肿瘤学-培训课件
肿瘤学-培训课件,肿瘤,培训,课件
Nanrong Yu Email:Tel:13710861960Gastric Cancer1 1The Affiliated Tumor Hospital of Guangzhou Medical UniversityEpidemiology and EtiologyPrevention and Early DetectionPathologyClinical PresentationDiagnosisStaging and AssessmentTreatmentFollow-up2 2*3 3*4 4Stomach cancer in 2002:incidence and mortality rates(age-standardised)in Europe.5 5Aetiology and risk factorsAetiological factors;Diet;Tobacco;Occuptional relationships;Precursor pathologic conditions;Gastric remnant;Helicobacter pyloriFamily history 6 6Migrant populations from high-risk countries show a marked diminution in risk when they move to a lower risk area.In Japanese migrants to the USA,there is quite a substantial fall in the risk between the migrant generation and US-born Japanese.Aetiological factors7 7*Food and nutrition play an important role in prevention and causation of stomach cancer.Diet8 8*There is strong evidence that non-starchy vegetables,including specifically allium vegetables,as well as fruits protect against stomach cancer.*There is also strong evidence that salt,and also salt-preserved foods,are causes of this cancer.*There is limited evidence suggesting that legumes,including soya and soya products,and also foods containing selenium protect against stomach cancer.*There is also limited evidence suggesting that chilli,processed meat,smoked foods,and grilled(broiled)and barbecued(charbroiled)animal foods are causes of stomach cancer.the World Cancer Research Fund(WCRF)and the American Institute for Cancer Research(AICR)9 9*Approximately 18%of gastric cancer may be attributable to tobacco smokingTobaccoDo you smoke?1010*Infection with the bacterium Helicobacter pylori(H.pylori)is established as a necessary cause of almost all cases of stomach cancer.Helicobacter pylori11 11*1212Screening procedures(H.pylori/endoscopy/risk factors);Tumor markers(CA19-9/CEA/CA242/CA724/AFP);Gene mutations(eg.CDH-1 gene);Microscopic evaluation.1313*1414Gross pathologic featuresMicroscopic pathologic featuresPathologyPathology1515Gross pathologic featuresType I Polypoid:well circumscribed polypoid tumours.Type II Fungating:polypoid tumours with marked central infiltrationType III Ulcerated:ulcerated tumours with infiltrative margins.Type IV Infiltrating:linitis plastica.Borrmanns types:1616Microscopic pathologic featuresAdenocarcinoma(90-95%)LymphomaLeiomyosarcomaCarcinoidAdenoacanthomaSquamous cell carcinomas1717*Adenocarcinoma.*Papillary adenocarcinoma.*Tubular adenocarcinoma.*Mucinous adenocarcinoma(greater than 50%mucinous).*Signet-ring cell carcinoma(greater than 50%signet-ring cells).*Adenosquamous carcinoma.*Squamous cell carcinoma.*Small cell carcinoma.*Undifferentiated carcinoma.*Other.Proposed by the World Health Organization is recommended.1818*Gastric cancer can spread directly,via lymphatic,or hematogenously.1919N1:perigastric nodes(groups 1-6)N2:nodes along the left gastric,common hepatic,celiac,and splenic arteries(groups 7-11)N3:portal,retropancreatic and mesenteric root(groups 12-14)N4:middle colic artery and para-aortic(groups 15-16)202021212222*2323*24242525Patients may present with a wide variety of symptoms,or they may remain completely asymptomatic.2626*2727*Signs and symptoms*Radiological techniques*Endoscopy and pathologic assessment*Biological markers2828*Positive finding on physical examination are those of advanced disease.Signs and symptoms2929Radiological techniques3030EndoscopyGastroscopyEGDEUS3131PET scan3232CA19-9CEACA242CA724AFPBiological markersGene mutation-CDH-1 geneCarriers of these mutation have a 70%lifetime risk of developing gastric cancer.3333*Biopsy for cytologic and histologic testing Pathologic assessment3434*3535*Treatment decisions are usually made in reference to the American Joint Committee on Cancer(AJCC)and the International Union Against Cancer(UICC)Stage classifications3636*TX Primary tumour cannot be assessed.*T0 No evidence of primary tumour.*Tis Carcinoma in situ:intraepithelial tumour without invasion of the lamina propria.*T1 Tumour invades lamina propria or submucosa.*T2 Tumour invades muscularis propria or subserosa.*T2a Tumour invades muscularis propria.*T2b Tumour invades subserosa.*T3 Tumour invades the serosa(visceral peritoneum)without invasion of adjacent structures.