gastrointestinal malignancies/gastric cancer

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Question 1 / 2

683d0d64c1b3f4bd827da71a

Oncology

gastrointestinal malignancies

gastric cancer

Case History

A 68-year-old woman presents to her general practitioner with a 6-week history of progressive epigastric discomfort, early satiety, and a 5 kg unintentional weight loss. She also reports intermittent dark, tarry stools. Her medical history includes well-controlled hypertension and a remote history of H. pylori infection treated 10 years ago. On physical examination, she appears pale and somewhat cachectic. Abdominal palpation reveals mild epigastric tenderness but no palpable masses or hepatomegaly. Digital rectal examination confirms melena. An upper endoscopy performed by a gastroenterologist identifies a large, ulcerative mass in the gastric fundus. Biopsy results are consistent with a poorly differentiated gastric adenocarcinoma. Given this presentation and confirmed pathology, which initial staging modality is most crucial, and what is the primary consideration for subsequent management planning?

Lab Parameter	Value	Reference Range
Hemoglobin	98 g/L	120-150 g/L
Mean Corpuscular Volume (MCV)	72 fL	80-100 fL
Ferritin	15 ng/mL	20-200 ng/mL
Platelet Count	450 x 10^9/L	150-450 x 10^9/L
Albumin	30 g/L	35-50 g/L
Lactate Dehydrogenase (LDH)	300 U/L	120-250 U/L

A ) Contrast-enhanced computed tomography of the abdomen and pelvis to assess for distant metastasis, followed by consideration for neoadjuvant systemic therapy.

B ) Positron emission tomography-computed tomography (PET-CT) for metabolic activity and direct referral for gastrectomy.

C ) Endoscopic ultrasound (EUS) for local staging and immediate discussion regarding definitive surgical resection.

D ) Magnetic resonance imaging (MRI) of the abdomen for liver involvement and planning for primary palliative chemotherapy.

E ) Tumor marker panel (CEA, CA 19-9) and preparation for upfront laparoscopic exploration.

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Question 2 / 2

683d0d64c1b3f4bd827da71b

Oncology

gastrointestinal malignancies

gastric cancer

Case History

A 52-year-old woman presents to her primary care physician with a 6-month history of progressive fatigue, early satiety, and intermittent epigastric discomfort that is often exacerbated by meals. She also reports a subtle, dark discoloration in her stools recently. Her past medical history is notable only for mild osteoarthritis. On physical examination, she appears pale and somewhat lethargic. Her vital signs are stable: temperature 37.0°C, blood pressure 118/78 mmHg, pulse 80/min, and respirations 16/min. Abdominal examination reveals mild, diffuse tenderness in the epigastrium without rebound or guarding. No palpable masses are noted. Digital rectal examination is positive for occult blood. An initial esophagogastroduodenoscopy performed a week prior revealed a sessile mass in the gastric antrum with surrounding erosions. Preliminary biopsy results suggest a low-grade mucosa-associated lymphoid tissue (MALT) lymphoma. Given this clinical picture, what is the most appropriate diagnostic confirmation and subsequent initial therapeutic approach?

Lab Parameter	Value	Reference Range
Hemoglobin	72 g/L	120-160 g/L
Hematocrit	0.23	0.36-0.48
Leukocyte count	11.0 x 10^9/L	4.0-10.0 x 10^9/L
Platelet count	470 x 10^9/L	150-450 x 10^9/L
Sodium (Na+)	137 mmol/L	135-145 mmol/L
Chloride (Cl-)	109 mmol/L	98-107 mmol/L
Potassium (K+)	3.1 mmol/L	3.5-5.0 mmol/L
Bicarbonate (HCO3-)	23 mmol/L	22-28 mmol/L
Blood Urea Nitrogen (BUN)	18.6 mmol/L	2.5-7.1 mmol/L
Glucose	4.9 mmol/L	3.9-6.1 mmol/L
Creatinine	79.5 µmol/L	44-97 µmol/L
Ferritin	15 µg/L	20-300 µg/L
Urea Breath Test (UBT)	Positive	Negative

A ) Confirmation of Helicobacter pylori infection via urea breath test and initiation of triple therapy with amoxicillin, clarithromycin, and a proton pump inhibitor

B ) Endoscopic ultrasound for detailed staging and consideration of systemic chemotherapy with rituximab and cyclophosphamide

C ) Repeat gastroscopy with deeper biopsies to confirm invasiveness and surveillance with serial EGDs

D ) Surgical resection of the gastric mass via partial gastrectomy followed by adjuvant radiation therapy

E ) Positron Emission Tomography (PET) scan for systemic evaluation and immediate initiation of R-CHOP chemotherapy

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