L7: Gastric Cancer Flashcards
(115 cards)
1
Q
Incidence of Gastric Cancer
A
2
Q
what is decrease in the incidence of Gastric Cancer attributed to?
A
- advances in food preservation
- public awareness about healthy diet.
3
Q
Highest Incidence of Gastric Cancer is in ……
A
In Eastern Asia, Eastern Europe, and South America.
4
Q
Lowest Incidence of Gastric Cancer is in ……
A
In North America and parts of Africa
5
Q
what are types of Gastric Cancer?
A
Two biological entities (classified by Lauren) which are different regarding epidemiology, etiology, pathogenesis, and behavior. Which are:
1) The Intestinal type.
2) The Diffuse type.
6
Q
Compare between Intestinal & Diffuse (Infiltrative) Gastric Cancer
A
7
Q
Precursor lesions of Intestinal type Gastric Cancer
A
8
Q
Chronic superficial gastritis
A
9
Q
Gastric atrophy with loss of parietal cell mass
A
10
Q
Atrophic gastritis
A
11
Q
Intestinal metaplasia and dysplasia
A
12
Q
Incidence of Familial Gastric Cancer
A
- Most gastric cancers are sporadic but familial pattern is noted in 10% of cases.
- Hereditary (familial) gastric cancer accounts for 1-3% of gastric cancer and comprises at least three major syndromes
13
Q
Types of Hereditary (familial) gastric cancer
A
1) Hereditary diffuse gastric cancer (HDGC).
2) Gastric adenocarcinoma and proximal polyposis of the stomach (GAPPS).
3) Familial intestinal gastric cancer (FIGC).
14
Q
Mode of inheritance of Hereditary diffuse gastric cancer (HDGC)
A
Autosomal dominant (AD) inherited form of diffuse type gastric cancer.
15
Q
Mutant Gene in Hereditary diffuse gastric cancer (HDGC)
A
It is due to germline truncating mutations in the cadherin 1 (CDH1) gene.
16
Q
CP of Hereditary diffuse gastric cancer (HDGC)
A
- Characterized by late presentation.
- Affected patients generally are diagnosed at an early age.
17
Q
Prognosis of Hereditary diffuse gastric cancer (HDGC)
A
Poor prognosis.
18
Q
when to suspect Hereditary diffuse gastric cancer (HDGC)?
A
19
Q
Prophylactic Therapy in Hereditary diffuse gastric cancer (HDGC)
A
- The risk of gastric cancer in asymptomatic carriers of a pathogenetic CDH1 mutation is sufficiently high to do prophylactic gastrectomy.
- Surgery is usually recommended between the age of 20 and 30.
20
Q
Risk Factors for Gastric Cancer
A
- Helicobacter pylori
- Diet
- Obesity
- Smoking
- Occupational Exposure
- EBV
- Abdominal Irradiation
- Gastric Surgery
- Blood Group A
- Gastric Ulcer
- Gastric Diseases
21
Q
Risk of H. Pylori in Gastric Cancer
A
- The WHO classified H. pylori as a group 1 or definite carcinogen.
- H. pylori is potentially modifiable risk factor for gastric cancer.
22
Q
How does H. Pylori Predispose to Gastric Cancer?
A
- It triggers inflammation at the mucosa → results in atrophy and metaplasia.
- It is associated with the risk of intestinal and diffuse types of adenocarcinomas.
23
Q
CP of H.Pylori
A
The majority of patients with H. pylori infection have no significant clinical symptoms.
24
Q
Diet as a risk factor for Gastric Cancer
A
25
Obesity
**Risk Factors for Gastric Cancer**
- High-level evidence supports of association () obesity and increase risk of gastric cancer.
- The strength of the association increased with increasing BMI.
26
Smoking
**Risk Factors for Gastric Cancer**
High-level evidence supports that:
- Smoking increases the risk of gastric cancer by 1.5-fold.
- The risk decreased after 10 years of smoking cessation.
27
Occupational Exposure
**Risk Factors for Gastric Cancer**
Weak evidence suggests that occupations as mining, metal processing (particularly steel and iron), and rubber manufacturing industries increase the risk of gastric cancer.
28
EBV
**Risk Factors for Gastric Cancer**
It is that about 5-10% of gastric cancers worldwide are associated with EBV.
29
Abdominal Irradiation
**Risk Factors for Gastric Cancer**
...
30
Gastric Surgery
**Risk Factors for Gastric Cancer**
31
Gastric Ulcer
**Risk Factors for Gastric Cancer**
- An association between benign gastric ulcers and gastric cancers probably reflects common risk factors (ie, mainly H. pylori infection).
- The risk of gastric cancer was increased among patients with benign gastric ulcers (incidence ratio 1.8).
31
Blood Group A
**Risk Factors for Gastric Cancer**
It is possible that the observed associations are not due to the blood group antigens themselves but to the effects of genes closely associated with them.
32
Gastric Diseases
**Risk Factors for Gastric Cancer**
Hypertrophic gastropathy (including Ménétrier's disease) and immunodeficiency syndromes → weak evidence suggests the link to gastric cancer.
