Jackson - Gastric Neoplasia Flashcards Preview

GI > Jackson - Gastric Neoplasia > Flashcards

Flashcards in Jackson - Gastric Neoplasia Deck (44)
Loading flashcards...
1

What are the 3 types of gastric polyps?

Non-neoplastic

1. Inflammatory/hyperplastic 

2. Fundic gland 

a. Sporadic (more common) - beta catenin 

b. Syndromic - APC 

Neoplastic

1. Adenomas -> precursor lesions to cancer 

2

What are these?

Hyperplastic gastric polyps: devo driven by chronic inflammation -> H. pylori 

- Most in the antrum: 60%

- Most BENIGN, small risk of dysplasia

- Some will regress when pts are treated for H. pylori 

3

What do you see here?

- Fundic gastric polyps: body or fundus

- Usually <1cm, cystic appearing, and clustered

- Surrounding stomach normal

- May be sporadic, associated with PPI use, or associated with familial adenomatous polyposis (FAP)

- Rare malignant potential, unless assoc with FAP

4

What do you see here?

- Gastric adenoma (up to 10% of all gastric polyps): INC incidence in pts w/FAP (like fundic gland polyps)

- Almost always on a background of chronic gastritis, with atrophy and intestinal metaplasia

1. Intestinal-type columnar epi w/varying degrees of dysplasia 

- Most are ANTRAL

- Pre-malignant neoplastic lesions with a high risk of transformation to invasive cancer -> usually removed

1. Risk of malignancy INC with size, villous lesions, or high-grade dysplasia

5

Gastric cancer epi

- More common in lower SES, developing countries

- Male:female = 2:1

- Peaks in 7th decade

- Declining incidence in US of distal gastric cancers, except in Caucasians age 29-39 (reason for this not really clear)

6

How have incidence and death by gastric cancer changed in the US? Why (3)?

- Incidence of cases and deaths have DEC

- Decreased incidence:

1. Tx H. pylori (carcinogen)

2. Refrigeration and DEC meat curing: addition to meats of some combo of salt, sugar, nitrite and/or nitrate for preservation, flavor and color

3. INC consumption of vegetables

7

What are the risk factors for gastric cancer?

- Chronic atrophic gastritis: DEC acid production

- Pernicious anemia: change in pH of stomach (loss of gastric parietal cells)

- Prior gastric surgery: INC risk after 10 years 

- High dietary nitrates: cured meats 

- Adenomatous gastric polyps: FAP

- Helicobacter pylori infection: INC risk 3-6x

8

What is a common mech by which factors predisposing to gastric cancer INC risk?

- May INC production of mutagens, like nitrites

9

What are some of the presenting symptoms of gastric cancer? Warning signs?

- Epigastric pain: can be relieved or exaggerated by food (can present like PUD)

- Ulceration/bleeding: can cause anemia, melena (black, tarry feces assoc w/upper abdominal bleeding)

- Distal lesions may obstruct stomach outlet 

Weight loss + epigastric pain + anemia -> think of gastric cancer 

- Nausea and dysphagia also reported 

10

What do you see here?

- Radiology showing infiltrating gastric carcinoma in region of the incisura 

- Irregular narrowing, affecting both the lesser and greater curvatures 

11

Which of these is malignant/benign? How do you know?

- TOP: malignant gastric ulcer of the cardia -> note the absence of folds radiating to the base, and the exophytic appearance 

- BOTTOM: benign gastric ulcer in prepyloric region; well-circumscribed, with folds radiating to ulcer base 

- NOTE: carcinoma may look like gastric ulcer endoscopically, so ALWAYS biopsy these 

12

What do you see here? How would you dx this?

- Gastric cancer ID'd by endoscopy: may show mass or malignant gastric ulcer 

- BIOPSY for diagnosis 

- NOTE: this patient would probably have anemia and abdominal pain due to evidence of bleeding 

13

What are the 4 types of gastric cancer?

- Adenocarcinoma: >90% in US 

1. Intestinal: DEC rates due to tx of H. pylori 

2. Diffuse 

- Lymphoma: 3% in US, and better prognosis than adenocarcinoma 

- Carcinoid: 0.2% in US 

- Gastrointestinal stromal tumor (GIST)

14

What are the epi differences b/t the 2 histo types of adenocarcinoma?

