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Questions and Answers
Which type of early gastric cancer has the best prognosis?
Which type of early gastric cancer has the best prognosis?
- Type IIa
- Type III
- Type IV
- Type I (correct)
Type IV in the Bormann Classification represents ulcerated lesions infiltrating the gastric wall.
Type IV in the Bormann Classification represents ulcerated lesions infiltrating the gastric wall.
False (B)
What mnemonic can be used to remember clinical features of gastric cancer?
What mnemonic can be used to remember clinical features of gastric cancer?
LOADS
Type IIb is characterized by a _____ mucosa, submucosa, and muscularis propria.
Type IIb is characterized by a _____ mucosa, submucosa, and muscularis propria.
Match the following advanced gastric cancer types with their descriptions:
Match the following advanced gastric cancer types with their descriptions:
What is the primary procedure performed in Billroth I Gastrectomy?
What is the primary procedure performed in Billroth I Gastrectomy?
In Billroth II Gastrectomy, the duodenum remains open.
In Billroth II Gastrectomy, the duodenum remains open.
List one component involved in the Roux-en-Y Gastrojejunostomy procedure.
List one component involved in the Roux-en-Y Gastrojejunostomy procedure.
Billroth II Gastrectomy involves establishing an end-to-side gastro-________.
Billroth II Gastrectomy involves establishing an end-to-side gastro-________.
Match the following gastrectomy procedures with their descriptions:
Match the following gastrectomy procedures with their descriptions:
What type of hernia occurs behind the Roux limb?
What type of hernia occurs behind the Roux limb?
Vagotomy is routinely performed for the treatment of gastric ulcers.
Vagotomy is routinely performed for the treatment of gastric ulcers.
What can happen if the motor branch to the gallbladder is cut during vagotomy?
What can happen if the motor branch to the gallbladder is cut during vagotomy?
The procedure that involves a longitudinal incision and transverse suturing to make the pylorus incompetent is called ______.
The procedure that involves a longitudinal incision and transverse suturing to make the pylorus incompetent is called ______.
Match the following branches of the vagus nerve with their respective functions:
Match the following branches of the vagus nerve with their respective functions:
Which procedure involves leaving a stomach pouch behind during surgery?
Which procedure involves leaving a stomach pouch behind during surgery?
H. pylori is solely responsible for gastric cancer.
H. pylori is solely responsible for gastric cancer.
Name one toxic gene associated with H. pylori.
Name one toxic gene associated with H. pylori.
The __________ enzyme allows H. pylori to survive in acidic environments.
The __________ enzyme allows H. pylori to survive in acidic environments.
Match the following conditions with their related outcomes:
Match the following conditions with their related outcomes:
Which of the following statements correctly describes late dumping syndrome?
Which of the following statements correctly describes late dumping syndrome?
Early dumping syndrome is relieved by rest.
Early dumping syndrome is relieved by rest.
What is a common dietary recommendation for managing dumping syndrome?
What is a common dietary recommendation for managing dumping syndrome?
In early dumping syndrome, symptoms usually occur within _____ minutes after food intake.
In early dumping syndrome, symptoms usually occur within _____ minutes after food intake.
Match the type of hernia with its description:
Match the type of hernia with its description:
What does the Tis classification in the TNM system indicate about gastric cancer?
What does the Tis classification in the TNM system indicate about gastric cancer?
The minimum number of lymph nodes that should be removed during surgery for gastric cancer is 10.
The minimum number of lymph nodes that should be removed during surgery for gastric cancer is 10.
What surgical procedure involves the removal of 60-70% of the stomach?
What surgical procedure involves the removal of 60-70% of the stomach?
The primary site of metastasis for gastric cancer is the ______.
The primary site of metastasis for gastric cancer is the ______.
Match the following surgical margins with their respective distances:
Match the following surgical margins with their respective distances:
Which of the following is a risk factor for gastric cancer?
Which of the following is a risk factor for gastric cancer?
Men are more likely to develop diffuse gastric cancer than women.
Men are more likely to develop diffuse gastric cancer than women.
What type of gastric cancer is characterized by poorly differentiated tumors and signet ring cells?
What type of gastric cancer is characterized by poorly differentiated tumors and signet ring cells?
The Lauren classification categorizes adenocarcinoma into ______ and diffuse types.
The Lauren classification categorizes adenocarcinoma into ______ and diffuse types.
Match the following characteristics with either Intestinal or Diffuse gastric cancer:
Match the following characteristics with either Intestinal or Diffuse gastric cancer:
What is the primary goal of chemotherapy in gastric cancer treatment?
