Stomach Cancer FRCR CO2A Flashcards
(93 cards)
1
Q
parts of stomach
A
Fundus
Body
Pylorus
2
Q
covering of stomach
A
antr: peritoneum of the greater sac
Post: peritoneum of lesser sac
3
Q
Blood supply of stomach
A
- Celiac axis via left gastric, right gastric and gastro-epiploic arteries
4
Q
at what vertebral level celiac axis originate?
A
T12 in 75 % and at or above the pedicle of L1 in 25%
5
Q
malignant conditions of stomach
A
Adenocarcinoma
Squamous Cell
Small Cell
Lymphoma
Carcinoid
GIST
6
Q
Peak Incidence of Gastric Cancer
A
65 years
7
Q
Risk Factors for Ca Stomach
A
- Environmental: diets low in vitamins A and C; diets high in salty/smoked foods or nitrates; smoking; low SE status
- infection: H. PYlori 3 to 6 X
- Inflammation: Barett’s esophagus
- pernicious anemia
- genertic: CDH1 mutation (E Cadherin), 80 % risk by age 80
8
Q
Protective factors for stomach cancer
A
use of aspirin or NSAIDS, diets rich in fruit and vegetables or vitamin C; blood group O
9
Q
2 Histological Variants
A
Lauren Classification:
1. Intestinal
2. Diffuse
both are mucin secreting adenocarcinoma
10
Q
IHC markers for Stomach Cancers
A
CK 7
CK 20 and mucin (MUC1, 2, 5 AC, and 6)
11
Q
what % of pts overexpress HER2
A
20 %
12
Q
spread of gastric cancer
A
- direct extension
- Lymphatic
- Hematogenous
13
Q
stomach cancer, at presentation, what % have liver and nodal involvement?
A
30 % and 60 %
14
Q
Krukenberg tumors
A
peritoneal dissemination after extension through the serosal surface of the stomach to the ovaries
15
Q
Blumer’s tumor
A
peritoneal dissemination after extension through the serosal surface of the stomach to the rectum or the rectal shelf
15
Q
s/s of stomach cancer
A
anorexia
wt loss
epigastric discomfort
early satiety
dysphagia
vomiting
bleeding (hemetemesis or malena)
16
Q
Rx fo Tis to T1b and N0
A
Endoscopic Resection or Surgery
17
Q
Rx for >T1b
A
perioperative Chemotherapy (cat 1)
18
Q
R1 post surgery
A
Chemo-Radiation
19
Q
R0 but T3 T4 or N+
A
CRT if < D2 dissection
chemotherapy if D2 dissection
20
Q
recommended regimen in peri-operative setting
A
FLOT
21
Q
CRT regimen post Surgery
with < D2 dissection
A
Fluoropyrimidine (infusional fluorouracil or capecitabine)
before and after fluoropyrimidine-based chemoradiation
22
Q
Adj. Chemo who has undergone D2 dissection
A
- Capecitabine and oxaliplatin (category 1)9
- Fluorouracil and oxaliplatin
23
Q
Metastatic disease Rx
A
depends on MSI/MMR status, HER 2 expression and PDL1 status
24
if dMMR/MSI - H, for metastatic stomach cancer
Pembrolizumab
Dostarlimab
Nivolumab and ipilimumab
Fluoropyrimidine (fluorouracil or capecitabine), oxaliplatin, and nivolumab
Fluoropyrimidine (fluorouracil or capecitabine), oxaliplatin, and pembrolizumab
25
2nd L regimens for stomach cancer
Ramucirumab and paclitaxel (category 1)
* Fam-trastuzumab deruxtecan for HER2 overexpression-positive adenocarcinoma
* Docetaxel (category 1)
* Paclitaxel (category 1)
* Irinotecan (category 1)
* Fluorouracil and irinotecan
* Trifluridine and tipiracil for third-line or subsequent therapy (category 1)
26
NTRK fusion +
* Entrectini, larotrectini, or repotrectinib
27
MSI - H/dMMR
TMB high i.e > 10 mutations/megabase
* Pembrolizumabe, for MSI-H/dMMR tumors
* Nivolumab and ipilimumab for MSI-H/dMMR tumors
* Pembrolizumabe,f for TMB-high (TMB-H) (≥10 mutations/megabase) tumors
* Dostarlimab-gxlye for MSI-H/dMMR tumors
28
surgery for distal tumors
partial gastrectomy if 6 cm proximal clearance can be achieved
29
D1 dissection
removal of perigastric nodes within 3 cm of the tumor
30
D2 resection
more extensive LND with removal of LNs around left gastric artery, hepatic artery, splenic hilum and also splenectomy and distal pancreatectomy
31
within what time should adjuvant RT be started
within 10 weeks of surgery
32
Evidence for adj CRT in gastric cancer
US Intergroup 0116 study
33
where is adj. CRT usually practiced for pts < D2 dissection
US
34
Dose constraint for kidneys
at least 3 quarters of one kidney should receive < 20 Gy
35
what's the target volume for post op gastric cancer RT?
tumor bed, anastomosis, residual gastric remnant
Nodal areas: gastric and Gastroepiploic, coeliac nodes, porta hepatis, sub pyloric, gastroduodenal, splenic suprapancreatic and retro pancreaticoduodenal nodes
36
Overall 5 yr survival in gastric cancer
< 10 %
37
T1 5 yr survival
70 %
38
median survival for unresectable disease or metastatic disease
4 months
39
pall RT dose
30 Gy/ 10 #
or 8 Gy SF
40
What is the second commonest cause of cancer death in the world?