- INTESTINAL: more frequent in M, and at older ages 

1. Environmental? Dietary association 

- DIFFUSE: little difference b/t sexes, and more freq at younger ages 

15

How is gastric cancer treated?

- CT for staging prior to surgery, looking for metastatic disease (about 50% present with mets)

- Endoscopic ultrasound (EUS) used for staging for potential surgical candidates to assess depth of invasion into gastric wall (deeper lesion may benefit from neoadjuvant therapy)

- Surgery is only chance for cure, but rarely curative

1. May also be used for palliation -> obstruction or bleeding

- Chemo may improve survival in pts who have sx

16

What is linitis plastica?

- Aggressive diffuse gastric cancer where gastric wall and submucosa infiltrated by malignancy -> rigid, thickened stomach

- 5% of gastric cancers; may not be resectable, so poor prognosis 

- Endoscopic biopsies may not pick up the diagnosis because may be submucosal -> also hard to identify because diffuse change 

17

What is the difference b/t these 2 images?

- Normal stomach on the left 

- Linitis plastica on the right: aggressive, diffuse gastric cancer where wall is infiltrated, leading to rigid, thickened stomach 

18

How does gastric cancer metastasize?

- May met to liver, peritoneum, or distal lymph nodes

- Virchow’s node: left supraclavicular node (TESTS)

- Sister Mary Joseph node: periumbilical nodule

19

What is this?

- Virchow's node

- Gastric cancer met to L. supraclavicular node 

20

What do you see here?

- Sister Mary Joseph nodule 

- Periumbilical nodule suggestive of metastatic gastric cancer 

21

What are the 4 stages of stomach cancer (image)? How does this affect survival?

- Based on penetration into stomach wall: 

Stage 0: mucosa only 

Stage 1: submucosal 

Stage 2: muscle 

Stage 3: impinging on serosa 

Stage 4: extra-serosal (outer-most layer) 

- 5-year survival: localized (61%), regional nodes (28%), distant metastases (4%)

22

66-y/o F with 6-mo history of vague epigastric pain, early satiety, 25 # weight loss, intermittent melenic stools. Her lab shows anemia. Does H. pylori predispose her to this lesion?
 

Absolutely

23

66-y/o F with 6-mo history of vague epigastric pain, early satiety, 25 # weight loss, intermittent melenic stools. Her lab shows anemia. Is this tumor most likely a lymphoma?

- NO 

- 90% of gastric cancer is adenocarcinoma 

24

66-y/o F with 6-mo history of vague epigastric pain, early satiety, 25 # weight loss, intermittent melenic stools. Her lab shows anemia. What is the best tx for her disease?

Surgery

25

What are the 4 regions of the stomach? How do they differ in cell type?

- Cardia: mucin-secreting foveolar cells that form small glands

- Body and fundus: also contain chief cells that produce and secrete digestive enzymes, i.e., pepsin

- Antrum/pylorus: similar, but also endocrine cells, like G cells, that release gastrin to stimulate luminal acid secretion by parietal cells in gastric fundus and body

26

What is this?

- Hyperplastic gastric polyp: dilated, elongated and torturous gastric foveolar epithelium

1. Torturous, deeper, and architecture different

- Edematous lamina propria containing inflam cells

- Note the erosion with granulation tissue -> getting beat up (erosion: superficial; ulcers: deep)

27

What do you see here?

- Fundic gland gastric polyp: cystically dilated 

- Lined by FLATTENED parietal and chief cells 

- Typically nice and round

28

What is this?

Fundic gland gastric polyp: cystically dilated 

- Lined by FLATTENED parietal and chief cells 

- Typically nice and round; some superficial erosion here

29

Briefly describe the multifactorial pathway leading to devo of gastric carcinoma.

- Many host, bacterial, and envo factors act in combo to contribute to precancerous cascade 

Superficial gastritis: reactive/chronic gastritis, i.e., via H. pylori infection

- Atrophic gastritis: process of chronic inflammation of the stomach mucosa, leading to loss of gastric glandular cells and their eventual replacement by intestinal and fibrous tissues

- Things to note: H. pylori, cigarette smoking, bac overgrowth/low acidity 

30

What is this?

Gastric adenoma: equivalent of low-grade dysplasia

- Nuclei more elongated; hyperchromatic

- More cigar-like

- May be a goblet cell in upper left corner

- Compare to normal (attached here)