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.Helicobacter pylori infection 2.Nutrition Salted meat or fish High nitrate consumption 3. Environment Smoking

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 IIType 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 T 1a T 1b T 4a T 4b T3T3 Subserosal connective tissue T 1b T 1a T 4a T 4b 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 2.Epigastric pain 3.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

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

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

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

Endoscopy Carcinoma in situ Advanced carcinoma

Niche Double-Contrast Barium Upper GI Radiography

EUS

T T N

CT scan

T NM1M1 T4N2M1 CT scan

PET-CT: T3N2

BUS Liver metastasis Krukenberg’s tumor left right

T T 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 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

Criteria for EMR Absolute indication (EMR/ESD): 1.Differentiated adenocarcinoma 2.T1a 3.diameter is ≤2 cm 4.without ulcer finding (UL-) Japanese Gastric Cancer Association 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

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

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 anastomosisBillroth II anastomosis Anastomosis Subtotal gastrectomy

Total gastrectomy

Left gastric A Hepatic A Splenic A No.11 LN

Portal 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 preoperative chemotherapy 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

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

1. Definition of the advanced gastric cancer and its metastatic way 2. Krukenburg’s tumor QUESTIONS

the West Lake, Hangzhou, China