*T4 Tumour directly invades adjacent structures.TNM classificationPrimary tumour(T)3737*NX Regional lymph node(s)cannot be assessed.*N0 No regional lymph node metastasis.*N1 Metastasis in 16 regional lymph nodes.*N2 Metastasis in 715 regional lymph nodes.*N3 Metastasis in more than 15 regional lymph nodes.TNM classificationRegional lymph nodes(N)3838*MX Presence of distant metastasis cannot be assessed.*M0 No distant metastasis.*M1 Distant metastasis.TNM classificationDistant metastasis(M):3939*Stage 0 is defined as follows:Tis N0 M0(carcinoma in situ).*Stage I is defined as follows:T1 N0 M0(IA),T1 N1 M0(IB),T2a/b N0 M0(IB).*Stage II is defined as follows:T1 N2 M0,T2a/b N1 M0,T3 N0 M0.*Stage III is defined as follows:T2a/b N2 M0(IIIA),T3 N1 M0(IIIA),T4 N0 M0(IIIA),T3 N2 M0(IIIB).*Stage IV is defined as follows:T4 N1 M0,T4 N2 M0,anyT N3 M0,anyT anyN M1.Stage grouping according to the AJCC UICC4040Japanese classification The major differences between the two classifications,the International Union Against Cancer(UICC)TNM classification and the JRSGC Japanese classification,in the multiple categories used in the Japanese system(clinical,surgical,pathological,final diagnosis),the separate description of P and H indicating poor prognosis,and in the N classification.Differences 41414242*4343Overall treatment strategy?4444Adjuvant TherapyBiological TherapyPrimary Therapy4545*Surgical treatment46464747Anatomy of stomach 4848Gastrectomy with removal of perigastric lymph nodesTreatment of cancer of the stomach depends on the stage of the disease,the part of the stomach where the cancer is,and the patients general health.4949Extent of gastric resectionExtent lymph node dissectionRole of splenectomyRole of distal pancreatectomyConcerns of the surgical treatment5050*Extent of gastric resectionTotal gastrectomy should be recommended for patients with lesions located in the proximal or middle third of the stomach,or when a diffuse type gastric cancer is found,which is commonly seen in patients in whom the whole stomach is involved.patients with distal gastric cancer subtotal gastrectomy should be recommended.A 5cm free proximal margin is required for gastric cancer of the infiltrative type.When the tumour invades the oesophagus,distal esophagectomy should be performed.5151*Extent lymph node dissectionThe extent of the lymph node dissection also depends on the location of the tumor.When performing a radical subtotal gastrectomy and omentectomy,all N1 and N2 nodes should be removed(D2 dissection).Some Japan surgeons routinely remove N3 lymph nodes(D3 dissection,usually portal and retropancreatic)N1:perigastric nodes(groups 1-6)N2:nodes along the left gastric,common hepatic,celiac,and splenic arteries(groups 7-11)N3:portal,retropancreatic and mesenteric root(groups 12-14)N4:middle colic artery and para-aortic(groups 15-16)5252*at least,a D1 lymphadenectomy is recommended.In patients where there is a suspicion of N2 nodes,a D2 resection should be advised and should performed by surgeons experienced with this technique.In cases where D1 dissection is performed,at least 15 nodes should be removed in patients with resectable cancer.5353*Role of splenectomy5454The Role of splenectomy,Because the removal of Station 10 lymph nodes is greatly facilitated by performing splenectomy,another much-debated issue has arisen:whether or not to perform splenectomy in the radical resection of the proximal stomach.The incidence of metastasis at splenic hilum lymph nodes is highly related to the depth of invasion and the tumour location.*Role of distal pancreatectomy5555In addition to splenectomy,distal pancreatectomy ensures complete removal of lymph nodes along the splenic artery(station 11).In a British trial,pancreaticosplenectomy carried a marked adverse effect on morbidity,mortality,and overall survival.Splenectomy and pancreaticosplenectomy,but not the extended lymphadenectomy,had been responsible for the increased morbidity and mortality in the D2 group of one of the European trials.The distal pancreatectomy should be recommended on a type 1 level of evidence only when there is direct invasion of the pancreas by the tumour through the gastric serosa.56565757*Several key points of the gastrectomy showed in following videos.