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Welcome to the self-evaluation episode of the ASCO University Weekly Podcast. My name is Teviah Sachs, and I am an Assistant Professor of Surgery at the Boston University School of Medicine and Surgical Oncologist at Boston Medical Center. Today we will feature a self-evaluation question on the treatment of gastric cancer.

And we begin by reading the question stem. A 53-year-old Hispanic woman presents to her primary care physician after noticing black tarry stools for the last three weeks, and complains of mild fatigue. A stool guaiac test is performed in the office, and is found to be hemoccult positive. Her laboratory tests were notable for a white blood cell count of 6,400, a hemoglobin of 9.2, and hematocrit of 27.3%, with platelets of 653. The mean corpuscular volume was 77, blood urea nitrogen was 40, and creatinine was 1.3.

A CT scan of the chest, abdomen, and pelvis was performed with IV contrast, and was notable only for nonspecific thickening of the gastric fundus. She was referred to a gastroenterologist, who performed an esophagogastroduodenoscopy, or EGD, which revealed an ulcerative mass along the greater curvature of the gastric fundus, with no evidence of active bleeding. This lesion was biopsied, and the pathology results confirmed adenocarcinoma, with signet ring cell features. A subsequent staging PET scan did not reveal any evidence of metastatic disease.

What is the most appropriate next step in the management of this patient? Choice A, recommend subtotal gastrectomy. Choice B, recommend neoadjuvant therapy using epirubicin, oxaliplatin, and capecitabine, or EOX. Choice C, recommend endoscopic ultrasound. Choice D, recommend palliative radiation to control the bleeding. Or choice E, start the patient on oral iron after transfusion of two units of blood.

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In order to determine the appropriate treatment plan, we first need to know the local staging of the tumor based on endoscopic ultrasound, or EUS. Therefore, the answer would be choice C. Based on the findings of the endoscopic ultrasound, the next step for management can be better determined, whether it be endoscopic mucosal resection, surgical resection, or neoadjuvant chemotherapy with or without radiotherapy.

Briefly the rationale for the other choices presented in this question do not represent the most appropriate therapy for the following reasons. Subtotal gastrectromy should not be entertained until staging endoscopic ultrasound is completed. If the lesion is a T1A lesion and amenable to endoscopic mucosal resection, then that would be more appropriate.

Whereas if the lesion is a T4 lesion, with or without local regional adenopathy and ultrasonic evaluation, neoadjuvant therapy with EOX would be more appropriate. As for choice D, palliative radiotherapy is not indicated, as there is no active or uncontrollable bleeding, and there is no evidence of distant disease.

Lastly, choice E, starting the patient on oral iron after transfusion of two units of blood is incorrect, because this patient doesn't warrant transfusion at this time, as she is asymptomatic other than mild fatigue. Thank you for listening to this week's episode of ASCO University Weekly Podcast. For more information on the treatment of gastric cancer, including opportunities for self-evaluation and board review, visit the comprehensive e-learning center at university.asco.org.

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The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.