Download - Gastric Cancer
Gastric Cancer
Zhejiang University
浙江大学医学院附属第一医院胃肠外科 于吉人
Ji-Ren Yu
Department of GI Surgery
The First Affiliated Hospital
College of Medicine, Zhejiang University
Epidemiology
Jemal A, Bray F, Center MM, et al. Global cancer statistics. CA Cancer J Clin 2011; 61:69.
Epidemiology
Jemal A, Bray F, Center MM, et al. Global cancer statistics. CA Cancer J Clin 2011; 61:69.
Risk Factors
1. NutritionLow fat or protein consumption
Salted meat or fish
High nitrate consumption
High complex-carbohydrate consumption
2. Environment and HeredityPoor food preparation (smoked, salted)
Lack of refrigeration
Poor drinking water (well water)
Smoking
3.SocialLow socioeconomic status (except in Japan)
Risk Factors
4.MedicalPrior gastric surgery
Helicobacter pylori infection
Gastric atrophy and gastritis
Adenomatous polyps
Pernicious anemia
Male gender
Etiological Factors
(Risk Factors)
Correa mode of the pathogenesis of human gastric adenocarcinoma
Pathology
Pathology
1.Early gastric cancer (EGC)
Gastric cancer confined to the mucosa or submucosa, regardless of the presence or absence of lymph node metastasis
2. Advanced gastric cancer (AGC)Cancer cells infiltrate the proprial muscle layer or serosa
EGC
Pathology
I: protruded
IIa: superficially elevated
IIc: superficially depressed
IIb: superficially flat
III: excavated
EGC: Endoscopic images
Type I Type II Type III
Pathology
Borrmann's classification of gastric cancer based on gross appearance
AGC: Borrmann’s classification
Linitis plastica
T stage are defined by depth of penetration into the gastric wall
Lamina propria
T1a T1bT4a T4bT3
Subserosal connective tissue
T1bT1a
T4a
T4b
T stage
Grouping of Regional Lymph Nodes (Groups 1-3) by Location of Primary Tumor According to the Japanese Classification of Gastric Carcinoma
N stage
Metastesis
Direct invasion
Lyphmatic metastesis
Hematogenous metastasis
Seeding metastasis
Clinical Presentation
1. Lacks specific symptoms early: vague epigastric discomfort indigestion.
2. Epigastric pain is constant, nonradiating, and unrelieved by food ingestion.
3. Advanced disease may present with weight loss, anorexia, fatigue, or vomiting.
4. Symptoms often reflect the site of origin of the tumor. Proximal tumors involving the gastroesophageal junction often present with dysphagia, whereas distal antral tumors may present as gastric outlet obstruction.
5. Hematemesis, anemic. 6. Very large tumors erode into the transverse colon, presenting as
large bowel obstruction.
Physical signs
1. A palpable abdominal mass,
2. A palpable supraclavicular or periumbilical \lymph node,
3. Peritoneal metastasis palpable by rectal examination
4. A palpable ovarian mass (Krukenberg's tumor).
5. As the disease progresses, patients may develop hepatomegaly
secondary to metastasis, jaundice, ascites, and cachexia.
Examination
Endoscopy
M-SCT (multiple detector-row spiral
CT)
BUS & EUS
Double-contrast radiography
MRI
DL (diagnostic laparoscopy )
PET-CT
Clinicpathological Staging
EUS
LaprascopyBUS
CTPET-CT
CT is the mainly procedure
MRI
Endoscopy
Carcinoma in situ Advanced carcinoma
Niche
Double-Contrast Barium Upper GI Radiography
EUS
EUS
T
TN
CT scan
TN H1
T4N2M1
CT scan
PET-CT: T3N2
BUS
Liver metastasisLiver metastasis
Krukenberg’s tumorKrukenberg’s tumor
left
right
TT
Laparoscopy
Abdominal metastasis
Treatment for Gastric Cancer
Surgery
Endoscopic mucosal resection (EMR)
Endoscopic submucosal dissection (ESD)
Laparoscopic Surgery
Open Surgery
Chemotherapy
Chemoradiotherapy
Target therapy
EMR for Earlier gastric cancer (EGC )
Criteria for EMR
NCCN 2011 V2.
