版权说明:本文档由用户提供并上传,收益归属内容提供方,若内容存在侵权,请进行举报或认领
文档简介
GastricCancer1EpidemiologyandEtiologyPreventionandEarlyDetectionPathologyClinicalPresentationDiagnosisStagingandAssessmentTreatmentFollow-up2EpidemiologyandEtiology
3Tremendousgeographicvariationexistsintheincidenceofthisdiseasearoundtheworld.RatesofthediseasearehighestinAsiaandpartsofSouthAmericaandlowestinNorthAmerica.4Stomachcancerin2002:incidenceandmortalityrates(age-standardised)inEurope.5AetiologyandriskfactorsAetiologicalfactors;Diet;Tobacco;Occuptionalrelationships;Precursorpathologicconditions;Gastricremnant;HelicobacterpyloriFamilyhistory……6Migrantpopulationsfromhigh-riskcountriesshowamarkeddiminutioninriskwhentheymovetoalowerriskarea.InJapanesemigrantstotheUSA,thereisquiteasubstantialfallintheriskbetweenthemigrantgenerationandUS-bornJapanese.Aetiologicalfactors7Foodandnutritionplayanimportantroleinpreventionandcausationofstomachcancer.Diet8Thereisstrongevidencethatnon-starchyvegetables,includingspecificallyalliumvegetables,aswellasfruitsprotectagainststomachcancer.Thereisalsostrongevidencethatsalt,andalsosalt-preservedfoods,arecausesofthiscancer.Thereislimitedevidencesuggestingthatlegumes,includingsoyaandsoyaproducts,andalsofoodscontainingseleniumprotectagainststomachcancer.Thereisalsolimitedevidencesuggestingthatchilli,processedmeat,smokedfoods,andgrilled(broiled)andbarbecued(charbroiled)animalfoodsarecausesofstomachcancer.theWorldCancerResearchFund(WCRF)andtheAmericanInstituteforCancerResearch(AICR)9Approximately18%ofgastriccancermaybeattributabletotobaccosmokingTobaccoDoyousmoke?10InfectionwiththebacteriumHelicobacterpylori(H.pylori)isestablishedasanecessarycauseofalmostallcasesofstomachcancer.Helicobacterpylori11PreventionandEarlyDetection
12Screeningprocedures(H.pylori/endoscopy/riskfactors…);Tumormarkers(CA19-9/CEA/CA242/CA724/AFP…);Genemutations(eg.CDH-1gene…);Microscopicevaluation…..13Pathology14GrosspathologicfeaturesMicroscopicpathologicfeaturesPathology15GrosspathologicfeaturesTypeIPolypoid:wellcircumscribedpolypoidtumours.TypeIIFungating:polypoidtumourswithmarkedcentralinfiltrationTypeIIIUlcerated:ulceratedtumourswithinfiltrativemargins.TypeIVInfiltrating:linitisplastica.Borrmann’stypes:16MicroscopicpathologicfeaturesAdenocarcinoma(90-95%)LymphomaLeiomyosarcomaCarcinoidAdenoacanthomaSquamouscellcarcinomas17Adenocarcinoma.Papillaryadenocarcinoma.Tubularadenocarcinoma.Mucinousadenocarcinoma(greaterthan50%mucinous).Signet-ringcellcarcinoma(greaterthan50%signet-ringcells).Adenosquamouscarcinoma.Squamouscellcarcinoma.Smallcellcarcinoma.Undifferentiatedcarcinoma.Other.ProposedbytheWorldHealthOrganizationisrecommended.18Gastriccancercanspreaddirectly,vialymphatic,orhematogenously.19N1:perigastricnodes(groups1-6)N2:nodesalongtheleftgastric,commonhepatic,celiac,andsplenicarteries(groups7-11)N3:portal,retropancreaticandmesentericroot(groups12-14)N4:middlecolicarteryandpara-aortic(groups15-16)202122Spreaddirectly,vialymphatic,orhematogenously.
