Patient Presentation
A 60-year-old man presents with a few months of weight loss, early satiety, and persistent epigastric pain. He also reports occasional vomiting and has a significant smoking history. On examination there is a palpable mass in the epigastric region.
Upper endoscopy with biopsy confirms gastric adenocarcinoma. You must now determine the extent of disease, resectability, and an appropriate treatment sequence.
He appears chronically ill but is currently hemodynamically stable. Your task is to work through staging, decide whether this patient is a surgical candidate, and plan definitive management including perioperative therapy.
What You'll Be Asked — and What a Strong Resident Discusses
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What features on history and physical exam suggest advanced or metastatic gastric cancer?
Expected answer
Presenting symptoms such as dysphagia, obstruction, GI bleed, weight loss, and anemia signal later-stage disease. Physical signs of advanced/metastatic disease include a palpable epigastric mass, Virchow's node (left supraclavicular), Sister Mary Joseph's node (umbilical), Irish node (left axillary), Krukenberg's tumor (ovary), Blumer's shelf (rectal/cul-de-sac mass), ascites, and jaundice. This patient's palpable epigastric mass and weight loss are concerning for advanced disease.
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This patient looks chronically ill. If he presented in extremis with gastric outlet obstruction and dehydration, what would you do first?
Expected answer
Restoring homeostasis takes priority over any workup. I would place an NG tube for decompression, provide IV fluid resuscitation, correct electrolyte abnormalities (this patient may have a hypochloremic, hypokalemic metabolic alkalosis from vomiting), and address severe malnutrition with nutritional support/TPN as needed. Only after stabilization would I proceed with staging.
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How would you stage this patient?
Expected answer
Staging follows AJCC TNM criteria. I would obtain EGD with biopsy (already done) and endoscopic ultrasound to assess T stage and regional nodes with FNA capability. Cross-sectional imaging with CT of the chest, abdomen, and pelvis with IV contrast is essential; PET/CT can add value for intestinal-type, nonmucinous tumors. I would also obtain a CBC and comprehensive metabolic panel. All data are reviewed in a multidisciplinary setting.
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What findings would make this tumor unresectable?
Expected answer
Unresectability is defined by suspicious or biopsy-proven positive nodes at the root of the mesentery or para-aortic nodes, distant metastases, or peritoneal seeding — including positive peritoneal cytology.
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Staging shows no distant metastasis and the tumor appears resectable. What is your next step before committing to a major resection?
Expected answer
A diagnostic laparoscopy with peritoneal washings and cytology is strongly recommended. Cross-sectional imaging frequently misses small-volume peritoneal and surface metastases; laparoscopy detects occult disease and prevents non-therapeutic laparotomy.
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Diagnostic laparoscopy washings return positive cytology. How does this change management?
Expected answer
Positive cytology is considered M1/unresectable disease. The patient should not proceed to immediate resection. Instead, he receives systemic chemotherapy per the multidisciplinary plan, with restaging afterward to reassess for possible resection if cytology converts and disease responds.
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Cytology is negative. Describe your definitive treatment plan and operative approach.
Expected answer
Negative cytology in resectable disease warrants surgery combined with perioperative chemotherapy (or chemoradiation) in a multidisciplinary framework. The operation is a formal gastrectomy — distal/subtotal or total depending on tumor location — with negative margins and a D2 lymphadenectomy for adequate nodal staging and locoregional control, reconstructed typically with a Roux-en-Y.
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The patient is deemed unresectable but has bleeding and impending obstruction. What are your options?
Expected answer
For unresectable disease or patients unfit for surgery, treatment is chemotherapy and/or chemoradiation. Palliative measures address symptoms: endoscopic stenting for obstruction, palliative resection or endoscopic control for uncontrollable bleeding, and gastrostomy or venting/feeding tubes for decompression or nutrition. Restaging may follow to reassess for resection.
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How do you approach nutritional optimization in this patient?
Expected answer
Gastric cancer patients are frequently malnourished from obstruction, dysphagia, and cachexia. I would assess weight loss, albumin/prealbumin, and functional status, and optimize nutrition preoperatively — enteral feeding when possible, or TPN if the gut is unusable. Malnutrition markedly increases anastomotic leak, infection, and mortality risk, so correcting it improves surgical outcomes.
What Residents Often Miss
- Rushing to imaging or the OR in a patient in extremis instead of first resuscitating with NG decompression, IV fluids, and electrolyte/nutritional correction.
- Skipping diagnostic laparoscopy with peritoneal washings before resection and thereby missing occult peritoneal disease or positive cytology.
- Proceeding to gastrectomy despite positive peritoneal cytology, which represents metastatic/unresectable disease.
- Performing an inadequate lymphadenectomy (less than a D2) or accepting positive margins, compromising staging and locoregional control.
- Failing to complete full staging with EUS and CT chest/abdomen/pelvis and missing metastatic disease or distant nodal spread.
- Ignoring malnutrition and not optimizing nutrition, leading to higher anastomotic leak and mortality.
- Not involving a multidisciplinary team or omitting perioperative chemotherapy, treating gastric cancer as a purely surgical disease.
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