A 65-year-old man comes to the office due to 4-week history of weakness and vague postprandial epigastric pain. Medical history is insignificant. He does not take any medications. The patient smokes 1 pack of cigarettes daily and drinks alcohol occasionally. Fecal occult blood test is positive. Gastroduodenoscopy shows an antral ulcer. Four of seven biopsies taken from the margins of the ulcer are consistent with adenocarcinoma. Which of the following is the most appropriate next step in management?

Question

A 65-year-old man comes to the office due to 4-week history of weakness and vague postprandial epigastric pain.  Medical history is insignificant.  He does not take any medications.  The patient smokes 1 pack of cigarettes daily and drinks alcohol occasionally.  Fecal occult blood test is positive.  Gastroduodenoscopy shows an antral ulcer.  Four of seven biopsies taken from the margins of the ulcer are consistent with adenocarcinoma.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec25c8_d8f4_a0b3_bc81_eb3b6574f716_MD0003_00 For adenocarcinoma of the stomach, treatment options and prognosis are determined primarily by the disease stage at the time of diagnosis. Surgical removal of the affected tissues is the mainstay of therapy; therefore, early detection of gastric cancer improves the chances of successful management. However, almost 90% of patients with gastric cancer are diagnosed at advanced stages (III-IV), at which point radical resection is very complicated or impossible. For this reason, evaluation of the extent of the cancer is the most important objective following initial histologic diagnosis. A CT scan of the abdomen and pelvis is commonly employed for disease staging and is sensitive for revealing metastases (especially in the liver). Depending on CT findings, additional staging procedures, such as laparoscopy, endoscopic ultrasound, chest CT, or positron emission tomography/CT (PET/CT) may be necessary (Choice D). Patients diagnosed with limited-stage disease may be considered for curative resection, but those with more advanced disease staging are generally referred for palliative interventions. (Choice B) Laparotomy is eventually required for curative or palliative management in most patients, but initial CT imaging is needed to plan the appropriate next steps in evaluation. (Choice C) Helicobacter pylori infection is a significant risk factor for gastric adenocarcinoma and lymphoma (mucosa-associated lymphoid tissue [MALT] lymphoma). Eradication is recommended for patients with documented H pylori infection who have resectable disease to reduce the risk of developing a second cancer. Eradication of H pylori causes remission in some patients with gastric MALT lymphoma but is not curative for adenocarcinoma. Empiric eradication (without testing) is not recommended. (Choice E) A number of serologic markers have been proposed for use in gastric cancer staging, including carcinoembryonic antigen and cancer antigen (CA) 125. These tumor markers are often elevated in patients with advanced disease, but studies have not found them to have any significant clinical utility and they are typically not routinely obtained prior to surgery. Educational objective: In gastric adenocarcinoma, tumor stage at the time of diagnosis determines prognosis and treatment options. A CT scan is the initial staging modality. References: Modern surgical considerations for gastric cancer. (http://www.ncbi.nlm.nih.gov/pubmed/18926098) Modern oncological approaches to gastric adenocarcinoma. (http://www.ncbi.nlm.nih.gov/pubmed/23639645) Preoperative serum tumor marker levels in gastric cancer (http://www.ncbi.nlm.nih.gov/pubmed/24639849)

A 65-Year-Old Man Comes to the Office Due to 4-Week