Gastric cancer
## Footnote
Gastric cancer accounts for a significant number of cancer-related deaths globally.
41
How many new gastric cancer patients are there approximately per year in the UK?
8200
## Footnote
This statistic highlights the prevalence of gastric cancer in the UK.
42
How many new gastric cancer patients are there approximately per year in the USA?
Over 26,000
## Footnote
This indicates a higher incidence compared to the UK.
43
What trend has been observed in the incidence of gastric cancer?
Overall incidence has decreased significantly, but there has been an exponential rise in tumours of the proximal stomach and cardia
## Footnote
This suggests changes in risk factors or detection methods over time.
44
What is the median age at diagnosis for men with gastric cancer?
70 years
## Footnote
This age reflects the demographic most affected by gastric cancer.
45
What is the median age at diagnosis for women with gastric cancer?
74 years
## Footnote
This indicates a slightly older demographic for women compared to men.
46
What is the male to female ratio for gastric cancer incidence?
2.3:1
## Footnote
This shows that gastric cancer is more common in men than in women.
47
What is the overall 5-year survival rate for gastric cancer?
15–20%
## Footnote
Only 20% of patients present with localized disease.
48
What are the dietary factors that increase the risk of gastric cancer?
Low consumption of fruits and vegetables and high intake of salts, nitrates and smoked or pickled foods
## Footnote
These dietary factors are associated with increased risk.
49
What role does Helicobacter pylori play in gastric cancer?
Associated with gastric lymphoma and adenocarcinoma, increasing risk by 2.8-fold
## Footnote
H. pylori infection is a significant risk factor.
50
Which blood group is associated with an increased risk for infiltrative type gastric cancer?
Blood group A
## Footnote
This group has a 20% increased risk.
51
What are some genetic syndromes linked to an increased risk of gastric cancer?
* Hereditary non-polyposis colorectal cancer
* Familial adenomatous polyposis
* Peutz–Jeghers syndrome
## Footnote
These syndromes are associated with a higher risk.
52
What is the predominant type of gastric cancer?
Adenocarcinoma
## Footnote
Adenocarcinoma accounts for 95% of gastric cancers.
53
What are the two histological subtypes of adenocarcinoma?
* Intestinal type
* Diffuse type
## Footnote
The intestinal subtype typically arises in older patients, while the diffuse type is more common in younger patients.
54
What clinical features are commonly associated with gastric cancer?
* Weight loss
* Persistent abdominal pain
* Nausea
* Anorexia
* Early satiety
## Footnote
These features are often nonspecific and indicate advanced disease.
55
What is the diagnostic procedure of choice for gastric cancer?
Flexible oesophagogastroduodenoscopy (OGD)
## Footnote
This procedure allows direct visualization and biopsy of suspicious lesions.
56
What is the purpose of staging investigations in gastric cancer?
To establish histological diagnosis, assess the extent of disease, and evaluate fitness for treatment
## Footnote
Staging is crucial for determining treatment options.
57
What imaging technique is useful for predicting depth of tumor invasion?
Endoscopic ultrasound (EUS)
## Footnote
EUS helps guide fine-needle aspiration of suspicious perigastric lymph nodes.
58
What preoperative evaluations should be conducted for gastric cancer patients?
* Full blood count
* Biochemistry
* Coagulation profile
* Arterial blood gas
* Pulmonary function tests
* ECG
## Footnote
Nutritional screening is also essential.
59
What defines early gastric cancer (EGC)?
Tumor limited to the gastric mucosa or submucosa (T1) irrespective of nodal involvement
## Footnote
EGC has a high survival rate if treated early.
60
What is the recommended surgical approach for resectable gastric cancer?
Laparoscopy with or without peritoneal washings for malignancy cells prior to open laparotomy
## Footnote
This assessment is critical for determining resectability.
61
What is the minimum number of lymph nodes recommended for recovery during lymphadenectomy?
14 lymph nodes
## Footnote
An optimal recovery is 25 lymph nodes.
62
What is the classification for lymphadenectomy based on the extent of dissection?
* D0: Incomplete dissection of level 1 nodes
* D1: Complete dissection of level 1 nodes
* D2: Complete dissection of level 1 & 2 nodes
* D3: Complete dissection of levels 1–3 nodes
* D4: Complete dissection of levels 1–4 nodes
## Footnote
The classification helps in guiding surgical approach.
63
What is the surgical margin required for infiltrative tumors during gastric resection?
5 cm
## Footnote
A smaller margin may be sufficient for expanding tumors.
64
True or False: The pylorus acts as a barrier to cancer extension.
