Gastric cancer


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Gastric cancer

  1. 1. Gastric Cancer(GC) Xu da-zhi Department of gastro-pancreas, Cancer Center Mobile:13660677656
  2. 2. What is gastric cancer?
  3. 3. GC is not far from us…… Napoleon‘s gastric cancer : tumor found on the lesser curvature of the stomach: What cause? How to treat? Ambition is never content , even on the summit of greatness . He conquered the larger part of Europe, but he could not conquer gastric cancer
  4. 4. How to diagnose What is epidemiology and etilogy What is the pathology How to treat Content
  5. 5. How to diagnose What is epidemiology and etilogy What is the pathology How to treat Content
  6. 6. GC Worldwide incidence In terms of geographic distribution, high rates apply to Japan, China and Eastern Europe and low rates to North America. Almost 40% of cases occur in China . Pazdur R et al. Cancer management: A multidisciplinary approach. edition,2002 Male 16.4 Female 8.2 Male 36.3 Female 16.9 Male 77.9 Female 33.3 Male 10.8 Female 4.9 Male 43.6 Female 19.0 Male 5.9 Female 2.6 Male 11.5 Female 4.3 Male 18.6 Female 13.3 Male 8.4 Female 4.0 Eastern Europe Japan Australia/ New Zealand China Northern Africa Southern Africa Central America Western Europe North America
  7. 7. Distribution of mortality in China In China, there is an obvious clustering of geographic distribution of GC, high mortality located in rural areas.
  8. 8. Etiological Factors of G C Gastric Cancer H. pylori Precancerous changes Genetic factors Diet
  9. 9. Helicobacter <ul><li>Implicated as precursor of gastric cancer. </li></ul><ul><li>H. Pylori associated with tumors of antrum, body, and fundus of stomach, but not in cardia. </li></ul>
  10. 10. Diet <ul><li>Certain diets are implicated : </li></ul><ul><li>Rich in pickled vegetables, salted fish, excessive dietary salt, smoked meat. </li></ul><ul><li>A diet that includes fruits and vegetables rich in vitamin C may have a protective effect. </li></ul>
  11. 11. Genetic factors <ul><li>Poorly understood </li></ul><ul><li>The majority of gastric tumor are sporadic in nature </li></ul>
  12. 12. Precancerous changes <ul><li>precancerous diseases </li></ul><ul><li>chronic atrophic gastritis </li></ul><ul><li>gastric ulcer </li></ul><ul><li>gastric polyps </li></ul><ul><li>gastric remnant  </li></ul><ul><li>precancerous lesion </li></ul><ul><li>atypical hyperplasia </li></ul>
  13. 13. Why Napoleon died of GC “ The new study suggest he was chronically infected with the bacteria Helicobacter pylori.” “ full of salt-preserved foods but sparse in fruits and vegetables--common fare for long military” H. pylori Genetic factors “ his father had also died of stomach cancer which led to the theory that he had inherited the disease.” Diet Precancerous changes chronic atrophic gastritis?
  14. 14. How to diagnose What is epidemiology and etilogy What is the pathology How to treat Content
  15. 15. Early gastric cancer <ul><li>Defined as a tumor confined to the mucosal or submucosal layer, with or without lymph node metastasis </li></ul>
  16. 16. Advanced gastric cancer <ul><li>invasion depth beyond submucosal layer </li></ul>
  17. 17. Bormann classifications <ul><li>Gross classification </li></ul><ul><li>phymatoid type </li></ul><ul><li>ulcerative type </li></ul><ul><li>infiltrative ulcerative </li></ul><ul><li>diffuse infiltrative type </li></ul>
  18. 18. Histology classification <ul><li>Adenocarcinoma occupy 95% </li></ul><ul><li>Lymphomas 2% </li></ul><ul><li>Carcinoids 1% </li></ul><ul><li>Adenocathomas 1% </li></ul><ul><li>Squamous cell 1% </li></ul>
  19. 19. Lauren classification <ul><li>Intestinal type </li></ul><ul><li>--- associated with most </li></ul><ul><li>environmental risk factors </li></ul><ul><li>--- carries a better prognosis </li></ul><ul><li>--- shows no familial history </li></ul><ul><li>Diffuse type </li></ul><ul><li>--- consists of scattered cell </li></ul><ul><li>clusters with poor prognosis </li></ul>
