Surgery Marrow Pg 161-170 (GIT)
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Questions and Answers

What is the optimum level of lymph node clearance during gastric surgery?

  • Only the left gastric station
  • 1-11 stations (correct)
  • 1-6 stations
  • Only the right para-cardial station

    • The main purpose of radiotherapy in gastric cancer is to completely eliminate the cancer cells.

    False

    What is the classification for a tumor that invades the subserosal connective tissue without invading adjacent structures?

  • T1a
  • T3 (correct)
  • T2
  • T4

    • Name two chemotherapy drugs commonly used for gastric cancer treatment.

    <p>5-FU and Cisplatin</p> Signup and view all the answers

    The most important prognostic factor in operable gastric cancer is the status of the ______.

    <p>lymph nodes</p> Signup and view all the answers

    The minimum number of lymph nodes that should be removed for esophageal cancer is 16.

    <p>False</p> Signup and view all the answers

    Match the following drugs with their classifications:

    <p>5-FU = Chemotherapy agent Cisplatin = Chemotherapy agent Pembrolizumab = PDL1 mutation therapy Trastuzumab = HER2 mutation therapy</p> Signup and view all the answers

    What type of management methods are included in the multimodality management of gastric cancer?

    <p>Surgery, chemotherapy, radiotherapy</p> Signup and view all the answers

    In a _____ gastrectomy, approximately 60-70% of the stomach is removed.

    <p>subtotal</p> Signup and view all the answers

    Match the following stages of tumor classification to their descriptions:

    <p>Tis = Carcinoma in situ; non-invasive T1b = Tumor invades the submucosa T4 = Tumor invades the serosa or adjacent structures T2 = Tumor invades the muscularis propria</p> Signup and view all the answers

    Which type of early gastric cancer classification has the best prognosis?

    <p>Type I</p> Signup and view all the answers

    Type IV in the Bormann classification is described as fungating or ulcerated.

    <p>False</p> Signup and view all the answers

    What is the mnemonic for clinical features of gastric cancer?

    <p>LOADS</p> Signup and view all the answers

    Type III in the early gastric cancer classification is characterized by __________ mucosa.

    <p>depressed</p> Signup and view all the answers

    Match the following types of gastric cancer with their descriptions:

    <p>Type I = Polypoid or fungating cancers Type II = Fungating or ulcerated with surrounding elevated borders Type III = Ulcerated lesions infiltrating the gastric wall Type IV = Linitis plastica: diffusely infiltrating</p> Signup and view all the answers

    Which of the following factors is considered a risk factor for gastric cancer?

    <p>Smoking</p> Signup and view all the answers

    The intestinal type of gastric adenocarcinoma occurs more frequently in women compared to men.

    <p>False</p> Signup and view all the answers

    What is the primary histopathological finding in the diffuse type of adenocarcinoma?

    <p>Poorly differentiated, signet ring cells</p> Signup and view all the answers

    Menetrier's disease is characterized by the hypertrophy of the ________ folds.

    <p>gastric mucosal</p> Signup and view all the answers

    Match each type of gastric adenocarcinoma to its associated risk factor:

    <p>Intestinal = Gastric atrophy Diffuse = Blood type A</p> Signup and view all the answers

    What is the surgical procedure done when the stomach is found to be viable?

    <p>De-rotate</p> Signup and view all the answers

    Trichobezoars are masses of food found in the stomach.

    <p>False</p> Signup and view all the answers

    What psychiatric issue is related to the formation of Trichobezoars?

    <p>Trichophagy</p> Signup and view all the answers

    A large Trichobezoar requires ______ for removal.

    <p>surgery</p> Signup and view all the answers

    Match the clinical features with their descriptions:

    <p>Gastric outlet obstruction = Blockage preventing contents from leaving the stomach Vomiting = Expelling stomach contents through the mouth Pain = Discomfort or ache in the abdominal area</p> Signup and view all the answers

    Which type of cancer is most commonly associated with Sister Mary Joseph's Nodule?

    <p>Stomach cancer</p> Signup and view all the answers

    Blummer's Shelf indicates early-stage cancer.

