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Gastric Cancer

Gastric Cancer

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Gastric Cancer

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  1. 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

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

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

  4. Risk Factors • 1.Helicobacter pylori infection • 2.Nutrition • Salted meat or fish • High nitrate consumption • 3. Environment • Smoking

  5. 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

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

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

  8. Pathology AGC: Borrmann’s classification Linitis plastica Borrmann'sclassification of gastric cancer based on gross appearance

  9. T3 T4a T4b T1a T1b T4b T4a Lamina propria T1a T1b Subserosal connective tissue T stage are defined by depth of penetration into the gastric wall T stage

  10. N stage Grouping of Regional Lymph Nodes (Groups 1-3) by Location of Primary Tumor According to the Japanese Classification of Gastric Carcinoma

  11. Metastesis Direct invasion Lyphmatic metastesis Hematogenous metastasis Seeding metastasis

  12. Clinical Presentation • Lacks specific symptoms early • Epigastric pain • Weight loss, anorexia, fatigue, or vomiting • 4. Symptoms often reflect the site of origin of the tumor • 5. Hematemesis, anemic • 6. Very large tumors erode into the transverse colon, presenting as large bowel obstruction

  13. 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. Patients may develop hepatomegaly secondary to metastasis, jaundice, ascites, and cachexia

  14. Examination Endoscopy M-SCT (multiple detector-row spiral CT) BUS & EUS Double-contrast radiography DL (diagnostic laparoscopy ) PET-CT

  15. Clinicpathological Staging CT Laprascopy BUS EUS MRI PET-CT CT is the mainly procedure

  16. Endoscopy Advanced carcinoma Carcinoma in situ

  17. Niche Double-Contrast Barium Upper GI Radiography

  18. EUS

  19. EUS T N T

  20. CT scan

  21. A B C N M1 T CT scan T4N2M1

  22. PET-CT: T3N2

  23. BUS left right Liver metastasis Krukenberg’s tumor

  24. Laparoscopy T T Abdominal metastasis

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

  26. EMR for Earlier gastric cancer (EGC )

  27. Criteria for EMR NCCN 2012 V2: 1.Tis or T1a 2. Well-differentiated or moderately differentiated histology 3.Tumors less than 15mm in size, 4.Absence of ulceration and no evidence of invasive finding

  28. 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

  29. EMR

  30. EMR

  31. EMR

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

  33. ESD for Earlier gastric cancer (EGC )

  34. ESD Oita Digestive Organs Hospital

  35. ESD Oita Digestive Organs Hospital

  36. 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

  37. 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

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

  39. 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 treatmentfor curable gastric cancer in eastern Asia

  40. Gastrectomy and D2 lymphadenectomy for advanced gastric carcinoma Gastrectomy

  41. Lymphadenectomy

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

  43. Total gastrectomy

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

  45. Portal Vein

  46. Stomach Spleen Greater omentum