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Case history

image An 81-year-old man presented with a 4 month history of nausea, epigastric discomfort and unintentional 6 kg weight loss. He was found to have mild anaemia (Hb 98 g/l, mean corpuscular volume 92 fl) and low iron indices. His baseline creatinine was 144 µmol/l and estimated glomerular filtration rate (eGFR) 47 ml/min. He underwent gastroscopy, during which an ulcer was detected at the gastro-oesophageal junction (GOJ). Histopathology confirmed an undiff erentiated adenocarcinoma. CT staging demonstrated tumour invasion into the gastric subserosa and two enlarged perigastric lymph nodes. His tumour was clinically staged as T3N1M0.

His past medical history included type 2 diabetes mellitus, diabetic nephropathy (stage 3 chronic kidney disease) and obesity (BMI 35.2 kg/m2). He suffered from painful osteoarthritis of the hips and knees and had an exercise tolerance of 100 m. He struggled to climb two flights of stairs without resting, mainly because of arthritic symptoms rather than because of dyspnoea or chest pain.

He was an ex-smoker who drank minimal alcohol. He lived in a first floor flat with his wife, who had had a stroke and suffered from reduced mobility. He was independent in his activities of daily living and required no support from social services. His medication at presentation included amlodipine, ramipril, metformin, gliclazide, and ibuprofen as and when required.

What are the current evidence-based treatment options for managing this tumour type?

What other information might influence treatment decisions?

What is the relevance of morbid obesity to perioperative management?

How will stage 3 chronic kidney disease affect his management?

What is important specifically about diabetes in this context?

Patient outcome

What are the current evidence-based treatment options for managing this tumour type?

The commonest locations for upper gastrointestinal malignancies include the oesophagus, stomach and GOJ. Ninety percent of gastric tumours are adenocarcinomas, which can be subdivided into diffuse (undifferentiated) and intestinal (well differentiated). Gastrointestinal stromal tumours, lymphoma and neuroendocrine tumours constitute the remaining 10%. Oesophageal tumours can consist of adenocarcinoma, squamous cell carcinoma or, rarely, small cell carcinoma.1 The commonest risk factors and clinical features are shown in Tables 7.1 and 7.2, respectively.

Table 7.1Commonest risk factors for upper gastrointestinal tumours.
Table 7.2Clinical features of non-disseminated gastrointestinal tumours.

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