GASTRIC

Question 1

Gastric cancer introduction?

Answer 1

5th most spread cancer worldwide and 3rd deadliest.
Risk factors include —> inherited mutations like HNPCC, BRCA2 and TP53, H pylori infections, EBV infection, smoking, alcohol.

Histological subtypes :
- SCC
- Adenocarcinoma —> further divide in intestinal type associated to intestinal metaplasia, more common in elderly and better prognosis. Diffuse type more prevalent in younger females with worse prognosis.

Question 2

Early gastric cancer?

Answer 2

Early Gastric Cancer (EGC) is defined when the tumor is invading the mucosa only, without any chance of nodal metastasis. The classification of EGC is based on the endoscopy and it is classified into: protruded, superficial, flat, excavated, and ulcerate.

Question 3

Symptoms?

Answer 3

Symptoms are correlated to the presenting stage. In case of advcanced cancer patients may experience: Decreased appetite, Stomach pain, Heartburn, Indigestion, Uncontrolled weight loss and vomit: sometimes containing blood.

Late signs of metastatic gastric cancer are:
• Supraclavicular lymphnode involvement (Virchow’s sign)
• Periumbilical lymphnode involvement (Sister’s Mary Joseph sign)
• Peritoneal metastasis that can be discovered during rectal examination (Blumer’s
shelf)
• Palpable ovarian lesion ascites (Krukenberg’s syndrome) • Ascites

Question 4

Diagnosis and staging?

Answer 4

Upon the presentation of the symptomatology the patient is usually seeking for medical advice. The first exam that is performed is GI endoscopy. Biopsy is always performed.

Thoracic and abdominal CT is performed to exclude advanced stage. Second line is PET.

Staging is based on TNM.

Question 5

Treatment?

Answer 5

It is multimodal. It includes chemotherapy, surgery, best supportive care and palliative care in case of too advanced cancer. Radiotherapy is not useful for gastric cancer apart in the case of unresectable cancer that gives small bleeding since radiotherapy has a hemostatic effect.

Chemotherapy includes neoadjuvant therapy like FLOT (5FU, leucovorin,oxiplatin, docetaxel), in metastatic we might use chemo+ targeted therapy like trastuzumab.

Surgical approach :
- total gastrectomy including lymphadenectomy and the Roux en Y esophago-jejunostomy and a jejuno-jejunal anastomisis that is responsible of emptying the biliarypancreatic part of the digestive tract.
- partial gastrectomy-

Question 6

Extension of lymphadenectomy?

Answer 6

D1: indicated in case of T1a tumors that do not
meet the indications for EMR.
D1+: Indicated in stage cT1N0.
D2: it is the most common one, being
compulsory from stage T2-T4, including stage N+
tumors.
D2 extended: it is performed extending the resection to the aortic lymph nodes. It is performed in very selected cases since there is a number of complications associated to a more extended lympahdenectomy.