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