1.Early gastric cancer (Tis or T1a tumors limited)2. Well-differentiated or moderately differentiated histology3.Tumors less than 15mm in size,4.Absence of ulceration and no evidence of invasive finding
Japanese Gastric Cancer Association
1. Differentiated adenocarcinoma2. Intramucosal cancer3. 20 mm in size4. without ulcer finding
EMR
EMR
EMR
1. Difficult to resect large than 20mm tumor in size
2. Difficult to resect ulcerative lesions
Limitation of EMR techniques
ESD has been developed
ESD for Earlier gastric cancer (EGC )
ESD
Oita Digestive Organs Hospital
ESD
Oita Digestive Organs Hospital
Criteria for ESD
National Cancer Center Hospital In Japan
Principles of radical operation for gastric cancer
1. Negative margin (R0 resection, adequate margins ≥4 cm )
2. D2 lymph node dissection for advance gastric cancer
3. Subtotal gastrectomy for distal gastric cancer
4.Total or proximal gastrectomy for proixmal gastric cancer
Surgical Treatment for Gastric Cancer
Laparoscopic Resection
1. A suitable procedure for ECG (Our experience)
2. The efficacy and safety of this approach for advanc gastric
carcinoma requires further investigation
Open Surgery for Advanced Gastric Cancer
1. A suitable procedure for ACG
2. R0 resection
3. R1 resection
4. R2 resection
Principles of advanced gastric cancer surgery
Gastrectomy with regional lymphatics: perigastric lymph
nodes(D1) and those along the named vessels of the celiac axis
(D2), with a goal of examining 15 or greater lymph nodes
Gastrectomy with D2 lymphadenectomy is the standard treatment for curable gastric cancer in eastern Asia
Gastrectomy and D2 lymphadenectomy for advanced gastric carcinoma
Gastrectomy
Lymphadenectomy
Roux-en-Y anastomosis Billroth II anastomosis
Anastomosis
Subtotal gastrectomy
Total gastrectomy
Left gastric AHepatic A
Splenic A
No.11 LN
Portal VeinPortal Vein
Spleen
Stomach
Greater omentum
Adjuvant Therapy
Chemotherapy
Radiation Therapy
Targeted Therapy
ECF: Epirubicin , Cisplatin, 5-Fu
FOLFOX: Oxaliplatin, 5-Fu, CF
SOX: S-1, Oxaliplatin
XELOX: Capecitabin, Oxaliplatin
DCF: Docetaxel, Cisplatin, 5-Fu
……
Chemotherapy
Preoperative Chemotherapy
Postoperative Chemotherapy
Ulcerative mass at antrum of stomach, about 4*5cm in size
The lesion is about 2.0*1.0cm in size
After 3 courses of FOLFOX
Before the neoadjvant chemotherapy
Our experience
Preoperative chemotherapy
After 3 courses of XELOX
Preoperative chemotherapy
Our experience
Lymphadectomy of group 7,8,9
Liver after Chemotherapy
Our experience
foam cells in lamina propria(40×10)
Our experience
Targeted Therapy
Herccptin Herb-2 receptor inhibitor
Iressa EGFR inhibitor
Avastin VEGFR inhibitor
Other Molecular Medicine Interventions of Gastric Cancer
1.Oncogene activation and targeted therapy
2.Tumor-suppressor-gene inactivation and related therapy
3. Apoptosis targeted therapy
4. Anti-metastasis therapy
5. Telomerase inhibition therapy
6. Gene directed chemotherapy
7. Immunotherapy
Palliative Treatment
Surgical palliation
Resection or bypass alone or in conjunction with percutaneous, endoscopic, or radiotherapy techniques
Laser recannulization and endoscopic dilation with or without stent placement
Nonoperative therapies
H. pylori infection and gastric carcinoma
Cyclooxygenase-2 Activation and gastric carcinoma
Mini-invasive operation
Sentinel node
Neoadjunctive chemotherapy
Micrometastasis
Individualized treatment
Molecular Targeted Therapies
Cutting edge: gastric carcinoma
1. Definition of the advanced gastric
cancer and its metastatic way
2. Krukenburg’s tumor
QUESTIONS
the West Lake, Hangzhou, China