16 Esophagus and Stomach Cancer

Hassan Hatoum and Renuka Iyer

QUESTIONS

Each of the numbered items below is followed by lettered answers. Select the ONE lettered answer that is BEST in each case unless instructed otherwise.

Question 16.1 Which of the following statements about the incidence of esophageal cancer is TRUE?

A. Esophageal cancer is relatively uncommon in the United States, and the lifetime risk of being diagnosed with the disease is less than 1%.

B. Incidence rates among white men continue to increase and now exceed 8 per 100,000 person-years, and reflect the marked increase in the incidence of adenocarcinoma of the esophagus of more than 400% in the past 2 decades.

C. Although the incidence of adenocarcinoma in white women (2 per 100,000) is lower than that in white men, rates of adenocarcinoma have increased in women by more than 300% during the past 20 years.

D. Only A and B

E. All of the above

Question 16.2 Which of the following statements are TRUE? (Select two correct responses)

A. Blood group B has been associated with gastric cancers.

B. Most of the patients with Helicobacter pylori infection will develop gastric cancer.

C. Epstein–Barr virus infection has been noted in a certain type of gastric carcinoma.

D. WHO classifies H. pylori infection as class I carcinogen.

Question 16.3 Which of the following are risk factors for development of esophageal adenocarcinoma? (Select two correct responses)

A. Gastroesophageal reflux disease

B. Low BMI

C. Barrett esophagus

D. H. Pylori infection

Question 16.4 Which of the following is TRUE for cancer of the esophagus?

A. Adenocarcinoma has a better outcome compared to squamous cell carcinoma of the esophagus.

B. HER2+ overexpression is an adverse prognostic factor similar to breast cancer.

C. The incidence of esophageal cancer is higher in African-American compared to Caucasian men.

D. The lifetime risk of being diagnosed with esophageal cancer is 1%.

Question 16.5 Which of the following statement(s) about the molecular biology of esophageal cancer is/are TRUE?

A. EGFR overexpression correlates with poor prognosis including poor response to chemotherapy.

B. Presence of p53 point mutation correlates with response to induction chemotherapy and predicts survival after esophagectomy.

C. Reduced expression of E-cadherin correlates with progression from Barrett esophagus to dysplasia and finally to adenocarcinoma.

D. All of above

Question 16.6 Which of the following is TRUE about Barrett esophagus with high-grade dysplasia?

A. Esophageal cancer incidence per year is 30%.

B. Esophagectomy is the only available treatment option.

C. Endoscopic mucosal resection can be used as a therapeutic option in this case.

D. Surveillance with annual endoscopy

Question 16.7 A 57-year-old Caucasian woman with long-standing reflux symptoms presented with hematemesis to a local emergency department. Endoscopy revealed a distal esophageal malignant ulcer with involvement of the gastroesophageal (GE) junction and 5 cm of the gastric cardia. Biopsy revealed intestinal metaplasia at the GE junction and confirmed a diagnosis of adenocarcinoma. CT shows thickened distal esophagus and proximal stomach, hiatal hernia, and enlarged celiac nodes. Which statement most accurately describes her cancer?

A. She has a Siewert type I cancer: adenocarcinoma of the distal esophagus, which usually arises from an area with specialized intestinal metaplasia of the esophagus (i.e., Barrett esophagus) and may infiltrate the esophagogastric junction from above.

B. She has a Siewert type II cancer: adenocarcinoma of the cardia, which arises from the epithelium of the cardia or from short segments with intestinal metaplasia at the esophagogastric junction.

C. She has a Siewert type III cancer: adenocarcinoma of the subcardial stomach, which may infiltrate the esophagogastric junction or distal esophagus from below.

Question 16.8 A 48-year-old man with a long-standing history of GERD presented to the clinic with dysphagia and weight loss. The patient had EGD with biopsies that showed a friable circumferential lesion in the lower part of the esophagus. EUS revealed a cT3 lesion with one regional lymph node. CT and PET scan for evaluation did not show any distant sites of metastasis. Initial treatment with preoperative chemoradiation using weekly carboplatin and paclitaxel was suggested for the patient. Which of the following is TRUE for this treatment modality?

A. The rate of pathologic complete response is 5%.

B. Chemoradiation followed by surgery can be used only for localized esophageal adenocarcinoma but not squamous cell carcinoma.

C. Chemoradiation followed by surgery improves PFS but not OS compared to surgery alone.

D. Chemoradiation followed by surgery improves both PFS and OS compared to surgery alone.

Question 16.9 A 54-year-old male has a 10-year history of untreated GERD. He presents to his primary care physician with melena. The patient underwent EGD which revealed a mass in the GEJ junction that is biopsy proven to be adenocarcinoma. EUS and PET-CT scan showed a mass that is abutting the diaphragm, but no evidence of distant metastasis. The patient has no comorbid conditions and has very good performance status. What of the following responses are TRUE about using perioperative chemotherapy ECF? (Select two correct responses)

A. The lesion is not resectable and hence only chemotherapy should be offered.

B. There was a 6-month improvement in progression-free survival, a 4-month improvement in median survival.

C. There was 25% pathologic complete response seen.

D. The use of ECF in this setting did not increase the rate of curative resection though it improves survival.

Question 16.10 A 49-year-old female with a long-standard history of GERD presents to her gastroenterologist with worsening abdominal pain, weight loss, and heart burn. EGD with biopsy shows a tumor in the lower third of the esophagus. Biopsy reveals high-grade adenocarcinoma. EUS shows cT3 and one paraesophageal lymph node. CT scan and PET scan done for staging shows multiple liver lesions consistent with metastasis. The patient has no comorbidities and her performance status is 0. Which of the following is the most appropriate next step?