    <p>False</p> Signup and view all the answers

    What is the most common site for Gastrointestinal Stromal Tumors (GIST)?

    <p>Stomach</p> Signup and view all the answers

    Sporadic GISTs are associated with Carney Stratakis syndrome.

    <p>False</p> Signup and view all the answers

    What is the malignancy most commonly associated with Migratory Thrombophlebitis?

    <p>Pancreatic cancer</p> Signup and view all the answers

    What is the most common presentation of GIST?

    <p>Upper GI hemorrhage</p> Signup and view all the answers

    Virchow's Node is a sign of advanced disease due to its connection with the __________.

    <p>thoracic duct</p> Signup and view all the answers

    The mutation of succinyl dehydrogenase B is associated with __________ GIST.

    <p>gastric</p> Signup and view all the answers

    Match the following atypical presentations of GIT cancer with their descriptions:

    <p>Sister Mary Joseph's Nodule = Periumbilical metastasis Krukenberg Tumor = Bilateral ovarian metastases Virchow's Node = Left supraclavicular lymph node enlargement Irish Nodule = Left axillary lymph node enlargement</p> Signup and view all the answers

    Match the following types of GIST with their associations:

    <p>Sporadic GIST = Carney's triad Familial GIST = Carney Stratakis syndrome Gastric GIST = Mutation of succinyl dehydrogenase B Paraganglioma = Associated tumor in syndromes</p> Signup and view all the answers

    What is the most common type of gastric lymphoma?

    <p>Diffuse large B-cell lymphoma (DLBCL)</p> Signup and view all the answers

    Imatinib is a first-line treatment for malignant GIST.

    <p>True</p> Signup and view all the answers

    What is the primary chemotherapy regimen used for gastric lymphoma?

    <p>R-CHOP regime</p> Signup and view all the answers

    The IHC marker most specific for GIST is ______.

    <p>DOG-1</p> Signup and view all the answers

    Match the following terms with their descriptions:

    <p>CD117 = An IHC marker used in GIST Rituximab = Monoclonal antibody against CD20 GIST = Gastrointestinal Stromal Tumor B Symptoms = Symptoms including fever and night sweats</p> Signup and view all the answers

    What is the most common cause of upper GI hemorrhage?

    <p>Peptic Ulcer</p> Signup and view all the answers

    Type A gastritis is primarily bacterial in nature.

    <p>False</p> Signup and view all the answers

    Name a risk factor associated with Type A gastritis.

    <p>Pernicious anemia</p> Signup and view all the answers

    The most common site for Curling's ulcer is the ______.

    <p>first part of the duodenum</p> Signup and view all the answers

    Match the following types of gastritis with their characteristics:

    <p>Type A = Autoimmune, antibodies against parietal cells Type B = Bacterial, associated with H. Pylori Cushing's Ulcer = Seen in head injury Curling's Ulcer = Seen in burns</p> Signup and view all the answers

    Which type of gastric volvulus is most commonly associated with diaphragmatic defects?

    <p>Organoaxial</p> Signup and view all the answers

    H. pylori eradication is the management approach for high-grade MALTOMA.

    <p>False</p> Signup and view all the answers

    What clinical feature is characterized by the inability to pass a Ryle's tube?

    <p>Inability to pass Ryle's tube</p> Signup and view all the answers

    The type of gastric volvulus where the twist occurs along a plane perpendicular to the long axis is called __________.

    <p>Mesenteroaxial</p> Signup and view all the answers

    Match the following types of gastric volvulus with their descriptions:

    <p>Organoaxial = Twist occurs along the long axis of the stomach Mesenteroaxial = Twist occurs perpendicular to the long axis Retching = A common clinical feature Borchardt's triad = Another clinical feature characteristic of volvulus</p> Signup and view all the answers

    Study Notes

    Japanese Classification of Early Gastric Cancer (Above Muscle Layer)

    • Type I: Protruded mucosa, submucosa, muscularis propria; Best prognosis.
    • Type IIa: Elevated mucosa, submucosa, muscularis propria.
    • Type IIb: Flat mucosa, submucosa, muscularis propria.
    • Type III: Depressed mucosa, submucosa, muscularis propria.
    • Type IV: Excavated mucosa, submucosa, muscularis propria.