  20. 20. TNM classification ——T <ul><li>Primary tumor: </li></ul><ul><li>depth of tumor invasion </li></ul><ul><li>Tx- cannot be assessed </li></ul><ul><li>T0- no evidence </li></ul><ul><li>Tis- carcinoma in situ, no invasion of lamina </li></ul><ul><li>T1- invades lamina propria or submucosa </li></ul><ul><li>T2- invades muscularis or subserosa </li></ul><ul><li>T3- penetrates serosa, no adjacent structure </li></ul><ul><li>T4- invades adjacent structures </li></ul>
  21. 21. T:Primary tumor <ul><li>Direct extension into omentum, pancreas, diaphragm, transverse colon, and duodenum. </li></ul><ul><li>If lesion extends beyond wall to a free peritoneal surface, peritoneal involvement is frequent. </li></ul>
  22. 22. TNM classification ——N <ul><li>Regional Lymph Nodes </li></ul><ul><li>NX- cannot be assessed </li></ul><ul><li>N0- no nodes </li></ul><ul><li>N1- mets in 1-6 regional </li></ul><ul><li>nodes </li></ul><ul><li>N2- mets in 7-15 regional </li></ul><ul><li>nodes </li></ul><ul><li>N3- mets in more than 15 </li></ul><ul><li>regional nodes </li></ul>
  23. 23. N: Regional Lymph Nodes <ul><li>Abundant lymphatic channels in submucosal and subserosal layers allow for easy spread </li></ul><ul><li>The greater number of positive nodes, the greater the likelihood of local or systemic failure postoperatively </li></ul>
  24. 24. TNM classification ——M <ul><li>Distant metastasis </li></ul><ul><li>MX- cannot be assessed </li></ul><ul><li>M0- no distant metastases </li></ul><ul><li>M1-distant metastases </li></ul>
  25. 25. Spread Patterns <ul><li>Direct invasion </li></ul><ul><li>Lymph node dissemination </li></ul><ul><li>Blood spread </li></ul><ul><li>Intraperitoneal colonization </li></ul>
  26. 26. Special term <ul><li>Blumer shelf </li></ul><ul><li>A shelf palpable by reactal examination, due to metastatic tumor cells gravitating from an abdominal cancer and growing in the rectovesical or rectouterine pouch </li></ul><ul><li>Krukenberg tumor </li></ul><ul><li>A tumor in the ovary by the spread of stomach cancer </li></ul>
  27. 27. TNM classification (UICC) <ul><li>Stage 0 Tis N0 M0 </li></ul><ul><li>Stage IA T1 N0 M0 </li></ul><ul><li>Stage IB T1 N1 M0 </li></ul><ul><li> T2 N0 M0 </li></ul><ul><li>Stage II T1 N2 M0 </li></ul><ul><li> T2 N1 M0 </li></ul><ul><li> T3 N0 M0 </li></ul><ul><li>Stage IIIA T2 N2 M0 </li></ul><ul><li> T3 N1 M0 </li></ul><ul><li> T4 N0 M0 </li></ul><ul><li>Stage IIIB T3 N2 M0 </li></ul><ul><li>Stage IV T4 N1-3 M0 </li></ul><ul><li> T1-3N3 M0 </li></ul><ul><li> Any T/N M1 </li></ul>
  28. 28. What is the classification for Napoleon , GC <ul><li>“ The scientists suggest that Napoleon died from a T3N1M0 (stage IIIA) gastric cancer. This means the tumour (T3) had spread to some local lymph nodes (N1) near the stomach, but had not spread or metastased (M0) to other organs. The prognosis for such tumours is known to be very poor. ” </li></ul>
  29. 29. Have a rest
  30. 30. How to diagnose What is epidemiology and etilogy What is the pathology How to treat Content
  31. 31. Clinical manifestation <ul><li>Early Gastric Cancer </li></ul><ul><li>Asymptomatic or silent 80% </li></ul><ul><li>Peptic ulcer symptoms 10% </li></ul><ul><li>Nausea or vomiting 8% </li></ul><ul><li>Anorexia 8% </li></ul><ul><li>Early satiety 5% </li></ul><ul><li>Abdominal pain 2% </li></ul><ul><li>Gastrointestinal blood loss <2% </li></ul><ul><li>Weight loss <2% </li></ul><ul><li>Dysphagia <1% </li></ul>
  32. 32. Clinical manifestation <ul><li>Advanced Gastric Cancer </li></ul><ul><li>Weight loss 60% </li></ul><ul><li>Abdominal pain 50% </li></ul><ul><li>Nausea or vomiting 30% </li></ul><ul><li>Anorexia 30% </li></ul><ul><li>Dysphagia 25% </li></ul><ul><li>Gastrointestinal blood loss 20% </li></ul><ul><li>Early satiety 20% </li></ul><ul><li>Peptic ulcer symptoms 20% </li></ul><ul><li>Abdominal mass or fullness 5% </li></ul><ul><li>Asymptomatic or silent <5% </li></ul>