What is the primary goal of chemotherapy in gastric cancer treatment?
Radiotherapy is used to enhance loco-regional recurrence of stomach cancer.
Radiotherapy is used to enhance loco-regional recurrence of stomach cancer.
Name one drug used in chemotherapy for gastric cancer.
Name one drug used in chemotherapy for gastric cancer.
The _______ lymph node clearance involves the removal of stations 1-11.
The _______ lymph node clearance involves the removal of stations 1-11.
Match the following treatments with their purposes:
Match the following treatments with their purposes:
Which type of cancer is most commonly associated with Sister Mary Joseph's Nodule?
Which type of cancer is most commonly associated with Sister Mary Joseph's Nodule?
Krukenberg tumor can be primarily associated with colorectal cancer.
Krukenberg tumor can be primarily associated with colorectal cancer.
What is the main diagnostic method for detecting GIT cancers?
What is the main diagnostic method for detecting GIT cancers?
Virchow's Node is an enlargement of the left ________ lymph node.
Virchow's Node is an enlargement of the left ________ lymph node.
Match the atypical presentations of GIT cancer with their descriptions:
Match the atypical presentations of GIT cancer with their descriptions:
Which of the following is a complication associated with gastric reconstruction?
Which of the following is a complication associated with gastric reconstruction?
Highly Selective Vagotomy results in maximum acid reduction.
Highly Selective Vagotomy results in maximum acid reduction.
Name one nutritional complication that can arise after gastric reconstruction.
Name one nutritional complication that can arise after gastric reconstruction.
The condition known as _____ is associated with an obstruction and perforation of the afferent loop in Polya reconstruction.
The condition known as _____ is associated with an obstruction and perforation of the afferent loop in Polya reconstruction.
Match the types of vagotomy with their main characteristics:
Match the types of vagotomy with their main characteristics:
Study Notes
Japanese Classification of Early Gastric Cancer (Above Muscle Layer)
- Type I: Protruded mucosa, best prognosis.
- Types IIa, IIb, III, IV: Varying degrees of mucosal elevation or depression.
Bormann Classification of Advanced Gastric Cancer (Muscle Layer Involved)
- Type I: Polypoid or fungating.
- Type II: Fungating or ulcerated with elevated borders.
- Type III: Ulcerated lesions infiltrating the gastric wall.
- Type IV (Linitis plastica): Diffusely infiltrating, worst prognosis.
- Type V: Unclassifiable.
Molecular Classification of Gastric Cancer
- Chromosomal Instability: Intestinal pathology, best prognosis.
- Genomically Stable: Diffuse pathology, worst prognosis.
Clinical Features of Gastric Cancer (LOADS mnemonic)
- Lump.
- Gastric outlet obstruction.
- Anemia, anorexia.
- Neodyspepsia (new onset GERD).
- Silent presentation.
Gastrectomy Reconstructions
- Billroth I: End-to-end gastro-duodenal anastomosis.
- Billroth II (Polya): End-to-side gastro-jejunostomy.
- Roux-en-Y: Gastric bypass, using a Roux limb and bypass limb (50cm jejunum).
Methods of Jejunal Mobilization
- Antecolic: In front of the colon, risk of Peterson hernia (bowel herniation behind Roux limb).
- Retrocolic: Behind the colon, risk of Stemmer's hernia (bowel herniation through transverse mesocolon).
Vagotomy
- Indications: Duodenal ulcers, Type 2 and 3 gastric ulcers. No longer routine procedure (replaced by PPIs).
- Branches: Celiac axis branch, anterior trunk, posterior trunk, posterior nerve of Latarjet, Crow's foot (supplies antrum), criminal nerve of Grassi (responsible for ulcer recurrence).
- Motor branches to gallbladder (GB stasis if cut) and pylorus (impaired gastric emptying if cut).
- Procedures often combined with gastrojejunostomy or pyloroplasty (longitudinal incision + transverse suturing).
Active Space Procedures for Gastric Ulcer
- Type IV Active Space includes Pauchet, Kelling Madlener, and Csendes procedures.
Helicobacter pylori
- Common cause of gastric ulcer disease.
- CagA and VacA genes encode toxins.
- Urease enzyme positive, survives acidic environment.
- Pathogenicity: Peptic ulcer, Type B gastritis, gastric cancer, MALTomas. Slightly protective against esophageal adenocarcinoma and GERD.
Internal Hernias
- Stemmer's hernia: Bowel herniates through transverse mesocolon.