    Bormann Classification of Advanced Gastric Cancer (Muscle Layer Involved)

    • Type I: Polypoid or fungating cancers.
    • Type II: Fungating or ulcerated with surrounding elevated borders.
    • Type III: Ulcerated lesions infiltrating the gastric wall.
    • Type IV: Linitis plastica: diffusely infiltrating, aka leather bottle appearance, most aggressive type, worst prognosis.
    • Type V: Unable to be classified.

    Molecular Classification of Gastric Cancer

    • Chromosomal Instability:
      • Intestinal pathology.
      • Best prognosis.
    • Genomically Stable:
      • Diffuse pathology.
      • Worst prognosis.

    Clinical Features of Gastric Cancer

    • LOADS:
      • Lump.
      • Gastric outlet obstruction.
      • Anemia, anorexia.
      • Neodyspepsia (New onset GERD).
      • Silent presentation.

    TNM Classification of Gastric Cancer

    • Primary Tumor (T):
      • Tis: Carcinoma in situ: Intraepithelial tumor without invasion of the lamina propria.
      • T1a: Tumor invades the lamina propria or muscularis mucosae.
      • T1b: Tumor invades the submucosa.
      • T2: Tumor invades the muscularis propria
      • T3: Tumor penetrates the subserosal connective tissue without invasion of the visceral peritoneum or adjacent structures.
      • T4: Tumor invades the serosa (visceral peritoneum) or adjacent structures.
    • Most Common Site of Metastasis: Liver.

    Management of Gastric Cancer

    • Multimodality Management:
      • Surgery.
      • Chemotherapy.
      • Radiotherapy.

    Surgical Management of Gastric Cancer

    • Surgery for Primary Tumor:
      • Proximal margin: 5 cm.
      • Distal margin: Pylorus.
      • To achieve R0 resection: microscopic freedom from disease.
      • Followed by: Esophageal jejunostomy.

    Total Gastrectomy

    • Subtotal Gastrectomy: 60-70% stomach removed.
    • Distal Gastrectomy: 30% stomach removed.

    Minimum Number of Lymph Nodes Removed

    • Gastric cancer: 16.
    • Esophageal cancer: 15.
    • Breast cancer: 10.
    • Colorectal cancer: 12.

    Japanese Stations for Lymph Node Clearance

    • DI lymph node clearance: Removal of stations 1-6.
    • DA lymph node clearance (Optimum): Removal of stations 1-11.

    Chemotherapy for Gastric Cancer

    • Drugs: 5-FU, Cisplatin.
    • Indications:
      • Lymph node (+)
      • Muscle invasion
      • Bulky lymph node
      • T3/T4

    Radiotherapy for Gastric Cancer

    • Site: Stomach bed.
    • Purpose: To reduce loco-regional recurrence (LRR).

    Newer Modalities for Metastatic Gastric Cancer

    • PDL1 mutation: Pembrolizumab, Nivolumab.
    • HER2 new mutation: Trastuzumab.
    • S1 chemotherapy: Tegafur (Oral fluoropyrimidine derivative).
    • Plus: 2 enzyme inhibitors (Oteracil & Gimeracil).

    Most Important Prognostic Factors for Gastric Cancer

    • Overall: Depth of invasion
    • Operable gastric cancer: Lymph node status.

    Gastric Cancer Risk Factors

    • Smoking.
    • Alcohol consumption.
    • Consumption of smoked food/fish.
    • Preservative-rich food.
    • Refrigeration: ↓ gastric cancer.
    • H. pylori.
    • Menetrier's disease (Hypertrophy of gastric mucosal folds).
    • Gastric resections.

    Lauren Classification of Gastric Adenocarcinoma

    • I. Lauren classification
      • Intestinal
      • Diffuse.

