外科学进展课件GastricCancer.ppt

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1、Gastric CancerEpidemiologyl The fifth most common cancer worldwidel The third most common cause of death from cancer l Higher rates in Eastern Asia,South America,Eastern Europel Lower rates in Western Europe and the United States GLOBOCAN 2012EpidemiologyEstimated age-standardised rates(World)per 10

2、0,000Nutritional Low fat or protein consumptionSalted meat or fishHigh nitrate consumptionHigh complex carbohydrate consumptionCausesEnvironmental Poor food preparation(smoked,salted)Poor drinking water SmokingothersCausesMedical Prior gastric surgeryH.pylori infectionGastric atrophy and gastritisAd

3、enomatous polypsOthers Male genderLow social classCausesHereditary Hereditary Diffuse Gastric Cancer Lynch SyndromeJuvenile Polyposis SyndromePeutz-Jeghers SyndromeFamilial Adenomatous PolyposisCausesNCCN 2015 ver.3NCCN 2015 ver.3SyndromeGene(s)Hereditary diffuse Gastric cancerCDH1Lynch syndrome(LS)

4、EPCAM,MLH1,MSH2,MSH6,PMS2Juvenile polyposis syndrome(JPS)SMAD4,BMPR1APeutz-Jeghers syndrome(PJS)STK11Familial adenomatous polyposis(FAP)/APCi)Early gastric cancer(EGC)Gastric cancer confined to the mucosa or submucosa,regardless of the presence or absence of lymph node metastasisPathology ii)Advance

5、d gastric cancer(AGC)Cancer cells infiltrate the proprial muscle layer or serosa I:protrudedIIa:superficially elevatedIIc:superficially depressedIIb:superficially flatIII:excavatedJapanese Endoscopy Society ClassificationMacroscopic type EGCEGC:Endoscopic imagesType IIIType IType IIAGC:Borrmanns cla

6、ssificationLinitis plasticaMacroscopic type Type I:MassType II:UlcerativeType III:Infiltrative ulcerativeType IV:Diffuse infiltrativeAGC:Borrmanns classificationMacroscopic type Type I:MassAGC:Borrmanns classificationMacroscopic type Type II:UlcerativeAGC:Borrmanns classificationMacroscopic type Typ

7、e III:Infiltrative ulcerativeAGC:Borrmanns classificationMacroscopic type Type IV:Diffuse infiltrativePhotomicrographs of Gastric CarcinomaH&E,400H&E,25Arrows on signet ring cellsT stageT1aT1bT4aT4bLymphnodestationMetastesisDirect invasionLyphmatic metastesisHematogenous metastasisSeeding metastasis

8、 Clinical Presentationi)Lacks specific symptoms early:vague epigastric discomfort indigestion.ii)Epigastric pain,nonradiating,and unrelieved by food ingestion.iii)Weight loss,anorexia,fatigue,or vomiting.iv)Hematemesis,anemic.v)Large bowel obstruction.Physical signs i)A palpable abdominal massii)A p

9、alpable supraclavicular or periumbilical lymph node ii)Peritoneal metastasis palpable by rectal examinationiii)A palpable ovarian mass(Krukenbergs tumor).iv)Jaundice,ascites,and cachexia.InvestigationsCT CT is the mainly procedureis the mainly procedureEUS/BUSLaparoscopyEndoscopyCTPET-CTMRIEndoscopy

10、 Double-Contrast Barium Upper GI Radiography AntrumCardiaLinitis plasticaEUSTTNEUSBUSleftrightLiver metastasisKrukenbergs tumorrightCT scan TNMT4N2M1CT scan MRI-DWI PET/CTT3N2M0TTLaparoscopyAbdominal metastasisTreatment for Gastric CancerSurgeryEndoscopic mucosal resection(EMR)Endoscopic submucosal

11、dissection(ESD)Laparoscopic SurgeryOpen SurgeryChemotherapyChemoradiotherapyTarget therapyResectable TumorsTis or T1a-EMR/ESDT1b-T3-Gastrectomy with negative microscopic margins(typically 4 cm from gross tumor)T4-En bloc resection of involved structuresSurgical Treatment for Gastric CancerGastrectom

12、y plus D1/D2NCCN 2015 V3:Unresectable TumorsLocoregionally advancedDisease infiltration of the root of the mesentery or para-aortic lymph node highly suspicious on imaging or confirmed by biopsyInvasion or encasement of major vascular structures(excluding the splenic vessels)Distant metastasis or pe

13、ritoneal seeding(including positive peritoneal cytology)Surgical Treatment for Gastric CancerNCCN 2015 V3:Palliative TreatmentPrinciples of radical operation for gastric canceri)Negative marginii)Extent of lymph node dissectioniii)En bloc resectioniV)No distant metastasisSurgical Treatment for Gastr

14、ic CancerEMR for Earlier gastric cancer(EGC)Criteria for EMRNCCN 2015 V3:1.Tis or T1a 2.Well or moderately differentiated histology3.Tumors less than 20mm in size4.Clear margins5.No evidence of invasive findingCriteria for EMRAbsolute indication(EMR/ESD):Differentiated adenocarcinomaT1adiameter is 2

