UPPER GI

Question 1

Physical findings of locally advanced/metastatic disease in gastric CA

Answer 1

Palpable abdominal mass in large primary tumor
Liver or ovarian mets (Krukenberg’s tumor)
Palpable left supraclavicular node (Virchow’s node)
Periumbilical nodule (Sister Mary Joseph)
Pelvic deposits (rectal Blummer’s sehelf)
Jaundice
Ascites

Question 2

Diagnostic modality of choice when gastric CA/malignancy suspected

Answer 2

Upper GI endoscopy

Question 3

Siewert 1 lesion

Answer 3

1-5 cm above GE junction

Question 4

Siewert 2 lesion

Answer 4

true GE junction (1 cm proximal and 2 cm distal)

Question 5

Siewert 3 lesion

Answer 5

gastric cardia (2-5 cm distal to EGJ)

Question 6

most sensitive noninvasive imaging mdodality for dx of hepatic mets in gastric CA

Answer 6

PET CT

Question 7

Intestinal gastric CA is often seen arising in what settings?

Answer 7

chronic atrophic gastritis, often 2/2 H. pylori and autoimmune gastritits

Question 8

When to perform EUS in gastric CA

Answer 8

Early-stage disease suspected or if ealy vs locally advanced disease needs to be determined

Question 9

Endoscopic resection in gastric CA - when is it essential?

Answer 9

Accurate staging of early stage CA T1a or T1b. Best diagnosed by ER. Can also be used curatively for T1a lesions <2 cm without LVI

Question 10

If metastatic gastric CA documented/suspected, what should you also test for?

Answer 10

HER2 and PDL1

Question 11

At what T stage of gastric CA is perioperative chemotherapy or preop chemoXRT preferred

Answer 11

cT2 or higher OR any N

Question 12

Tx option in locoregional gastric CA disease in medically fit patients but surgically unresectable

Answer 12

chemoxrt or systemic therapy

Question 13

Unresectable criteria for gastric CA

Answer 13

Locoregionally advanced (infiltration of root of mesentery or para-aortic lymph node highly suspicious on imaging or confirmed by biopsy OR invasion/encasement of major vascular structures excluding splenic vessels
Distant mets or peritoneal seeding incl. positive peritoneal cytology

Question 14

D1 dissection

Answer 14

Gastrectomy + resectio nof both greater and lesser omenta (which includes LN along right and left cardia, lesser and greater curvature, suprapyloric along right gastric A and infrapyloric area)

Question 15

Goal # of lymph nodes examined ain gastric resection

Answer 15

16+

Question 16

D2 dissection

Answer 16

D1 + all nodes along L gastric A, common hepatic a, celiac a and splenic a

Question 17

When should you consider palcing feeding tube in gastric CA

Answer 17

patients undergoing total gastrectomy (Especially if postop chemoXRT appears a likely recommendation)

Question 18

Gene assoc with hereditary diffuse gastric CA

Answer 18

CDH1

Question 19

In CDH1 mutation carriers when is prophylactic total gastrectomy recommended?

Answer 19

Between ages 18-40 yo - need baseline endoscope beforehand!

Question 20

When to consider postop chemoXRT in gastric CA

Answer 20

Those who received less than a D2 lymph node dissection

Question 21

Resection margin in gastric CA

Answer 21

At least 5 cm

Question 22

Appropriate surgery for Siewert type III tumors

Answer 22

Extended total gastrectomy with segment of esophagus to provide adequate margin

Question 23

Appropriate surgical procedure for Siewert type I lesions

Answer 23

Transhiatal/transthoracic esophagectomy with proximal gastrectomy and gastric pull up with cervical/thoracic esophagogastrostomy

Question 24

Tumors in the distal stomach. - appropriate surgical treatment?

Answer 24

Subtotal gastrectomy with Billroth II or Roux en Y reconstruction

Question 25

Pitfalls during routine gastrectomy - gastrohepatic ligament might contain?

Answer 25

Accessory left hepatic artery (15-20%) which sometimes represents only arterial flow to the left lobe of the liver

Question 26

Ischemic looking duodenal stump during gastrectomy, next step?

Answer 26

Oversew with lembert sutures to prevent leak

Question 27

When gastric tumor extends susbtantial distance up esophagus and dow nstomach and don't have proper oncologic resection margins, what should you perform?

Answer 27

total esophagogastrectomy with colon or jejunum interposition - left colonic segment based on ascending branch of L colic vessels (maybe middle colic) - can use jejunum if really in a pinch or colon is absent/no good

Question 28

When to begin jejunostomy feeds in post-gastrectomy pt

Answer 28

Day 2

Question 29

In cases of total gastrectomy, what type of supplementation needed?

Answer 29

Multivitamin, B12 and iron

Question 30

T1a vs T1b gastric tumor

Answer 30

T1a - lamina propria or muscularis mucosa | T1b - submucosa

Question 31

T2 gastric tumor

Answer 31

Muscularis propria

Question 32

T4a vs T4b gastric tumor

Answer 32

``` Invades serosa (visceral peritoneum) T4b - invades adjacent structures/organs ```

Question 33

N1 gastric tumor

Answer 33

Mets in 1-2 LN

Question 34

N2 gastric CA

Answer 34

3-6 regional LN

Question 35

Stage I gastric CA

Answer 35

T1-2, N0 M0

Question 36

Stage III gastric CA

Answer 36

T3-T4a + N (if no nodes, then IIb)

Question 37

Immunohistochemical expression of what is consistent with GIST?

Answer 37

KIT (CD117 antigen)

Question 38

First line therapy for metastatic GIST

Answer 38

Imatinib

Question 39

MC sites for metastatic GIST

Answer 39

Liver and peritoneum

Question 40

3 major factors predicting mets following resection of the primary are

Answer 40

tumor site of origin, size and mitotic rate

Question 41

3 main indications for cytoreductive surgery in metastatic or recurrent GIST

Answer 41

)emergencies such as hemorrhage, bowel perforation or obstruction 2) resectable disease stable or responsive to imatinib 3) focal progression defined as developemnt of secondary drug resistance to imatinib in one or few sites while other sites of mets remain stable

Question 42

Gross margins recommended in GIST resection

Answer 42

1 cm

Question 43

Lowest risk GIST

Answer 43

< or = 2 cm and <5 mitoses/HPF