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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.

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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. 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

  5. Risk Factors • 3.Social • Low socioeconomic status (except in Japan) • 4.Medical • Prior gastric surgeryHelicobacter pylori infection • Gastric atrophy and gastritisAdenomatous polyps • Pernicious anemia • Male gender

  6. Etiological Factors (Risk Factors)

  7. Correa mode of the pathogenesis of human gastric adenocarcinoma Pathology

  8. 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

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

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

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

  12. 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

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

  14. Metastesis Direct invasion Lyphmatic metastesis Hematogenous metastasis Seeding metastasis

  15. 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.

  16. 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.

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

  18. CT Clinicpathological Staging Laprascopy BUS EUS MRI PET-CT CTis the mainly procedure

  19. Endoscopy Advanced carcinoma Carcinoma in situ

  20. Niche Double-Contrast Barium Upper GI Radiography

  21. EUS

  22. EUS T N T

  23. CT scan

  24. A B C N H1 T CT scan T4N2M1

  25. PET-CT: T3N2

  26. BUS left right Liver metastasis Krukenberg’s tumor

  27. Laparoscopy T T Abdominal metastasis

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

  29. EMR for Earlier gastric cancer (EGC )

  30. 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 • Differentiated adenocarcinoma • Intramucosal cancer • 20 mm in size • without ulcer finding

  31. EMR

  32. EMR

  33. EMR

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

  35. ESD for Earlier gastric cancer (EGC )

  36. ESD Oita Digestive Organs Hospital

  37. ESD Oita Digestive Organs Hospital

  38. Criteria for ESD NationalCancer Center Hospital In Japan

  39. 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

  40. 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

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

  42. 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 lymphadenectomyis the standard treatmentfor curable gastric cancer in eastern Asia

  43. Gastrectomy and D2 lymphadenectomy for advanced gastric carcinoma Gastrectomy

  44. Lymphadenectomy

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

  46. Total gastrectomy

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

  48. Portal Vein

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