23ClinicalPresentation2425Patientsmaypresentwithawidevarietyofsymptoms,ortheymayremaincompletelyasymptomatic.26Diagnosis27SignsandsymptomsRadiologicaltechniquesEndoscopyandpathologicassessmentBiologicalmarkers28Positivefindingonphysicalexaminationarethoseofadvanceddisease.Signsandsymptoms29Radiologicaltechniques30EndoscopyGastroscopyEGDEUS31PETscan32CA19-9CEACA242CA724AFP………BiologicalmarkersGenemutation----CDH-1geneCarriersofthesemutationhavea70%lifetimeriskofdevelopinggastriccancer.33BiopsyforcytologicandhistologictestingPathologicassessment34StagingandAssessment35TreatmentdecisionsareusuallymadeinreferencetotheAmericanJointCommitteeonCancer(AJCC)andtheInternationalUnionAgainstCancer(UICC)Stageclassifications36TXPrimarytumourcannotbeassessed.T0Noevidenceofprimarytumour.TisCarcinomainsitu:intraepithelialtumourwithoutinvasionofthelaminapropria.T1Tumourinvadeslaminapropriaorsubmucosa.T2Tumourinvadesmuscularispropriaorsubserosa.T2aTumourinvadesmuscularispropria.T2bTumourinvadessubserosa.T3Tumourinvadestheserosa(visceralperitoneum)withoutinvasionofadjacentstructures.T4Tumourdirectlyinvadesadjacentstructures.TNMclassificationPrimarytumour(T)37NXRegionallymphnode(s)cannotbeassessed.N0Noregionallymphnodemetastasis.N1Metastasisin1–6regionallymphnodes.N2Metastasisin7–15regionallymphnodes.N3Metastasisinmorethan15regionallymphnodes.TNMclassificationRegionallymphnodes(N)38MXPresenceofdistantmetastasiscannotbeassessed.M0Nodistantmetastasis.M1Distantmetastasis.TNMclassificationDistantmetastasis(M):39Stage0isdefinedasfollows:TisN0M0(carcinomainsitu).StageIisdefinedasfollows:T1N0M0(IA),T1N1M0(IB),T2a/bN0M0(IB).StageIIisdefinedasfollows:T1N2M0,T2a/bN1M0,T3N0M0.StageIIIisdefinedasfollows:T2a/bN2M0(IIIA),T3N1M0(IIIA),T4N0M0(IIIA),T3N2M0(IIIB).StageIVisdefinedasfollows:T4N1M0,T4N2M0,anyTN3M0,anyTanyNM1.StagegroupingaccordingtotheAJCCUICC40Japaneseclassification
Themajordifferencesbetweenthetwoclassifications,theInternationalUnionAgainstCancer(UICC)TNMclassificationandtheJRSGCJapaneseclassification,inthemultiplecategoriesusedintheJapanesesystem(clinical,surgical,pathological,finaldiagnosis),theseparatedescriptionofPandHindicatingpoorprognosis,andintheNclassification.
Differences4142Treatment43Overalltreatmentstrategy?44AdjuvantTherapyBiologicalTherapyPrimaryTherapy45Surgicaltreatment4647Anatomyofstomach48GastrectomywithremovalofperigastriclymphnodesTreatmentofcancerofthestomachdependsonthestageofthedisease,thepartofthestomachwherethecanceris,andthepatient’sgeneralhealth.49ExtentofgastricresectionExtentlymphnodedissectionRoleofsplenectomyRoleofdistalpancreatectomyConcernsofthesurgicaltreatment50ExtentofgastricresectionTotalgastrectomyshouldberecommendedforpatientswithlesionslocatedintheproximalormiddlethirdofthestomach,orwhenadiffusetypegastriccancerisfound,whichiscommonlyseeninpatientsinwhomthewholestomachisinvolved.patientswithdistalgastriccancersubtotalgastrectomyshouldberecommended.A5 