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Gastric Cancer

Gastric Cancer

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Gastric Cancer

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  1. Gastric Cancer 浙江大学附属第一医院 胃肠外科 于吉人 Ji-Ren Yu Department of GI Surgery, The First Affiliated Hospital, Zhejiang University

  2. Epidemiology • The fourthmost common cancer worldwide • The second most common cause of death from cancer • Higher rates in Eastern Asia, South America, Eastern Europe • Lower rates in Western Europe and the United States

  3. Epidemiology Jemal A, Bray F, Center MM, et al. Global cancer statistics. CA Cancer J Clin 2011; 61:69.

  4. Nutritional Low fat or protein consumption Salted meat or fish High nitrate consumption High complex carbohydrate consumption Causes

  5. Environmental Poor food preparation (smoked, salted) Lack of refrigeration Poor drinking water Smoking Causes

  6. Medical Prior gastric surgery H. pylori infection Gastric atrophy and gastritis Adenomatous polyps Other Male gender Low social class Causes

  7. i) Early gastric cancer(EGC) Pathology Gastric cancer confined to the mucosa or submucosa, regardless of the presence or absence of lymph node metastasis ii) Advanced gastric cancer(AGC) Cancer cells infiltrate the proprial muscle layer or serosa

  8. EGC Pathology I: protruded IIc: superficially depressed III: excavated IIa: superficially elevated IIb: superficially flat

  9. EGC:Endoscopic images Type I Type II Type III

  10. Pathology AGC:Borrmann’s classification Linitis plastica

  11. Photomicrographs of Gastric Carcinoma H&E, ×25 H&E, ×400 Arrows on signet ring cells

  12. Lymph node station

  13. Metastesis Direct invasion Lyphmatic metastesis Hematogenous metastasis Seeding metastasis

  14. Clinical Presentation Lacks specific symptoms early: vague epigastric discomfort indigestion. Epigastric pain, nonradiating, and unrelieved by food ingestion. Weight loss, anorexia, fatigue, or vomiting. Hematemesis, anemic. Large bowel obstruction.

  15. Physical signs i) A palpable abdominal mass ii) A palpable supraclavicular or periumbilical lymph node ii) Peritoneal metastasis palpable by rectal examination iii) A palpable ovarian mass (Krukenberg's tumor). iv) Jaundice, ascites, and cachexia.

  16. Endoscopy M-SCT (multiple spiral CT) BUS & EUS Double-contrast radiography MRI DL (diagnostic laparoscopy ) PET-CT Investigations

  17. Endoscopy Carcinoma in situ Advanced carcinoma

  18. Niche Double-Contrast Barium Upper GI Radiography

  19. EUS

  20. EUS T N T

  21. CT scan

  22. A B C N M T CT scan T4N2M1

  23. MRI-DWI

  24. Laparoscopy T T Abdominal metastasis

  25. BUS left right right Liver metastasis Krukenberg’s tumor

  26. PET/CT T3N2M0

  27. Treatment for Gastric Cancer Surgery Endoscopic mucosal resection (EMR) Endoscopic submucosal dissection (ESD) Laparoscopic Surgery Open Surgery Chemotherapy Chemoradiotherapy Target therapy

  28. Principles of radical operation for gastric cancer i) Negative margin ii) Extent of lymph node dissection iii) Enbloc resection Surgical Treatment for Gastric Cancer

  29. EMR for Earlier gastric cancer (EGC )

  30. Criteria for EMR • NCCN 2014 V1: • 1.Tis or T1a • 2. Well or moderately differentiated histology • 3.Tumors less than 20mm in size • 4. Clear margins • 5.No evidence of invasive finding

  31. Criteria for EMR Japanese Gastric Cancer Association • Absolute indication (EMR/ESD): • Differentiated adenocarcinoma • T1a • diameter is ≤2 cm • without ulcer finding (UL-) • Expanded indication (ESD): • Tumors clinically diagnosed as T1a and: • (a) Differentiated, UL( - ), but>2 cm • (b) Differentiated-type, UL(+), and ≤ 3 cm • (c) Undifferentiated-type, UL(-), and ≤ 2cm

  32. EMR

  33. EMR

  34. EMR

  35. 1. Difficult to resect large than 20mm tumor in size 2. Difficult to resect ulcerative lesions Limitation of EMR techniques ESD has been developed

  36. ESD for EGC

  37. ESD

  38. ESD

  39. Laparoscopic Resection 1) A suitable procedure for ECG; 2) The efficacy and safety of this approach for advanc gastric carcinoma requires further investigation

  40. Open Surgery for Advanced Gastric Cancer 1. A suitable procedure for ACG 2. R0 resection 3. R1 resection 4. R2 resection

  41. Principles of radical operation 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 treatmentfor curable gastric cancer in eastern Asia

  42. Gastrectomy and D2 lymphadenectomy for advanced gastric carcinoma Gastrectomy

  43. Lymphadenectomy

  44. Anastomosis Billroth II anastomosis Roux-en-Y anastomosis Subtotal gastrectomy

  45. Total gastrectomy

  46. Left gastric A Hepatic A Splenic A No.11 LN