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1、.,Clinical Rounds in General Surgery,.,Gastric carcinoma,.,Although its incidence in developed countries has declined, gastric cancer remains one of the most common human malignancies.,background,Today, we will reviews the modern approach to gastric cancer using the treatment guidelines published by
2、 UICC and JGCA.,.,GL aim to provide a standard indication for doctors to select the proper treatments of gastric cancer according to the clinical stages of patients.,Purpose of Guideline,.,Kernel of the Guideline,TNM staging,Stage-oriented treatment,.,Divisions of the stomach,Basic knowledge about G
3、astric carcinoma,.,The stomach is reflected cephalad,Blood supply to the stomach and duodenum,.,Tumor Location,.,Gross classifications,Early gastric carcinoma： defined as a primary lesion confined to the mucosa and submucosal layer with or without lymph mode metastasis. D 10mm is named little gastri
4、c cancer，D 5mm is named mini gastric cancer. The focus that is smaller than the mini gastric cancer is diagnosed cancer only when the biopsy of gastric mucosa under gastroscopy. Although cancer tissue is not seen in the removal gastric sample, it is named “ one point cancer”. Advanced gastric carcin
5、oma：lesions beyond submucosa layer and intrade into muscle layer which is called mid-stage gastric cancer；when the lesions reach subserosa or infiltrate adjacent organs or has metastasis, it is called late carcinoma. Moderate and late gastric carcinoma are both called advanced carcinoma.,.,The early
6、 gastric carcinoma(Type 0) was divided into three basic types:,Type 0 I : protruded typeType 0 II : superficial type which includes superficial elevated type, type IIa; superficial flat type, type IIb; superficial depressed type, type IIcType 0 III: excavated type,.,Advanced gastric carcinoma may be
7、 classified as one of four types,Type 1：polypoid or fungating carcinoma Type 2：ulcerated carcinoma without diffuse spread Type 3：ulcerated carcinoma with diffuse spread Type 4： diffuse carcinoma,.,Examples of Macroscopic Type Classification,.,.,.,.,.,What is the TNM stage?,.,Depth of tumor invasion
8、(T stage),T1: tumor invade mucosa and submucosa; T2: tumor invade muscle layer and subserosa; T3：tumor perforate serosa； T4: tumor invade adjacent tissue and organ.,.,Lymph node metastasis(N stage),The regional lymph nodes of the stomach are classified into stations numbered as follows:,.,distant me
9、tastases (M stage),M0 : No other distant metastases, (although peritoneal, liver, or cytological metastases may be present) M1 : Distant metastases other than the peritoneal, liver, or cytological metastases,.,Standard TNM staging,.,Kernel of the Guideline,TNM staging,Stage-oriented treatment,.,endo
10、scopic mucosal resection (EMR), laparoscopic gastrectomy, modified gastrectomy A and B (MG A and B), standard gastrectomy, extended gastrectomy, chemotherapy, radiotherapy, multimodality therapy (including neoadjuvant and adjuvant chemotherapy, immunochemotherapy, hyperthermochemotherapy), terminal
11、care.,The available treatment modalities for gastric cancer,.,Stage-oriented treatment,EMR: endscopic mucosal resection Mod.G(A): modified gastrectomy with D1+ dissection Mod.G(B): modified gastrectomy with D1+ dissection Stand. G: standard gastrectomy with D2 dissection Ext. G: extended gastrectomy
12、 Pal. G: palliative gastrectomy and other surgical palliation Pal. care: palliative care Adj. chem : adjuvant or neoadjuvant chemotherapy.,.,Case reports,.,diagnostic and treatment procedure for patients with gastric cancer.,.,Clinical assessment and lab tests,.,Gastric adenocarcinoma lacks specific
13、 symptoms early in the course of the disease. Pain and weight loss are common clinical symptoms of advanced gastric carcinoma. The epigastric pain is similar to pain caused by benign ulcers Symptoms often reflect the site of origin of the tumor. Proximal tumors involving the gastroesophageal junctio
14、n often present with dysphagia, whereas distal antral tumors may present as gastric outlet obstruction.,Clinical Presentation,.,Physical signs develop late in the course of the disease and are most commonly associated with locally advanced or metastatic disease. Patients may present with a palpable
15、abdominal mass, a palpable supraclavicular (Virchows) or periumbilical (Sister Mary Josephs) lymph node, peritoneal metastasis palpable by rectal examination (Blumers shelf), or a palpable ovarian mass (Krukenbergs tumor). As the disease progresses, patients may develop hepatomegaly secondary to met
16、astasis, jaundice, ascites, and cachexia.,Physical Examination,.,Major examination in diagnosis of gastric cancer：1 X-ray barium meal2 gastroscopy3 abdominal ultrasound 4 enhanced CT,.,Upper GI BE（Barium Examination）,.,Niche,.,Niche,.,Filling Defect,.,Filling Defect,.,Filling Defect with Niche,.,Fil
17、ling Defect with Niche,.,Type 1,.,Type 1,.,Type 2,.,Type 2,.,Type 3,.,Type 4（ linitis plastica ）,.,Type 4（ linitis plastica ）,.,Although double-contrast barium upper GI radiography is cost-effective with 90% diagnostic accuracy, the inability to distinguish benign from malignant gastric ulcers makes endoscopy preferable,
