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Stem A (advanced presentation)
A 58-year-old man has 3 months of epigastric discomfort, early satiety, and 8 kg weight loss. Examination: hard epigastric mass; palpable left supraclavicular node. Hb 8.8 g/dL. He is a long-term H. pylori-positive patient with prior untreated dyspepsia.
Stem B (resectable pathway — for part d)
Separately, a fit 55-year-old has a distal antral adenocarcinoma, cT3N1M0 after CT and staging laparoscopy negative for peritoneal disease. HER2 negative.
Questions
a) Diagnosis and significance of the left supraclavicular node; name three other classical metastatic signs. (3 marks)
Gastric carcinoma with Virchow’s node (Troisier’s sign) — thoracic duct drainage → left supraclavicular metastasis ⇒ stage IV unresectable for cure.
Other signs: Sister Mary Joseph nodule (umbilical), Krukenberg tumour (ovarian), Blumer’s shelf (pouch of Douglas), Irish node (left axillary), malignant ascites/peritoneal carcinomatosis.
b) Investigations with contribution of each; role of staging laparoscopy. (4 marks)
- OGD + ≥6 biopsies (more if ulcerated) — diagnosis, Lauren type, H. pylori, HER2/PD-L1/MMR as indicated
- CT CAP — T/N estimate, liver/lung mets
- Staging laparoscopy ± peritoneal washings — detects radiologically occult peritoneal disease in ~10–20% — avoids non-therapeutic laparotomy
- EUS selectively for early T staging if endoscopic therapy considered
- Baseline nutrition, CEA/CA19-9 optional adjuncts only
c) Correa cascade, Lauren types, and hereditary diffuse gastric cancer pearl. (4 marks)
Correa: normal → chronic gastritis (H. pylori) → atrophy → intestinal metaplasia → dysplasia → intestinal-type adenocarcinoma (decades). H. pylori = IARC Class I carcinogen; eradicate when found.
Lauren: intestinal (gland-forming, env/H. pylori, older males, better prognosis) vs diffuse (signet-ring, CDH1/E-cadherin loss, linitis plastica, younger, worse).
HDGC (CDH1): prophylactic total gastrectomy in carriers after counselling (timing often mid-20s per guidelines) + endoscopic surveillance if surgery deferred.
d) Stem B — surgery extent, lymphadenectomy evidence, perioperative chemo regimen (correct name), lifelong supplements. (4 marks)
Distal/subtotal gastrectomy (total if proximal/diffuse/linitis) with D2 lymphadenectomy (perigastric + along left gastric, common hepatic, splenic, coeliac) — Dutch D1D2 long-term: lower gastric-cancer death with D2 when spleen/pancreas preserved.
Perioperative chemotherapy: FLOT (5-FU, leucovorin, oxaliplatin, docetaxel) preferred modern regimen (FLOT4); historically MAGIC ECF/ECX.
Not mFOLFIRINOX (pancreas adjuvant).
Post-total gastrectomy: lifelong IM vitamin B12; iron, calcium/vitamin D, dietary counselling; dumpingsyndromes education.
Additional teaching points
Metastatic HER2+ may receive trastuzumab with chemo.
Early gastric cancer (Japan/Korea screening context): ESD for selected T1a.
Paraneoplastic: acanthosis nigricans, Trousseau (less specific than pancreas).