  33. 33. Special signs <ul><li>Linitis plastica : </li></ul><ul><li>--- diffusely infiltrating with a rigid stomach </li></ul><ul><li>Virchow’s node : </li></ul><ul><li>--- left supraclavicular lymph node </li></ul><ul><li>Sister Mary Joseph’s node : </li></ul><ul><li>--- umbilical lymph node </li></ul><ul><li>prerectal pouch mass (Blumer shelf) </li></ul><ul><li>--- seeding metastasis </li></ul>
  34. 34. Sister Mary Joseph’s node
  35. 35. Laboratory tests <ul><li>Assists in determining optimal therapy. </li></ul><ul><li>CBC identifies anemia, with may be caused by bleeding, liver dysfunction, or poor nutrition. </li></ul><ul><li>30% have anemia. </li></ul><ul><li>Tumor markers </li></ul><ul><li>CEA :carcino-embryonic antigen </li></ul><ul><li>CA19-9 :carbohydrate antigen </li></ul><ul><li>CA724 :carbohydrate antigen </li></ul>
  36. 36. Imaging Studies <ul><li>Radiologic diagnosis </li></ul>Distal GC Proximal GC Linitis plastica
  37. 37. Imaging Studies <ul><li>Endoscopic diagnosis </li></ul><ul><li>--- biopsy needed for definitive diagnosis </li></ul><ul><li>Endoscopic screening </li></ul><ul><li>--- general population or high risk persons </li></ul>
  38. 38. Preoperative staging: C TNM <ul><li>Endoscopic Ultrasonography : </li></ul><ul><li>--- T depth of invasion: the accuracy 70%-90% </li></ul><ul><li>--- N metastasis of lymph node: 50%-90% </li></ul>
  39. 39. Preoperative staging: C TNM <ul><li>CT scan : </li></ul><ul><li>T, the lesion </li></ul><ul><li>N, neighboring lymph node metastasis </li></ul><ul><li>M, distant metastasis </li></ul>
  40. 40. How to diagnose Napoleon , GC Endoscopic diagnosis? Endoscopic Ultrasonography? CT scan? Preoperative staging ...... Why?
  41. 41. How to diagnose What is epidemiology and etilogy What is the pathology How to treat Content
  42. 42. Treatment Surgical resection EMR/ESD Adjuvant therapy Palliative therapy
  43. 43. Surgical treatment <ul><li>Surgical treatment : no distant metastasis </li></ul><ul><li>the only prospective of cure </li></ul><ul><li>1. Early staged carcinoma: </li></ul><ul><li>reduced radical resection </li></ul><ul><li>laparoscopic surgery </li></ul><ul><li>endoscopic mucosal resection (EMR) </li></ul><ul><li>endoscopic submucosal dissection (ESD) </li></ul><ul><li>2. Advanced carcinoma: </li></ul><ul><li>Radical resection </li></ul><ul><li>Palliative surgery </li></ul>
  44. 44. Radical resection <ul><li>D1 gastrectomy = If tumour and N1 nodes resected </li></ul><ul><li>D2 gastrectomy = If tumour and N1,N2 nodes resected </li></ul><ul><li>To the different location of the stomach cancer, N1 and N2 is different. </li></ul>
  45. 45. Radical resection <ul><li>D2 radical lymphadenectomy: </li></ul><ul><li>--- regarded as the Gold Standard treatment for GC </li></ul><ul><li>--- be associated with improved long-term survival </li></ul>
  46. 46. Adjuvant Therapy <ul><li>Rationale is to provide additional loco-regional control </li></ul><ul><li>Chemotherapy </li></ul><ul><li>the most widely used regimen is 5-FU(S1/Xeloda) , DDP , Oxaliplatin and Taxol </li></ul><ul><li>Radiotherapy </li></ul><ul><li>provides relief from bleeding, obstruction and pain in 50-75%. Median duration of palliation is 4-18 months </li></ul>
  47. 47. <ul><li>Chemotherapy </li></ul><ul><li>Distant metastasis </li></ul><ul><li>Obstruction/bleeding Palliative surgery : </li></ul><ul><li>Simple resection / by-pass operation / </li></ul><ul><li>intubation for enteral nutrition support </li></ul>Palliative operations
  48. 48. How to treat Napoleon , GC Surgical resection? EMR? ESD? Adjuvant therapy? Palliative therapy? ...... Why?
  49. 49. Prognosis <ul><li>The TNM classification/staging of gastric cancer is the best prognostic indicator: </li></ul><ul><li>Survival is about 90%, 60%, 30% and 8% for Stages 1,2,3 and 4 </li></ul><ul><li>The 5 years survival rate depends mostly on the depth of gastric cancer invasion </li></ul><ul><li>Patients in whom tumors are resectable for cure also have good prognosis </li></ul>
  50. 50. Recommend reading article <ul><li>Lancet. 2009 Aug 8;374(9688):477-90. </li></ul>
  51. 51. Thank you!