33
Does Iatrogenic Achlohydria predispose to Gastric Cancer?
- **Iatrogenic achlorhydria** induced by **long-term use of histamine 2 receptor antagonists or proton pump inhibitors** has **not** been **associated** with an **increased risk of either gastric adenocarcinomas or neuroendocrine tumors**.
- An association between maintenance therapy with omeprazole and the development of atrophic gastritis in individuals with H. pylori infection has been suggested, but the data are inconclusive.
34
what are possible protetictive factors from Gastric Cancer?
- Fruits, vegetables, and fiber
- NSAIDs
- Reproductive hormones
- Helicobacter pylori eradication
35
Fruits, veges & Fibers
**possible protetictive factors from Gastric Cancer**
It is most likely due to vitamin C content → ↓ the formation of carcinogenic N- nitroso compounds inside the stomach.
36
NSAIDs
**possible protetictive factors from Gastric Cancer**
Regular use has been inversely associated with the risk of distal gastric adenocarcinoma
37
H.Pylori Eradication
**possible protetictive factors from Gastric Cancer**
38
Reproductive Hormones
**possible protetictive factors from Gastric Cancer**
- Gastric cancer incidence rates are consistently lower in women.
- This supports that reproductive hormones may have a protective role in gastric cancer risk in women.
39
Intro to screening of **Gastric Cancer**
Screening for gastric cancer is controversial, and recommendations for screening differ based on the incidence of gastric cancer.
40
Screening for **Gastric Cancer** in High Incidence Countries
41
what are individuals at high risk for **Gastric Cancer**?
42
Screening for **Gastric Cancer** in low incidence Countries
Selective screening of high-risk subgroups is recommended.
43
Screening in High-risk patients from families with hereditary diffuse gastric cancer
44
Presentation of **Gastric Cancer**
- Most patients with gastric cancer are symptomatic.
- Weight loss and persistent abdominal pain are the most common symptoms at initial diagnosis.
- Approximately 25% of patients with gastric cancer have a history of gastric ulcer.
45
CP of **Gastric Cancer**
- Weight loss
- Abdominal pain
- Nausea or early satiety
- Dysphagia
- Gastric outlet obstruction
- Bleeding
- Palpable abdominal mass
- Distant Metastasis
- Local Infiltration
46
Weight Loss in **Gastric Cancer**
results from:
- Insufficient caloric intake
- Attributable to anorexia, nausea, abdominal pain, early satiety, and/or dysphagia.
47
Abdominal Pain in **Gastric Cancer**
- Early in the disease → tends to be epigastric, vague, and mild.
- When the disease progresses → more severe and constant.
48
Nausea & Early Satiety in **Gastric Cancer**
Due to tumor mass and in cases of linitis plastica (aggressive form of diffuse type gastric cancer), these symptoms arise from the inability of the stomach to distend.
49
Dysphagia in **Gastric Cancer**
It is common in patients with proximal gastric cancer.
50
Gastric Outlet Obstruction in **Gastric Cancer**
In advanced distal tumor.
51
Bleeding in **Gastric Cancer**
- Occult gastrointestinal bleeding, with or without iron deficiency anemia.
- Overt bleeding (i.e., melena or hematemesis) is seen in fewer than 20% of cases.
51
Palpable Abdominal Mass in **Gastric Cancer**
It is uncommon but it is the most common physical finding and generally indicates long-standing & advanced disease.
52
Manifestation of Distant Metastasis in **Gastric Cancer**
53
Def of **Linitis plastica**
Linitis plastica is a particularly aggressive form (5%) of diffuse-type gastric cancer.
54
Manifestation of Local Infiltration in **Gastric Cancer**
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Spread of **Linitis plastica**
56
Investigations in **Linitis plastica**
- Barium study,
- Abdominal computerized tomography (CT),
- Endoscopic ultrasound (EUS).
57
Prognosis of **Linitis plastica**
It has an extremely poor prognosis.
58
TTT of **Linitis plastica**
Some surgeons consider it a potentially curative resection.
59
Investigations in **Gastric Cancer**
- Routine laboratory investigation
- Serum tumor markers
- Barium studies
- Upper endoscopy with biopsy
- Contrast-enhanced CT of chest, abdomen, and pelvis
- Endoscopic ultrasound (EUS)
- Staging laparoscopy
60
What are tumor Markers used in **Gastric Cancer**?
CEA and CA 125.
60
Routine Lab Investigations in **Gastric Cancer**
61
Advantages of tumor Markers used in **Gastric Cancer**
Useful in the evaluation of the response to neoadjuvant therapy.
62
Disadvantages of tumor Markers used in **Gastric Cancer**
Low sensitivity and specificity → low diagnostic value.
63
Barium Studies in **Gastric Cancer**
64
Importance of **Upper endoscopy with biopsy** in Gastric Cancer
Mandatory for tissue diagnosis by biopsy and anatomic localization of the primary tumor.
65
Findings of **Upper endoscopy with biopsy** in Gastric Cancer
66
The typical appearance of gastric cancer is .......
friable, ulcerated mass
67
Up to 5% of malignant ulcers appear benign grossly → Histologic examination of tissue is required to establish the diagnosis.