- Peterson hernia: Bowel herniates behind Roux limb.
Dumping Syndrome
- Most common after Polya and Roux-en-Y procedures.
- Early dumping: Hyperosmolar contents cause fluid influx (nausea, vomiting, bloating).
- Late dumping: Rapid sugar absorption leads to insulin release and hypoglycemia (headache, sweating, tachycardia).
Dumping Syndrome Management
- Dietary recommendations: small frequent meals, high fat and protein, avoid large meals, liquids with meals, and sugar-rich liquids. Octreotide considered if dietary changes fail.
TNM Classification of Gastric Cancer
- Tis: Carcinoma in situ.
- T1a: Invasion of lamina propria or muscularis mucosae.
- T1b: Invasion of submucosa.
- T2: Invasion of muscularis propria.
- T3: Penetration of subserosal connective tissue.
- T4: Invasion of serosa or adjacent structures. Most common site of metastasis: Liver.
Gastric Cancer Management
- Multimodality: Surgery, chemotherapy (5-FU, cisplatin), radiotherapy.
- Surgical margins: Proximal 5cm, distal to pylorus; R0 resection (microscopically free of disease). Followed by esophagogastrostomy.
- Total or subtotal gastrectomy (60-70% or 30%).
- Minimum lymph nodes removed: Gastric cancer (16), Esophageal cancer (15), Breast cancer (10), Colorectal cancer (12).
Japanese Lymph Node Stations for Gastric Cancer
- D1 clearance: Stations 1-6.
- D2 clearance (optimal): Stations 1-11.
Gastric Cancer Chemotherapy and Radiotherapy
- Chemotherapy indications: Lymph node positive, muscle invasion, bulky lymph nodes, T3/T4.
- Radiotherapy: To stomach bed, to reduce loco-regional recurrence.
Newer Modalities for Metastatic Gastric Cancer
- PDL1 mutation: Pembrolizumab, Nivolumab.
- HER2 mutation: Trastuzumab.
- S1 chemotherapy: Tegafur (oral fluoropyrimidine derivative), oteracil, and gimeracil.
Gastric Cancer Prognostic Factors
- Overall: Depth of invasion.
- Operable: Lymph node status.
Gastric Cancer Risk Factors
- Smoking, alcohol, smoked/preserved foods, H. pylori, Menetrier's disease, gastric resections.
Lauren Classification of Gastric Adenocarcinoma
- Intestinal type.
- Diffuse type.
Intestinal vs. Diffuse Gastric Cancer
- Intestinal: Environmental risk factors, gastric atrophy, older patients, men > women, gland formation, hematogenous spread. Mutations: Microsatellite instability, APC gene mutations, p53, p16 inactivation.
- Diffuse: Familial risk factors, blood type A, younger patients, women > men, poorly differentiated, signet ring cells, transmural/lymphatic spread. Mutations: Decreased E-cadherin, p53, p16 inactivation.
Atypical Presentations of Gastric Cancer
- Sister Mary Joseph's nodule (periumbilical metastasis).
- Krukenberg tumor (bilateral ovarian metastases).
- Blummer's shelf (pelvic/Pouch of Douglas metastasis).
- Virchow's node/Troisier's sign (left supraclavicular lymph node enlargement).
- Irish nodule (left axillary lymph node enlargement).
- Trousseau syndrome (migratory thrombophlebitis).
- Leser-Trélat sign and tripe palms (dermatological presentations).
Gastric Cancer Investigations
- Diagnosis: Endoscopic biopsy.
- Staging: PET-CT (overall), EUS (T & N stage).
- Most common site: Antrum. Higher incidence of proximal gastric cancer in the West.
Types and Complications of Vagotomy
- HSV: Less acid reduction, maximum ulcer recurrence, fewer complications.
- Truncal vagotomy + antrectomy: Maximum acid reduction, least ulcer recurrence, maximum complications.
Complications of Gastric Reconstruction and Vagotomy
- Nutritional deficiencies (iron, B12, calcium).
- Anastomotic leak (Billroth I > II).
- Duodenal stump blowout.
- Hemorrhage.
- Bilious vomiting.
- Peptic ulcers.
- Afferent loop syndrome.
- Post-vagotomy diarrhea.
- Gallstone formation.
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Description
This quiz covers the classifications of gastric cancer including Japanese, Bormann, and molecular types, as well as their clinical features using the LOADS mnemonic. Additionally, it explores various gastrectomy reconstructions. Test your knowledge on this critical area of oncology.
