Gastric - Esophageal

Question 1

Epidemiology -3

Answer 1

Gastric male versus female 1.57:1

esophageal male versus female 4:1

Incidence declining worldwide
A. Recognition of h.pylori
B. Introduction of refrigeration and reduction of salt-based food preservation

Question 2

Pathophysiology - Gastric -4

Answer 2

Most begin in the mucosa (innermost layer) then invade the wall of the stomach and to regional lymph nodes

90-95% adenocarcinoma

Others: GIST, MALT lymphoma, carcinoids

Proximal (upper third) cancer in cardia and g-e junction are increasing -> inc Barrett’s esophagus

Question 3

Pathophysiology – esophageal -2

Answer 3

Adenocarcinoma - nonendemic regions, white males, inc incidence, better long term prognosis after resection

Squamous - endemic regions, dec incidence

Question 4

Risk factors – gastric -9

Answer 4

H. Pylori
age, 2/3 over 65
Male gender 1.57:1
Ethnicity: More in Hispanic African-American Asian
Genetics: FH, inherited (FAP, HNPCC)
Smoking
Alcohol
Gastric surgery
Type a blood

Question 5

Risk factors – esophageal -5

Answer 5

Tobacco
Alcohol
Obesity
GERD
Barrett's esophagus (30-60x risk)

Question 6

Prevention -3

Answer 6

Diet – fresh fruit and vegetables, whole grains, vitamin C, green tea, carotenoids

Chemo prevention 1– beta carotene, vitamin C and selenium = dec mortality

Treatment of GERD or H. pylori has NOT been shown to prevent cancer

Question 7

Screening -1

Answer 7

No screening recommendations

Question 8

Signs and symptoms - Initial presentation -5

Answer 8

Weight loss,

abdominal pain,

occult G.I. bleeding,

abdominal mass,

gastric ulcer

Question 9

Signs and symptoms – late presentation -4

Answer 9

Feculent emesis (from gastrocolic fistula),

strange lymph node spread (L supraclavicular, periumbilical, L axillary, peritoneal to ovary, rectal),

ascites,

palpable liver

Question 10

Diagnosis -1

Answer 10

Upper EGD -> biopsy

Question 11

Staging -7

Answer 11

Chest-Abd-pelvic CT,

CXR,

endoscopic U/S,

common PET-CT to rule out mets and verify resectability,

if needed laparoscopy to rule out mets prior to surgery

At least 15 regional lymph nodes must be sampled to accurately assign N

AJCC staging -> TNM system

Question 12

Staging – TNM -4

Answer 12

T: Invasion of tumor through layers of stomach and to adjacent structures

N: (Gastric) Number of nodes from zero to 16 or more (Esophageal) 0 to 7 or more

M: no distant vs distant mets

G: Esophageal only. Well differentiated to undifferentiated

Question 13

Prognosis – gastric -4

Answer 13

Highly dependent on stage and site of primary

Stage 3-4 (2/3 of pts): 5 yr OS 23%

Localized distal (10-20%): 5 yr OS 50%

Localized proximal: 5 yr OS 10-15%

Question 14

Principles of treatment -3

Answer 14

Goal for localized disease is cure with surgery.

Otherwise goal is palliative treatment.

Treatment selection is by stage.

Question 15

Surgery -2

Answer 15

Palliative or curative treatment of choice.

Exploratory surg often needed.

Question 16

Radiation -3

Answer 16

Adjuvant radiation alone or in combo with chemo after curative resection is common.

Palliative for symptoms of obstructions.

Neoadjuvant xrt or chemo-xrt not standard in gastric, with chemo improves OS vs surg alone in esophageal

Question 17

Stage II or III, R0, gastric
M0
R0 = negative margins

IF STAGE II ON EXAM -> LIKELY RESECTABLE

Answer 17

1 ADJ: (SOC) surg->5-FU +/- leucovorin or cape,

then fluoropyrimidine-based chemoXRT,
then 5-FU +/- leucovorin or cape (cat 1)

3. NEOADJ + ADJ (periop) chemoXRT (fluoropyrimidine, taxane, or platinum based) (cat 2B)

Question 18

Stage II or III, R1, gastric
M0

R1= Microscopic residual cancer

Answer 18

1 ADJ: surg->fluoropyrimidine-based chemoXRT

Question 19

Stage II or III, R2, gastric
M0

R2= Macroscopic residual cancer or M1B

Answer 19

1 ADJ surg->fluoropyrimidine-based chemoXRT OR chemotherapy (ECF)

Question 19

REAL-2 trial and ECF mods

Answer 19

M1 gastric.

showed ECF mods ok->cape may replace 5-FU.

oxaliplatin may replace ciplatin.

Question 20

ECF

Answer 20

cat 1 for stage II and III;

3 preop cycles then 3 postop cycles;

epirubicin 50mg/m2 d1, cisplatin 60mg/m2 d1, CI 5-FU 200mg/m2/d d1-21

5yr OS 36 vs 21% for surg alone

Question 22

Stage IV or locally advanced unresectable - gastric or esophageal - concepts

doublet OS: 8-10mo
triplet OS: 8-12mo

Answer 22

No std front line regimen.

Base decision on PS, access to frequent toxicity evals, and tox profile of regimen (IF HAVE ALL OF THESE CAN USE 3 DRUG COMBOS)

Question 23

ToGA trial -gastric -6

HER 2+ prefer IHC testing (confirm with FISH if score 2)

junction 25-30% (+)

Answer 23

Stage IV or locally advanced unresectable. KEY

traztuzumab +cis +5FU or cape (cat 1).

HER2+. ORR 47 vs 35%.

OS 13.8 vs 11mo.

traztuzumab +other chemo (cat 2b)

DO NOT COMBINE WITH ANTHRACYCLINE

Question 24

Stage IV or locally advanced unresectable -first line- cat 1 regimens - gastric or esophageal =4

NO SOC

OS: 8-12mo

KNOW

ASK WHAT PT CAN TOLERATE

Answer 24

DCF (doce)

ECF

ECF mods (change cis to oxal OR 5fu to cape)

fluoropyrimidine or Cape + cis

Question 25

Stage IV or locally advanced unresectable - first line -cat 2a regimens - gastric or esophageal

Answer 25

DCF mods, (oxal for cis)

5FU +irino,

paclitaxel +cis or carbo,

doce +cis,

5FU or cape,

doce,

pac

Question 26

Stage IV or locally advanced unresectable - second line - gastric or esophageal -7

NO SOC

NO TRIPLETS

based on prior therapy and PS

BULKY DZ PROBABLY BSC

Answer 26

doce,

pac,

irino,

irino+cis,

irino+5FU or cape,

doce+irino

BSC

Question 26

Stage II or III esophageal

Answer 26

similar chemo to gastric but more nuance. will not study

Question 28

Adjuvant chemoXRT and resected Stage II-III esophageal

Answer 28

5FU+leucovorin+XRT std approach.

OS 36 vs 27 mo with surg alone,

17% stopped due to tox