A. Chemotherapy with cisplatin and 5FU

B. Docetaxel, cisplatin, and 5FU

C. Epirubicin, cisplatin, and 5FU

D. Check for HER2 overexpression on the esophageal tumor tissue

Question 16.11 In the question above, HER2 was overexpressed on the tumor tissue. Which treatment do you offer?

A. Chemotherapy

B. Chemotherapy plus cetuximab

C. Chemotherapy plus trastuzumab

D. Supportive care

Question 16.12 Which of the following cases would be sent for genetic testing? (Select two correct responses)

A. A patient with gastric cancer histopathologically confirmed as diffuse and older than 50 years with a first-degree relative with stomach cancer at the age of 55.

B. A patient with diffuse gastric cancer, who has an uncle with stomach cancer diagnosed at the age of 45 years with an aunt with lobular breast cancer.

C. A 37-year-old man diagnosed with diffuse gastric cancer, and no family history of gastric cancer.

D. A 62-year-old male smoker diagnosed with gastric cancer and history of nasopharyngeal cancer.

Question 16.13 Which of the following syndrome is usually associated with intestinal type of gastric cancer?

A. Lynch syndrome

B. Li–Fraumeni syndrome

C. Familial adenomatous polyposis syndrome

D. Peutz–Jeghers syndrome

Question 16.14 Which of the following gene mutations is associated with the highest gastric cancer risks?

A. BRCA1/2

B. P53

C. CDH1

D. APC

Question 16.15 A 22-year-old woman is diagnosed with metastatic gastric cancer, with diffuse involvement of the stomach and linitis plastica. Her father died of the same cancer at an age of 42 years. Her mother is concerned about familial gastric cancer and is asking for information about hereditary gastric cancer and appropriate screening for her other children. Which of the following would be the most appropriate recommendation to this family?

A. Hereditary gastric cancer is rare and unlikely. She may just have some environmental exposures or DNA mismatch repair gene mutations that cannot be screened for.

B. She may very well have hereditary early onset diffuse gastric cancer, but no surveillance or workup is recommended because this has yet to be confirmed in larger studies.

C. E-cadherin mutation testing should be considered here, and, in fact, prophylactic gastrectomy should be considered strongly for her siblings if a germline E-cadherin mutation is confirmed and mucosal abnormality can be documented by endoscopic examination of the stomach.

D. E-cadherin mutation testing should be considered, and, in fact, prophylactic gastrectomy should be considered strongly for her siblings if a germline E-cadherin mutation is confirmed even if no mucosal abnormalities are seen by endoscopic examination of the stomach.

Question 16.16 Which of the following is TRUE about the use of diagnostic modalities in patients with gastric cancer?

A. PET scan is less useful in assessing metastasis of signet cell subtype.

B. The accuracy rate of CT scan for staging of advanced gastric cancer was 96%.

C. There is no role for laparoscopy if staging CT scan was negative.

D. Brain MRI should be routinely done as part of the initial work up.

Question 16.17 A 48-year-old male who was diagnosed with adenocarcinoma of the stomach underwent partial gastrectomy. PET-CT prior to surgery shows no evidence of distant disease. He had 1 of 18 lymph nodes removed involved with cancer. Margins were negative for cancer. The pathologic stage is IIB (T3 N1 tumor). He was referred to you to discuss adjuvant treatment options. He has an ECOG performance status of 1. What is the best treatment modality?

A. Chemotherapy with Carboplatin and Paclitaxel

B. There is no evidence for benefit from adjuvant treatment in this case.

C. 5FU and leucovorin, followed by 45 Gy in 25 fractions plus concurrent 5FU and leucovorin.

D. Check for HER2 over expression and if positive, treat with cisplatin/5FU plus trastuzumab.

Question 16.18 A 48-year-old gentleman presents to the clinic with abdominal pain and weight loss. CT scan of the abdomen and pelvis showed diffuse gastric wall thickening as well as liver lesions suspicious for metastasis. CT-guided biopsy of one of the lesions confirmed metastatic adenocarcinoma of the stomach. HER2 was not overexpressed on the tumor tissue. Which of the following are TRUE regarding combination chemotherapy for the treatment of metastatic gastric cancer? (Select two correct responses)

A. Cisplatin is superior to oxaliplatin with a better OS.

B. 5FU is superior to capecitabine with better OS.

C. Oxaliplatin is noninferior to cisplatin in terms of OS.

D. Capecitabine is noninferior to 5FU in terms of OS.

Question 16.19 57-year-old man presented to your clinic for a second opinion on treatment of metastatic HER2 negative gastric cancer. The patient has received first-line treatment with epirubicin/cisplatin/5FU. On his last evaluation, his CT scan of the chest, abdomen, and pelvis showed progression of the disease in the lungs and liver. The patient remains asymptomatic except for fatigue. His weight is stable and his performance status is 1. Blood work included CBC that showed mild anemia and his chemistry panel including liver function test and bilirubin was normal. Which of the following is the best recommendation for this patient?

A. Refer to hospice

B. Erlotinib single agent

C. Ramucirumab single agent

D. Trastuzumab/cisplatin/capecitabine

Question 16.20 Which of the following is TRUE about ramucirumab?

A. It is used only in combination with chemotherapy as a second-line for advanced gastric cancer.

B. It prolongs only progression-free survival but not overall survival.

C. It prolongs overall survival when used as a single agent in the second line.

D. It is a murine monoclonal antibody targeting VEGF.

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