily fractions of 1.8 Gy given in 5 weeks (25#)

with concomitant 5FU and Leucovorin (& 2 cycles chemo post RT)

Question 23

What are some OAR tissue tolerances?

Answer 23

the liver V30 should be below 60 per cent and two thirds of one kidney (and ideally both) should be below 20 Gy.

Question 24

What are some steps to ensure patient care?

Answer 24

Monitored carefully
Weekly full blood counts (spleen produces red blood cells and helps with immune system thus doing blood counts also shows if it is affected)

Biochemistry

Dietetic assessments – including weight

Adequate measures for gastrointestinal toxicity (nausea, vomiting and diarrhoea)