Gastric Cancer

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

17. 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.

18. 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.

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

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

21. Endoscopy Advanced carcinoma Carcinoma in situ

22. Niche Double-Contrast Barium Upper GI Radiography

23. EUS

24. EUS T N T

25. CT scan

26. A B C N H1 T CT scan T4N2M1

27. PET-CT: T3N2

28. BUS left right Liver metastasis Krukenberg’s tumor

29. Laparoscopy T T Abdominal metastasis

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

31. EMR for Earlier gastric cancer (EGC )

32. 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

33. EMR

34. EMR

35. EMR

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

37. ESD for Earlier gastric cancer (EGC )

38. ESD Oita Digestive Organs Hospital

39. ESD Oita Digestive Organs Hospital

40. Criteria for ESD NationalCancer Center Hospital In Japan

41. 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

42. 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

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

44. 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

45. Gastrectomy and D2 lymphadenectomy for advanced gastric carcinoma Gastrectomy

46. Lymphadenectomy

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

48. Total gastrectomy

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

50. Portal Vein