cmfreeproximalmarginisrequiredforgastriccanceroftheinfiltrativetype.Whenthetumourinvadestheoesophagus,distalesophagectomyshouldbeperformed.51ExtentlymphnodedissectionTheextentofthelymphnodedissectionalsodependsonthelocationofthetumor.Whenperformingaradicalsubtotalgastrectomyandomentectomy,allN1andN2nodesshouldberemoved(D2dissection).SomeJapansurgeonsroutinelyremoveN3lymphnodes(D3dissection,usuallyportalandretropancreatic)N1:perigastricnodes(groups1-6)N2:nodesalongtheleftgastric,commonhepatic,celiac,andsplenicarteries(groups7-11)N3:portal,retropancreaticandmesentericroot(groups12-14)N4:middlecolicarteryandpara-aortic(groups15-16)52atleast,aD1lymphadenectomyisrecommended.InpatientswherethereisasuspicionofN2nodes,aD2resectionshouldbeadvisedandshouldperformedbysurgeonsexperiencedwiththistechnique.IncaseswhereD1dissectionisperformed,atleast15nodesshouldberemovedinpatientswithresectablecancer.53Roleofsplenectomy54TheRoleofsplenectomy,BecausetheremovalofStation10lymphnodesisgreatlyfacilitatedbyperformingsplenectomy,anothermuch-debatedissuehasarisen:whetherornottoperformsplenectomyintheradicalresectionoftheproximalstomach.Theincidenceofmetastasisatsplenichilumlymphnodesishighlyrelatedtothedepthofinvasionandthetumourlocation.Roleofdistalpancreatectomy55Inadditiontosplenectomy,distalpancreatectomyensurescompleteremovaloflymphnodesalongthesplenicartery(station11).InaBritishtrial,pancreaticosplenectomycarriedamarkedadverseeffectonmorbidity,mortality,andoverallsurvival.Splenectomyandpancreaticosplenectomy,butnottheextendedlymphadenectomy,hadbeenresponsiblefortheincreasedmorbidityandmortalityintheD2groupofoneoftheEuropeantrials.Thedistalpancreatectomyshouldberecommendedonatype1levelofevidenceonlywhenthereisdirectinvasionofthepancreasbythetumourthroughthegastricserosa.5657Severalkeypointsofthegastrectomyshowedinfollowingvideos.Neoadjuvanttreatment58NeoadjuvantchemotherapyNeoadjuvantradiotherapy59NeoadjuvantchemotherapyInWesterncountries,themajorityofpatientsarediagnosedwithlocallyadvancedgastriccancer,namelyT3-4N0-2M0disease.Acurativeresectionmaybeperformedinabouthalfofthesepatients,andevenafteranR0resectiontwothirdofthepatientswillshowrecurrencewithin2–3years.60Preoperativeassessmentofresectabilityofgastriccanceriscritical.CTscanisusefulfordetectingofbothtumourinvasionofadjacentorgansandlivermetastases.EUSisquiteaccuratefortheassessmentoftheexactT-category,andlaparoscopymayexcludeperitonealtumourspreadandallowanassessmentofthepresenceoftumourcellsbyperitoneallavage.TheaccuracyofpredictionoflymphnodestatusmaybeincreasedbyaddingEUStoCTscan.61Newactiveagentsforgastriccancer,suchasdocetaxel,paclitaxel,andirinotecanhavebeenintroducedintoneoadjuvantregimens.Basedonthepublisheddata,perioperativeECFor5-FU/CisplatinbasedregimenschemotherapyshouldbeconsideredtofitpatientswithstageII/IVM0gastriccancer.62NeoadjuvantradiotherapyPreoperativeradiationtherapyimprovedlocalcontrol,whereasnodifferenceindistantfailurewasobserved.Neoadjuvantradiotherapyisdescribedassafeandwelltolerated,butfurtherrandomisedtrialsarerequiredtoassessthebenefitintermsofoverallsurvivalofradiotherapygivenpreoperatively.Adjuvanttreatment63AdjuvantchemotherapyAdjuvantradiotherapyAdjuvantchemoradiotherapy