..
68
Performing seven biopsies from the ulcer margin, edge, and base increases the .......
sensitivity to greater than 98%.
69
Uses of **Contrast-enhanced CT of chest, abdomen, and pelvis** in gastric Cancer
70
Disadvantages of **Contrast-enhanced CT of chest, abdomen, and pelvis** in gastric Cancer
It has a limited value in assessment of depth of tumor invasion and LN metastasis.
71
Advantages of **Endoscopic ultrasound (EUS)** in Gastric Cancer
- It is the most reliable nonsurgical method for evaluating the depth of invasion.
- Superior to CT in assessment of tumor depth (T stage) and LN involvement (N stage), particularly if fine-needle aspiration (FNA) is performed.
72
When to do **Endoscopic ultrasound (EUS)** in Gastric Cancer?
It is better to be done when it is anticipated to change the plan of management.
73
Disadvantages of **Endoscopic ultrasound (EUS)** in Gastric Cancer
- More invasive than CT
- Not easily available
- Requires special experience.
74
Advantages of **Staging laparoscopy** in Gastric Cancer
75
Staging of gastric cancer is important to: ......
1) Determine the plan of management.
2) Minimize unnecessary surgery, and
3) Maximize the value of the treatment for the patient.
76
There are two main classification systems for staging of gastric cancer:
77
TNM Staging of Gastric Cancer
- T
78
TNM Staging of Gastric Cancer
- M
79
TNM Staging of Gastric Cancer
- N
80
Clinical Staging of Gastric Cancer
- Locoregional, potentially resectable (stage I to III)
- Locally advanced, unresectable or metastatic (stage IV)
81
Locoregional, potentially resectable (stage I to III)
These are potentially curable, and the decision can be neoadjuvant therapy then surgery or upfront surgery based on a multidisciplinary evaluation.
82
Locally advanced, unresectable or metastatic (stage IV)
Palliative therapy depending on their symptoms and functional status.
83
Stage 0 in Gastric Cancer TNM
84
Stage 1 in Gastric Cancer TNM
85
Stage 2A in Gastric Cancer TNM
86
Stage 2B in Gastric Cancer TNM
87
Stage 3 in Gastric Cancer TNM
88
Stage 4A in Gastric Cancer TNM
89
Stage 4B in Gastric Cancer TNM
90
Prognosis of Gastric Cancer
The prognosis of gastric cancer is generally poor
91
Why is the prognosis of gastric cancer poor?
1) The tumor has often metastasized by the time of discovery.
2) Most people with the condition are elderly at presentation.
92
5-year survival rate of:
- Locoregional disease
- Locally advanced or metastatic disease
93
TTT of **Early gastric cancer**
Treatment includes:
1) Gastrectomy
2) Endoscopicresection,
3) Antibiotic treatment for eradication of Helicobacter pylori
4) Adjuvant therapies.
## Footnote
**Gastrectomy remains the main treatment modality used for early gastric cancer worldwide**
94
Indications of **Endoscopic resection** in Gastric Cx
95
- CI of Endoscopic resectio. in Gastric Cx
- Indications of Gastrectomy in Gastric Cx
96
Procedure in **Surgical Resection in Gastric Cancer**
- Complete surgical eradication with adequate safety margin and proper lymphadenectomy is the treatment of choice for gastric cancer.
97
Indications of ****Surgical Resection in Gastric Cancer****
- Radical resection of early or localized gastric cancer.
- Palliative resection for advanced cancer for management of bleeding or obstruction.
98
Types of **Surgical Resection in Gastric Cancer**
99
CI of **Surgical Resection in Gastric Cancer**
Anesthetic unfitness and suspected metastasis.
100
The choice of operation for gastric cancer depends on:
1) The location of the tumor within the stomach,
2) The clinical stage,
3) The histologic type.
100
SOC in Proximal tumors away from the cardia
Can be managed by proximal or total gastrectomy.
101
SOC in Distal gastric tumors
Can be managed by partial, subtotal, or total gastrectomy
102
SOC in Large tumors or linitis plastica
Better managed by total gastrectomy.
103
extent of lymphadenectomy in Gastric Surgery
104
Neoadjuvant therapy in gastric cancer
105
Palliative gastrectomy in gastric surgery
Surgical intervention can be performed in patients with metastatic cancer for palliation of symptoms such as bleeding, or obstruction.
106
Managment of **Obstructing gastric tumors**
Can be managed by
1) Endoscopic laser canalization,
2) Endoscopic stent,
3) Gastrojejunostomy.
107
Managment of **Unresectable, progressive, and metastatic disease**
Systemic therapy and supportive care
108
Clinical Surveillance in Gastric Cancer
- History and physical examination → Every 3-6 months for 1-2 years
- then every 6 to 12 months for 3-5 years
- then annually.
109
Lab Surveillance in gastric Cancer
Patients are evaluated by:
1) CBC and chemistry profile, nutritional assessment,
2) Upperendoscopy,
3) Computed tomography (CT) of the chest / abdomen / pelvis with oral and intravenous contrast as clinically indicated.
110
Algorithm in TTT of Gastric Cancer
111
Done
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