    Intestinal vs. Diffuse Adenocarcinoma

    Feature Intestinal Diffuse
    Risk Factors Environmental Familial
    Gastric atrophy, intestinal metaplasia Blood type A
    Gender Men > Women Women > Men
    Age Increasing incidence with age Younger age group
    HPE Gland formation Poorly differentiated, more aggressive
    Signet ring cells (+)
    Spread Hematogeneous spread Transmural/Lymphatic spread
    Mutations Microsatellite instability APC gene mutations Decreased E-cadherin
    p53, p16 inactivation p53, p16 inactivation

    Atypical Presentations of GIT Cancer

    • Sister Mary Joseph's Nodule:
      • Description: Periumbilical metastasis.
      • Malignancy Connection: m/c cancer: Stomach > Ovarian.
    • Krukenberg Tumor:
      • Metastasis: B/L ovarian metastases.
      • Seen in: Stomach, Breast > Colorectal.
      • Theories:
        • Latest theory: Retrograde lymphatic spread.
        • Old theory: Transcoelomic (Drop mets).
    • Blummer's Shelf:
      • Details:
        • Metastasis to Pelvis/Pouch of Douglas.
        • Sign of advanced cancer.
      • Diagnosis: Digital rectal examination (DRE)/imaging.
    • Virchow's Node/Troisier's Sign:
      • Description: Left supraclavicular lymph node enlargement.
      • Anatomical Reason: Involvement of thoracic duct.
      • Seen in: GI/Genitourinary (GU) causes.
      • Sign of: Advanced disease.
    • Irish Nodule:
      • Description: Left axillary lymph node enlargement.
    • Migratory Thrombophlebitis/Trousseau Syndrome:
      • Malignancy Connection: m/c: Pancreatic cancer.
    • Dermatological Presentations: Signs of Internal Malignancy:
      • a. Leser-Trélat Sign
      • b. Tripe Palms

    Investigations for Gastric Cancer

    • Diagnosis: Endoscopic biopsy.
    • 10C:
      • Overall staging: PET-CT.
      • T & N stage: Endoscopic ultrasound (EUS).
    • Site: m/c overall: Antrum.
    • West: Incidence of proximal gastric cancer.

    Management of Gastric Cancer:

    • Surgery (Exploratory Laparotomy):
    • Stomach Viable:
      • De-rotate
    • Not Viable:
      • Resection & Reconstruction
      • Gastropexy (Fix the stomach)
      • Repair diaphragmatic defect

    Trichobezoar

    • Mass of hair (Hairball) inside the stomach.
    • Related to trichophagy (hair-eating).
    • Psychiatric referral required.

    Clinical Features of Trichobezoar

    • Gastric outlet obstruction.
    • Vomiting.
    • Pain.

    Management of Trichobezoar

    • Small size: Endoscopically.
    • Large size: Surgically.

    Upper GI Hemorrhage

    • Diagnosis & Management: Upper GI endoscopy.

    Causes of Upper GI Hemorrhage

    • Non-Variceal (80%)
    • Variceal (20%): Portal hypertension

    Non - Variceal Causes of Upper GI Hemorrhage

    • Peptic Ulcer:
      • Most common cause of upper GI hemorrhage.
      • More common in the duodenum than the stomach.
      • Posterior duodenal ulcer can bleed.
      • Gastroduodenal artery and left gastric artery are the most common vessels involved in bleeding in the stomach and duodenum.
    • Gastritis:
      • Type A:
        • Autoimmune.
        • Antibodies against parietal cells and intrinsic factor.
        • Associated with vitiligo.
        • Antrum is spared.
        • Pernicious anemia and achlorhydria.
        • Increased risk of gastric cancer.
      • Type B:
        • Bacterial (H.Pylori).
        • Affects the antrum, and ↑ risk of gastric cancer.
      • Stress Gastritis:
        • Most sensitive to hypovolemia and stomach mucosa.
        • Types:
          • a. Cushing's Ulcer:
            • Seen in head injury.
            • Acid producing area of stomach.
          • b. Curling Ulcer:
            • Seen in burns.
            • Most common site: first part of the duodenum.
    • Other Causes:
      • AIDS: Cryptosporidia
      • NSAID-induced

    Management of Upper GI Hemorrhage

    • Endoscopic Management: If endoscopic management fails, repeat endoscopy and then surgical management.

