Gastric Cancer

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Author:
thesaint81
ID:
159086
Filename:
Gastric Cancer
Updated:
2012-06-17 11:48:49
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gastric cancer
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Description:
gastric cancer ABSITE
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  1. Histological types
    •  two histologic types
    • - intestinal (glands)
    • - diffuse (no glands)
  2. Morphological types
    • - ulcerative (25%)
    • - polyploid (25%)
    • - superficial spreading (10%)
    • - linitis plastica (10%)
    • - the entire stomach is involved and looks thickened
  3. sign of Leser-Trelat
    diffuse seborrheic keratosis
  4. Virchow's node
    left supraclavicular space
  5. Sister Mary Joseph sign
    mass in umbilicus (infiltration along falciform ligament) 
  6. Blumer shelf
    intraperitoneal metastases palpable on rectal exam
  7. Krukenberg tumors
    ovarian metastases
  8. Role of CT
    CT CAP: r/o liver, lung mets.  50% accurate for regional nodal involvement. T-stage accurate in 42-85%
  9. PET Scan
    Combined PET/CT scan has high sensitivity (68%) then PET and CT alone.
  10. Role of EUS
    EUS is indicative for detecting depth of tumor invasion. The accuracy of EUS for T staging 65-92% and N staging 50-95% but operator dependent.
  11. Role of EGD
    • - 90-95% accurate in diagnosing advanced cancers
    • Multiple biopsies (four to six), brush and lavage cytology improve accuracy
  12. Risk factors for Gastric Cancer
    •  - adenomatous polyps (not hyperplastic polyps) 
    •  - atrophic gastritis
    •  - chronic gastritis (H.pylori), achlorhydria and pernicious anemia
    •  - intestinal metaplasia/dysplasia from   h.pylori or bile reflux or radiation
    •  - ingestion of N-nitroso compounds and/or bacterial colonization of stomach (which produces N-nitroso compounds)
    •  - smoking (OR1.6)
    •  - prior gastric surgery (OR1.5-3).  BII higher risk than BI
    •  - EBV infection (5-10% of gastric cancers)
    •   family history
    •  - FAP
    •  - E-cadherin (CDH1) mutants -> linitis plastica = hereditary diffuse gastric cancer
  13. T Staging
    Tis
    T1
    T2
    T3
    T4
    • Tis carcinoma in situ
    • T1 invades lamina prop, confined to submucosa
    • T2 invasion of muscularis propria (T2a) or subserosa (T2b)
    • T3 penetrates serosa (visceral peritoneum) without invasion into adjacent structures
    • T4 invasion of adjacent structures
  14. N STAGING
    Nx
    No
    N1
    N2
    N3
    • Nx cannot be assessed
    • N0 No nodes
    • N1 1-6 regional nodes
    • N2 7-15 regional nodes
    • N3 >15 nodes
  15. M STAGING
    Mx
    M0
    M1
    • Mx cannot be assessed
    • M0 No distant metastasis
    • M1 distan mets present (generally liver, peritoneum, distant LNs.  Rare bone, ling, brain, soft tissue)
  16. What is R1
    R1 indicates microscopic residual disease
  17. What is R2
    R2 indicates gross (macroscopic) residual disease in the absence of distant metastasis
  18. Role of Surgery
    • -if distal 2/3, subtotal gastrectomy. Proximal of distal margin of 4cm or greater. Use frozen sections for margins. Recon=B2 or Roux-en-y. No survival benefit for total gastrectomy
    • - Total Gastrectomy for proximal (upper 1/3) tumor
  19. Lymphadenectomy
    • Most controversial area in gastric cancer. Need 15 nodes for adequate staging.
    •  
  20. Describe N1,N2 and N3 lymph node station
    • N1 refers to perigastric lymph node station along lesser curvature(station 1,3,5) and greater curvature (station 2,4,6).
    • N2 involve nodes around left gastric artery (station 7), common hepatic artery (station 8), celiac artery station (9) and splenic artery (10,11)
    • More distant lymph node including para-aortic are grouped as N3,N4.
  21. Describe D0,D1, and D2 lymph node dissection
    • D0- Incomplete resection of N1 lymph node
    • D1- D1 involves gastrectomy and removal of proximal or distal part of teh stomach or entire stomach (distal or total resection), including the greater and lesser omental LN which would include LN along the righ and left cardiac, alonger lesser and greater curv, suprapyloric along righ gastric artery infrapyloric area).
    • D2- involve D1 + removal of the anterior leaf of transverse mesocolon, and all the nodes along corresponding arteies (i.e left gastric, common hepatic, celiac splenic hilum and splenic artery). A splenectomy (to remove station 10and 11) is required for D2 lymph node dissection for proximal gastric tumors.
  22. The most common location of gastric cancer is
    Antrum has 40% of gastric cancers
  23. Adenomatous polyps confer what % of risk for gastric cancer? How do you treat these?
    • Adenomatous polyps - 10-20% risk of cancer.
    •  
    • Tx: endoscopic resection
    •  
  24. Which one has the less favorable prognosis?Intestinal gastric cancer or diffuse gastric cancer?
    Diffuse gastric cancer is less favorable prognosis than intestinal gastric cancer
  25. What is the survival rate for stage II disease in linitis plastica?
    Stage II disease - <50% 5-year survival rate
  26. What are options for chemothreapy in linitis plastica?
    • Chemotherapy - 5FU, doxorubicin, mitomycin C 
    •  
  27. A patient with gastric cancer has an obstruction: What do you do to palliate this? How will your management change if it is a proximal vs distal lesion?
    Obstruction - proximal lesions can be stented; distal lesion bypasses with gastrojejunostomy?
  28. Which type of gastric adenocarcinoma has glands on histology? Which type doesn't?
    • Intestinal gastric cancer: Glands on histology
    •  
    • Diffuse gastric cancer (linitis plastica): No glands
  29. Which type of gastric adenocarcinoma has blood invasion on histology? Which type has lymphatic invasion on histology?
    • Intestinal gastric cancer: Blood invasion on histology
    •  
    • Duffuse gastric cancer (linitis plastica): Lymphatic invasion
  30. In which populations do you find intestinal gastric cancer
    Intestinal gastric cancer: increased in high-risk populations, older men
  31. Role of CEA
    • CEA elevated in 30% of cases
    • - (if + useful for surveillance)
  32. Gastric cancers

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