15、 cmwithout ulcer finding(UL-)Japanese Gastric Cancer AssociationExpanded 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(d)Differentiated-type including undifferentiated components,UL(+

16、),and 3 cm (New Added 2014.ver.4)EMREMREMR1.Difficult to resect large than 20mm tumor in size2.Difficult to resect ulcerative lesions Limitation of EMR techniquesESD has been developedESD for EGCESDESDMinimal Invasive Surgery Robotic Gastrectomy Robotic Gastrectomy Laparoscopic Laparoscopic surgerys

17、urgery 3D 3D Laparoscopic Laparoscopic surgerysurgeryLaparoscopic Resection 1)A suitable procedure for ECG;2)The efficacy and safety of this approach for advanc gastric carcinoma requires further investigation Laparoscopic surgery3D Laparoscopic surgeryDaDa VinciVinci Si surgical systemSi surgical s

18、ystemOpen Surgery for Advanced Gastric Cancer1.A suitable procedure for ACG2.R0 resection3.R1 resection4.R2 resection Principles of radical operationGastrectomy 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

19、 greater lymph nodesGastrectomy with D2 lymphadenectomy is the standard treatment for curable gastric cancer in eastern Asia Gastrectomy and D2 lymphadenectomy for advanced gastric carcinomaGastrectomyLymphadenectomyAnastomosisSubtotal gastrectomyRoux-en-Y anastomosis Billroth II anastomosisTotal ga

20、strectomyLeft gastric AHepatic ASplenic ANo.11 LNPORTAL VEINLymphadectomy of group 7,8,9Lymphadectomy of group 11Lymphadectomy of group 10Lymphadectomy of group 13Lymphadectomy of group 14vLymphadectomy of group 16en bloc resectionen bloc resectionStomachStomachSpleenSpleenOmentumOmentumPostgastrect

21、omy Syndromes1.Dumping SyndromeEarly Dumping2.Metabolic DisturbancesAnemiadeficiency in iron impairment in vitamin B12 metabolismImpaired absorption of fatOsteoporosis and osteomalacia Early DumpingLate DumpingPostgastrectomy Syndromes3.Related to Gastric ReconstructionAfferent Loop SyndromeEfferent

22、 Loop ObstructionAlkaline Reflux GastritisDuodenal Stump FistulaAnastomosis ObstructionCauses of afferent loop syndromePostgastrectomy SyndromesPostvagotomy Diarrhea4.Postvagotomy SyndromesPostvagotomy DiarrheaPostvagotomy Gastric AtonyIncomplete Vagal Transection5.Remnant gastric cancerIncidence 1%

23、5%Adjuvant Therapy ChemotherapyRadiation TherapyChemoradiation TherapyTargeted TherapyImmunotherapyECF:Epirubicin,Cisplatin,5-FuFOLFOX:Oxaliplatin,5-Fu,CFSOX:S-1,OxaliplatinXELOX:Capecitabin,OxaliplatinDCF:Docetaxel,Cisplatin,5-FuChemotherapyPreoperative Chemotherapy Postoperative ChemotherapyPreop

24、erative chemotherapyNCCN GuidelinesUlcerative mass at antrum of stomach，about 4*5cm in sizeThe lesion is about 2.0*1.0cm in sizeAfter 3 courses of FOLFOXBefore the neoadjvant chemotherapyPreoperative chemotherapyAfter 3 courses of preoperative chemotherapyPreoperative chemotherapyLiver after Chemoth

25、erapy Targeted TherapiesAngiogenesis inhibitorBevacizumab（FDA approved）Proteasome inhibitor PS2341，bortezomib（FDA approved）Growth factor receptor(EGFR),HER receptors inhibitorCetuximabEMD72000，matuzumabGefitinibErlotinibTrastuzumab Cyclin-dependent kinase inhibitor(CDKI)Flavop iridolImmunotherapiesP

26、D-1/PD-L1CTLA-4Tumor associated lymphocyteCancer Vaccine.Laser recannulization and endoscopic dilation with or without stent placementPalliative TreatmentSurgical palliation Resection or bypass alone or in conjunction with percutaneous,endoscopic,or radiotherapy techniquesNonoperative therapies No o

27、ther non-radical factors,expanded dissection could be selectively appliedSurgical treatment for special types of IV GC Liver metastasesNumber of metastatic nodules was three or fewer,surgery could be considered Para-aortic lymph node metastasisJapanese gastric cancer treatment guidelines(2014 ver.4)

28、Positive peritoneal cytologyNo other non-radical factors,comprehensive treatment includes surgery could be consideredH.pylori infection and gastric carcinoma Cyclooxygenase-2 Activation and gastric carcinomaMini-invasive operationSentinel node Neoadjunctive chemotherapyMicrometastasis Individualized treatmentMolecular Targeted TherapiesCutting edge:gastric carcinomathe West Lake,Hangzhou,China