    GIST (Gastrointestinal Stromal Tumors)

    • Origin: Intestinal pacemaker cells of Cajal.
    • Most Common Site: Stomach.
    • Types:
      • Sporadic.
      • Familial.

    Sporadic GISTs

    • Associated with Carney's triad:
      • Gastric GIST.
      • Paraganglioma.
      • Pulmonary chondroma.

    Familial GISTs

    • Associated with Carney Stratakis syndrome:
      • Gastric GIST.
      • Paraganglioma.

    Presentation of GIST

    • Most common presentation: Upper GI hemorrhage.
    • Other presentation: Mass.
    • Other: Pain, Perforation.

    Spread of GIST

    • Local invasion: Yes.
    • Hematogeneous (spread via blood): Most common to the liver.
    • Lymphatic spread: Less than 10% (LN clearance is not mandatory).

    Management of GIST

    • Investigations:
      • CECT (Computed tomography scan): Initial screening/radiological diagnosis.
      • PET-CT (Positron emission tomography-computed tomography): Treatment monitoring, especially in malignant GIST.
    • Biopsy:
      • Fletcher classification to determine malignant, intermediate, or benign tissue.
      • Malignancy risk assessment is based on size and mitotic figures.
      • Determining prognosis.

    Treatment of Benign/Borderline GIST

    • First-line: Surgery (wedge resection) with a 2 cm margin.

    Treatment of Malignant/Metastatic GIST

    • Surgery + Imatinib (Tyrosine Kinase inhibitors).
    • Resistant to Imatinib:
      • Sorefenib.
      • Sunitinib.

    Gastric Lymphoma

    • Generalized lymphomatous process → 1° gastric lymphoma.
    • Most common: Non-Hodgkins B-cell lymphoma.
    • Most common type: DLBCL (Diffuse large B-cell lymphoma).

    Clinical Features of Gastric Lymphoma

    • Upper GI hemorrhage.
    • Pain.
    • Lump.
    • B Symptoms:
      • Fever.
      • Night sweats.
      • Pruritus.
      • Weight loss.

    Investigation of Gastric Lymphoma

    • Endoscopic biopsy.

    Management of Gastric Lymphoma

    • 1.Chemotherapy (1st line): R-CHOP regime
      • Rituximab (mAb against CD20).
      • Cyclophosphamide.
      • Hydroxydaunorubicin.
      • Oncovin/Vincristine.
      • Prednisolone.
    • 2.Surgery: Residual disease/recurrence.

    Maltoma (Mucosa Associated Lymphoid Tissue Tumor)

    • Most common site: Stomach (Associated with H.pylori).
    • Types:
      • Low grade.
      • High grade.

    Management of Maltoma

    • Low grade: Management: H.pylori eradication.
    • High grade: R CHOP (managed as lymphoma).

    Gastric Volvulus

    • Types:
      • Organoaxial.
      • Mesenteroaxial.

    Organoaxial Gastric Volvulus

    • Twist occurs along a line connecting the cardia and pylorus along the luminal (Long) axis of the stomach.
    • Most common type.
    • Associated with diaphragmatic defect (Rolling hiatal hernia).

    Mesenteroaxial Gastric Volvulus

    • Twist occurs along a plane perpendicular to the luminal (Long) axis of the stomach from lesser to greater curvature.
    • Vascular compromise common.
    • Chronic symptoms common.
    • Diaphragmatic defects less common.

    Clinical Features Of Gastric Volvulus

    • Retching.
    • Cascade sign.
    • Borchardt's triad.
    • Pain.
    • Inability to pass Ryle's tube.

    Investigations for Gastric Volvulus

    • Stable patient: CECT.
    • Unstable: Contrast study.

    X-ray for Gastric Volvulus

    • X-ray image of a contrast study of volvulus.
    • Image shows a grayscale structure, likely the stomach, filled with contrast material.

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    Description

    This quiz explores the various classifications of gastric cancer, including the Japanese classification for early stages, Bormann classification for advanced stages, and the molecular classification based on chromosomal instability. Test your knowledge on the different types and prognoses associated with each classification.

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