Upper GI

Question 0

Women or men with GERD has a higher risk of Barrett?

Answer 0

Men.

Question 1

What are the risk factors for squamous cell carcinoma of the esophagus, adenocarcinoma of the esophagus, and gastric cancer?

Answer 1

Squamous esophageal: diet, smoking. Adeno esophageal: Barrett. Gastric: diet, H. pylori.

Question 2

True or False: The longer the Barrett’s segment is, the higher the risk of cancer is.

Answer 2

True.

Question 3

Does endoscopic surveillance decrease mortality from esophageal adenocarcinoma?

Answer 3

No.

Question 4

At what depth of invasion is endoscopic mucosal resection no longer curative?

Answer 4

Submucosa. However, endoscopic submucosal resection for shallow submucosal invasion can be considered.

Question 5

In Japan, what is the reduction in gastric cancer mortality by screening with barium studies?

Answer 5

40-60%

Question 6

Which countries have the highest incidence of esophageal cancer (mostly squamous)?

Answer 6

Iran, Russia, and northern China. Less common in Japan, Europe, and the US.

Question 7

What are the risk factors for Barrett’s esophagus?

Answer 7

GERD, white or Hispanic, male, advancing age, smoking, obesity.

Question 8

What is the relative risk of developing esophageal adenocarcinoma in patients with Barrett’s esophagus?

Answer 8

11.3 compared to the general population.

Question 9

Does H. pylori infection reduce or increase the risk of esophageal cancer? How about HPV infection?

Answer 9

Reduce esophageal adenocarcinoma due to reduced acidity. HPV increases incidence of squamous cell cancers of the upper esophagus.

Question 10

Is adjuvant therapy needed after trimodality treatment for esophageal cancer?

Answer 10

No. Not supported by strong evidence but still often given, especially for positive nodes.

Question 11

What is the 5-year survival for patients with esophageal cancer treated with just surgery?

Answer 11

Less than 10-15%

Question 12

For esophageal cancer, neoadjuvant or adjuvant radiation has been associated with what outcomes?

Answer 12

Tumor shrinkage, dysphasia improvement, better local-regional control, but no survival benefit over surgery alone.

Question 13

Are squamous cancers of the esophagus or adenocarcinomas more sensitive to chemorad, suggesting surgery might not be necessary afterwards?

Answer 13

Squamous.

Question 14

What are the results of the MAGIC trial comparing perioperative ECF with surgery alone?

Answer 14

Better survival for perioperative chemo. This trial included gastric, esophageal, and GEJ cancers. Only about 55% of patients on the chemo arm received postoperative chemo, suggesting that the benefit was due to preoperative chemo.

Question 15

T or F: Neoadjuvant chemorad for esophageal cancer has similar outcomes to surgery alone.

Answer 15

False. Neoadjuvant chemorad has significantly better outcome.

Question 16

In esophageal cancer treatment, is chemorad with carbo/taxane less or more toxic than 5-FU/platinum?

Answer 16

Less toxic.

Question 17

What are the roles of bevacizumab and cetuximab in the treatment of metastatic esophageal cancer?

Answer 17

Bev not helpful. Cetuximab might even be harmful. On the other hand, ramucirumab (anti-VEGFR-2) had better survival than BSC.

Question 18

T or F: Aspirin and other NSAID use has been associated with a lower risk for GI cancer.

Answer 18

True.

Question 19

Main risk factors for gastric cancer?

Answer 19

High salt and nitrate intake, low vitamin A and C intake, smoked or cured foods, poor drinking water. H. pylori too.

Question 20

Does treating H. pylori reduce gastric cancer risk?

Answer 20

A large Chinese study says no. A meta-analysis suggests yes.

Question 21

T or F: Surgical resection is the only potentially curative treatment for gastric cancer.

Answer 21

True. For early-stage, node-negative disease, the cure rate for surgery can be 75-80%.

Question 22

T or F: D2 resection for gastric cancer is routinely done in Asia but has not been proven to be better than D1 resection.

Answer 22

False. A large Dutch trial showed D2 had better locoregional control and fewer gastric cancer-related deaths than D1.

Question 23

For gastric cancer, is surgery alone as good as surgery followed by chemorad?

Answer 23

Not as good.

Question 24

What are the general approaches to early-stage gastric cancer?

Answer 24

Adjuvant chemorad in the US, perioperative chemo in the UK, adjuvant chemo after D2 resection in Asia.

Question 25

What is the standard chemo regimen for advanced gastric cancer?

Answer 25

A platinum and a fluoropyrimidine, with or without epirubicin or docetaxel. Irinotecan can replace the platinum.

Question 26

The ToGA trial randomized patients with advanced gastric or GEJ adenocarcinoma and HER2 over expression to cis/5-FU or cis/5-FU/trastuzumab. What were the results?

Answer 26

Trastuzumab increased OS from 11.1 mos to 13.8 months. (Trials with lapatinib have been disappointing, as are ones involving EGFR monoclonal antibodies.)

Question 27

What is the role of bev in advanced gastric cancer?

Answer 27

The AVAGAST trial showed superior OS with bev, but for Asian patients.

Question 28

What is the role of ramucirumab in advanced gastric?

Answer 28

In the second line setting, ramucirumab plus paclitaxel was associated with better OS than paclitaxel alone.

Question 29

What are the risk factors for pancreas cancer?

Answer 29

Tobacco, chronic pancreatitis, selective mutations of BRCA2 and, to a lesser degree, BRCA1...

Question 30

T or F: Most pancreatic cancers have KRAS mutations.

Answer 30

True

Question 31

What are the precursors of invasive ductal carcinoma of the pancreas?

Answer 31

Pancreatic intraepithelial neoplasia, intraductal papillary mucinous neoplasms, and mucinous cystic neoplasms.

Question 32

Surgery is the only potentially curative treatment for pancreatic cancer. What is the 5-year survival rate for those able to undergo resection?

Answer 32

5-25%

Question 33

What is the adjuvant therapy after resection of pancreatic cancer?

Answer 33

Gemcitabine is better than nothing. Gemcitabine is similar to bolus 5-FU/LV. Gemcitabine is inferior to S-1. Gem + chemorad with 5-FU + gem is better than chemorad with 5-FU.

Question 34

What is the treatment for locally advanced pancreatic cancer?

Answer 34

Chemorad with 5-FU is commonly used. However, in a European phase III, chemorad with cis/5-FU is inferior to gem alone. The LAP-07 phase III showed that (1) the addition of erlotinib to gem has no added benefit and (2) no survival benefit when switching from chemotherapy to consolidating chemorad.

Question 35

Should preoperative biliary drainage be done routinely in patients undergoing subsequent surgery for pancreas cancer?

Answer 35

No

Question 36

What is the treatment for metastatic pancreatic cancer?

Answer 36

Gem is better than 5-FU (without LV). Gem + erlotinib is better than gem, by 2 weeks. Gem + a platinum or fluoropyrimidine might be better than gem for patients with good PS. Gem is inferior to FOLFIRINOX, 6.8 mos vs 11.1 mos. Gem is inferior to gem + nab-paclitaxel, 6.7 mos vs 8.5 mos. VEGF and EGFR therapies (except for erlotinib) have been disappointing.

Question 37

Hereditary diffuse gastric cancer is associated with __ mutation in 30-50% of affected kindreds.

Answer 37

CDH1 (E-Cadherin)