Download 2. Advanced gastric cancer

Zhejiang University
Gastric Cancer
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. Nutrition
Low fat or protein consumption
Salted meat or fish
High nitrate consumption
High complex-carbohydrate consumption
2. Environment and Heredity
Poor food preparation (smoked, salted)
Lack of refrigeration
Poor drinking water (well water)
Smoking
Risk Factors
3.Social
Low socioeconomic status (except in Japan)
4.Medical
Prior gastric surgery
Helicobacter pylori infection
Gastric atrophy and gastritis
Adenomatous polyps
Pernicious anemia
Male gender
Etiological Factors
(Risk Factors)
Pathology
Correa mode of the pathogenesis
of human gastric adenocarcinoma
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
Pathology
EGC
IIb: superficially flat
I: protruded
IIc: superficially depressed
IIa: superficially elevated
III: excavated
EGC: Endoscopic images
Type I
Type II
Type III
Pathology
AGC: Borrmann’s classification
Linitis plastica
Borrmann's classification of gastric cancer based on gross appearance
T stage
T1a T1b
T3
T4a
T4b
T
T4a 4b
Lamina
propria
T1a T
1b
Subserosal
connective
tissue
T stage are defined by depth of penetration into the gastric wall
N stage
Grouping of Regional Lymph Nodes (Groups 1-3) by Location of
Primary Tumor According to the Japanese Classification of Gastric
Carcinoma
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
Laprascopy
EUS
PETCT
MRI
BUS
CT
CT is the mainly procedure
Endoscopy
Carcinoma in situ
Advanced carcinoma
Double-Contrast Barium Upper GI Radiography
Niche
EUS
EUS
T
T
N
CT scan
CT scan
N
T
T4N2M1
H1
PET-CT: T3N2
BUS
left
right
Liver metastasis
Krukenberg’s tumor
Laparoscopy
T
Abdominal metastasis
T
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 histology
3.Tumors less than 15mm in size,
4.Absence of ulceration and no evidence of invasive finding
Japanese Gastric Cancer Association
1.
2.
3.
4.
Differentiated adenocarcinoma
Intramucosal cancer
20 mm in size
without ulcer finding
EMR
EMR
EMR
Limitation of EMR techniques
1. Difficult to resect large than 20mm tumor in size
2. Difficult to resect ulcerative lesions
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
Surgical Treatment for Gastric Cancer
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
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
Anastomosis
Billroth II anastomosis
Roux-en-Y anastomosis
Subtotal gastrectomy
Total gastrectomy
Left gastric A
Hepatic A
Splenic A
No.11 LN
Portal Vein
Stomach
Spleen
Greater omentum
Adjuvant Therapy
Chemotherapy
Radiation Therapy
Targeted Therapy
Chemotherapy
ECF: Epirubicin , Cisplatin, 5-Fu
FOLFOX: Oxaliplatin, 5-Fu, CF
SOX: S-1, Oxaliplatin
XELOX: Capecitabin, Oxaliplatin
DCF: Docetaxel, Cisplatin, 5-Fu
……
Preoperative Chemotherapy
Postoperative Chemotherapy
Preoperative
chemotherapy
Before the neoadjvant
chemotherapy
Ulcerative mass at antrum of stomach，about 4*5cm in size
After 3 courses of FOLFOX
The lesion is about 2.0*1.0cm in size
Our experience
Preoperative chemotherapy
After 3 courses of XELOX
Lymphadectomy of group 7,8,9
Our experience
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
Nonoperative therapies
Laser recannulization and endoscopic dilation with or
without stent placement
Cutting edge: gastric carcinoma
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
QUESTIONS
1. Definition of the advanced gastric
cancer and its metastatic way
2. Krukenburg’s tumor
the West Lake, Hangzhou, China