Adjuvantintraperitonealchemotherapy64AdjuvantchemotherapyTheprognosisforpatientswithgastriccancerislargelydependentonthestageofthediseaseatthetimeofdiagnosis.PatientswithEGChaveacurerateexceeding70–80%afteroperationalone,whereaspatientswithstageT3N0gastriccancershaveatleasta50%chanceofdyingwithin5years,andthepercentagecureratesaredismalforpatientswithlymphnodemetastases.Theneedforadditivetreatmentaftersurgeryforpatientswithhigh-riskgastriccancerisobvious.Inthepastdecadesnumerousrandomisedtrialsofadjuvantchemotherapyhavebeenconducted,byusingdifferentdrugsandregimens.JapaneseAuthorsrecommendedS-1adjuvantchemotherapyforstageII/IIIgastriccancerpatientsaftercurativeD2dissection.65Abenefitfromchemotherapywassuggestedforpatientswithsixormoreinvolvedlymphnodes.S-1isafourth-generationoralfluoropyrimidinederivative,thathasbeendevelopedmainlyinJapan.66
AdjuvantintraperitonealchemotherapyAsignificantproportion–upto50%–ofpatientscurativelyresectedforgastriccancerdevelopclinicallyevidentperitonealcarcinomatosisatasiteoffailure.Thisfrequenteventsupportedtheuseofintraperitonealtherapyafterresectionoftheprimarygastriccancer.Inthepast,cisplatin,mitomycin,or5FUwerecommonlyusedforthispurpose67Onlyhyperthermicintraoperativeintraperitonealchemotherapywithorwithoutpostoperativeintraperitonealchemotherapyafterresectionofadvancedgastriccancerwasassociatedwithanimprovedoverallsurvival.However,intraperitonealchemotherapywasalsofoundtobeassociatedwithincreasedrisksofintra-abdominalabscessandneutropenia.68AdjuvantradiotherapyTherewasnoevidenceofabenefitforadjuvantradiotherapy.69AdjuvantchemoradiotherapyAsresultswithadjuvantradiotherapyalonehavebeendisappointing,investigatorshavetriedtoimprovetheefficacyofradiationtherapybyusingconcomitant5FUchemotherapy.Postoperativechemoradiotherapyprolongedsignificantlysurvivalanddisease-freesurvival.Follow-up7071Inageneralpopulationofpatientstreatedcurativelyforgastriccancerapproximately40–60%ofthemwilldeveloparecurrence.About75–80%ofthesewilloccurwithin2years,andinnearly98%ofpatientswithin5yearsfromsurgery.Local-regionaldiseaseastheonlysiteoffailureoccursin23–56%ofpatients;bycontrast,distantorganmetastasesassinglesiteofrelapseisquiterare(6%),andaregenerallyfoundinthesettingofadvancedlocoregionalorperitonealdisease.72Themajoraimsinthefollow-upstrategyaretheearlydetectionoflocalrelapse(generally,thestump)amenabletotreatmentwithcurativeintent,andtheassessmentandtreatmentofdisordersrelatedtothenutritionalstatusofpatientsaftergastrectomy(e.g.,dumpingsyndrome),orotherfunctionaldisordersrelatedtorecurrence.73SuggestedprotocolsThereis
温馨提示
- 1. 本站所有资源如无特殊说明,都需要本地电脑安装OFFICE2007和PDF阅读器。图纸软件为CAD,CAXA,PROE,UG,SolidWorks等.压缩文件请下载最新的WinRAR软件解压。
- 2. 本站的文档不包含任何第三方提供的附件图纸等,如果需要附件,请联系上传者。文件的所有权益归上传用户所有。
- 3. 本站RAR压缩包中若带图纸,网页内容里面会有图纸预览,若没有图纸预览就没有图纸。
- 4. 未经权益所有人同意不得将文件中的内容挪作商业或盈利用途。
- 5. 人人文库网仅提供信息存储空间,仅对用户上传内容的表现方式做保护处理,对用户上传分享的文档内容本身不做任何修改或编辑,并不能对任何下载内容负责。
- 6. 下载文件中如有侵权或不适当内容,请与我们联系,我们立即纠正。
- 7. 本站不保证下载资源的准确性、安全性和完整性, 同时也不承担用户因使用这些下载资源对自己和他人造成任何形式的伤害或损失。
最新文档
- 2024个人房屋租赁合同简单版
- 2024建筑装饰工程合同书
- 八年级地理下册 7.1 南方地区的区域特征教案 (新版)商务星球版
- 工伤认定办理须知(官渡区)(标准)
- 护理文书书写规范
- 《探索“倍”的奥秘》(教学设计)-2024-2025学年三年级上册数学人教版
- 光电传感器产业发展结论与展望
- 2024秋七年级数学上册 第一章 走进数学世界 1.1数学伴我们成长教案(新版)华东师大版
- 露营行业概述
- 抵押反担保契约书(物品抵押)(标准版)
- 零跑汽车-市场前景及投资研究报告-厚积薄发轻资产出海破发
- 2024年一带一路金砖大赛(轨道车辆电气检修赛项)理论考试题库-(单选题)
- 2024年大学秋季开学典礼主持词(四篇)
- 第一章 有理数 单元测试 2024-2025学年人教版七年级数学上册
- 牙齿矫正协议书范本(2024版)
- 2024云南新华书店集团限公司公开招聘34人(高频重点提升专题训练)共500题附带答案详解
- 《财务会计基础》课件-认知原始凭证
- 第25课これは明日会議で使う資料です课件高中日语标准日本语初级下册
- 强国复兴有我课件模板
- 2024年“学宪法 讲宪法”知识竞赛题库及答案
- 【课件】点线传情-造型元素之点线面高中美术人美版(2019)选择性必修1+绘画
评论
0/150
提交评论