True
## Footnote
This impacts the surgical margins required.
65
What is the significance of a body mass index (BMI) of <18.5 in gastric cancer patients?
Predicts an increased risk of perioperative complications
## Footnote
Nutritional status is crucial in preoperative evaluation.
66
What is Stage 0 in TNM staging of gastric cancer?
TisN0M0 - carcinoma-in-situ (intraepithelial tumour without invasion of the lamina propria)
## Footnote
Carcinoma-in-situ indicates that the cancer cells are present but have not invaded deeper tissues.
67
What does Stage IA indicate in TNM staging for gastric cancer?
T1N0M0 - tumour invades lamina propria or submucosa
## Footnote
This stage marks the initial invasion beyond the epithelial layer.
68
What are the criteria for Stage IB in gastric cancer staging?
T1N1M0 - metastasis in 1–6 regional lymph nodes;
T2N0M0 - tumour invades muscularis propria (a) or subserosa (b)
## Footnote
Stage IB includes both initial lymph node involvement and deeper tissue invasion.
69
What does Stage II indicate in TNM staging of gastric cancer?
T1N2M0 - metastasis in 7–15 regional lymph nodes;
T2N1M0;
T3N0M0 - tumour penetrates serosa (visceral peritoneum)
## Footnote
Stage II represents more advanced disease with greater lymph node involvement.
70
What are the criteria for Stage IIIA in gastric cancer?
T2N2M0;
T3N1M0;
T4N0M0 - tumour invades adjacent structures
## Footnote
This stage indicates significant local and regional spread of the cancer.
71
What does Stage IIIB in TNM staging signify?
T3N2M0
## Footnote
Stage IIIB indicates further progression with more extensive lymph node involvement.
72
What are the criteria for Stage IV in gastric cancer?
T1–3N3M0 - metastasis in >15 regional lymph nodes;
T4N1–3M0;
Any T Any N M1
## Footnote
Stage IV indicates advanced disease with distant metastasis.
73
What is the survival benefit of adjuvant chemotherapy according to meta-analyses?
Improved survival benefit (HR 0.85–95%; CI: 0.80–0.90)
## Footnote
There is no standard chemotherapy regime, hence not offered except in clinical trials.
74
What did a randomized trial show about adjuvant chemoradiotherapy?
Better 3-year survival (50% vs. 41%; p = 0.005) compared to surgery alone
## Footnote
Not accepted as standard treatment in the UK and Europe due to study drawbacks.
75
What is the standard of care for perioperative treatment in gastric cancer according to the UK MRC MAGIC trial?
Three cycles of pre- and postoperative chemotherapy with ECF
## Footnote
ECF consists of epirubicin, cisplatin, and continuous infusion of 5-fluorouracil.
76
What is the median survival for patients with unresectable non-metastatic gastric cancer without treatment?
6 months
77
What are palliative measures for bleeding in unresectable gastric cancer?
Endoscopic laser photocoagulation or argon plasma coagulation
## Footnote
Palliative resection may be considered if these measures fail.
78
What types of obstructions can occur in unresectable gastric cancer?
Dysphagia and gastric outlet obstruction
79
What is an effective palliative measure for obstruction in gastric cancer?
Endoscopic stent placement
## Footnote
15–40% may develop recurrent symptoms.
80
What is the role of radiotherapy in unresectable gastric cancer?
Effective in controlling bleeding or obstruction and managing pain
81
What is the ECF chemotherapy regimen for perioperative treatment?
Epirubicin 50 mg/m² IV day 1, cisplatin 60 mg/m² IV day 1, 5-fluorouracil 200 mg/m²/day continuous IV infusion
## Footnote
Cycle repeated every 3 weeks for a total of 3 cycles preoperatively.
82
What does the ECX chemotherapy regimen consist of?
Epirubicin 50 mg/m² day 1, cisplatin 60 mg/m² day 1, capecitabine 625 mg/m² orally twice daily
83
What is recommended for patients with unresectable gastric cancer?
Consideration for clinical trials and systemic therapy for good performance status (0–2)
84
How does chemotherapy compare to best supportive care in unresectable gastric cancer?
Improves survival (9–11 months vs. 3–4 months; HR 0.39) and quality of life
85
What is the standard chemotherapy regimen in the UK for gastric cancer?
ECF regimen
## Footnote
A recent study (REAL 2) showed ECF is comparable to EOX.
86
What are important prognostic factors in resectable gastric cancer?
Depth of invasion, number of lymph nodes involved, positive resection margins
87
What is the estimated 5-year survival rate for Stage I gastric cancer?
70%
88
True or False: Routine screening is recommended for gastric cancer.
False
89
What is gastric stump cancer?
Cancer developing in the gastric remnant at least 5 years after surgery for benign peptic ulcer disease
90
What is the treatment for gastric stump cancer?
Complete removal of gastric remnants with D2 lymphadenectomy
91
What is the increased risk for gastric cancer after distal gastric resection?
4–7 fold increase
92
What is the prognosis of gastric stump cancer compared to primary gastric cancer?
Prognosis is the same as primary gastric cancer