*Neoadjuvant treatment5858Neoadjuvant chemotherapyNeoadjuvant radiotherapy5959*Neoadjuvant chemotherapyIn Western countries,the majority of patients are diagnosed with locally advanced gastric cancer,namely T3-4N0-2M0 disease.A curative resection may be performed in about half of these patients,and even after an R0 resection two third of the patients will show recurrence within 23 years.6060Preoperative assessment of resectability of gastric cancer is critical.CT scan is useful for detecting of both tumour invasion of adjacent organs and liver metastases.EUS is quite accurate for the assessment of the exact T-category,and laparoscopy may exclude peritoneal tumour spread and allow an assessment of the presence of tumour cells by peritoneal lavage.The accuracy of prediction of lymph node status may be increased by adding EUS to CT scan.6161New active agents for gastric cancer,such as docetaxel,paclitaxel,and irinotecan have been introduced into neoadjuvant regimens.Based on the published data,perioperative ECF or 5-FU/Cisplatin based regimens chemotherapy should be considered to fit patients with stage II/IV M0 gastric cancer.6262*Neoadjuvant radiotherapy Preoperative radiation therapy improved local control,whereas no difference in distant failure was observed.Neoadjuvant radiotherapy is described as safe and well tolerated,but further randomised trials are required to assess the benefit in terms of overall survival of radiotherapy given preoperatively.*Adjuvant treatment6363Adjuvant chemotherapyAdjuvant radiotherapyAdjuvant chemoradiotherapy Adjuvant intraperitoneal chemotherapy6464Adjuvant chemotherapyThe prognosis for patients with gastric cancer is largely dependent on the stage of the disease at the time of diagnosis.Patients with EGC have a cure rate exceeding 7080%after operation alone,whereas patients with stage T3N0 gastric cancers have at least a 50%chance of dying within 5 years,and the percentage cure rates are dismal for patients with lymph node metastases.The need for additive treatment after surgery for patients with high-risk gastric cancer is obvious.In the past decades numerous randomised trials of adjuvant chemotherapy have been conducted,by using different drugs and regimens.Japanese Authors recommended S-1 adjuvant chemotherapy for stage II/III gastric cancer patients after curative D2 dissection.6565A benefit from chemotherapy was suggested for patients with six or more involved lymph nodes.S-1 is a fourth-generation oral fluoropyrimidine derivative,that has been developed mainly in Japan.6666 Adjuvant intraperitoneal chemotherapyA significant proportion up to 50%of patients curatively resected for gastric cancer develop clinically evident peritoneal carcinomatosis at a site of failure.This frequent event supported the use of intraperitoneal therapy after resection of the primary gastric cancer.In the past,cisplatin,mitomycin,or 5FU were commonly used for this purpose6767Only hyperthermic intraoperative intraperitoneal chemotherapy with or without postoperative intraperitoneal chemotherapy after resection of advanced gastric cancer was associated with an improved overall survival.However,intraperitoneal chemotherapy was also found to be associated with increased risks of intra-abdominal abscess and neutropenia.6868Adjuvant radiotherapyThere was no evidence of a benefit for adjuvant radiotherapy.6969Adjuvant chemoradiotherapyAs results with adjuvant radiotherapy alone have been disappointing,investigators have tried to improve the efficacy of radiation therapy by using concomitant 5FU chemotherapy.Postoperative chemoradiotherapy prolonged significantly survival and disease-free survival.*70707171In a general population of patients treated curatively for gastric cancer approximately 4060%of them will develop a recurrence.About 7580%of these will occur within 2 years,and in nearly 98%of patients within 5 years from surgery.Local-regional disease as the only site of failure occurs in 2356%of patients;by contrast,distant organ metastases as single site of relapse is quite rare(6%),and are generally found in the setting of advanced locoregional or peritoneal disease.7272The major aims in the follow-up strategy are the early detection of local relapse(generally,the stump)amenable to treatment with curative intent,and the assessment and treatment of disorders related to the nutritional status of patients after gastrectomy(e.g.,dumping syndrome),or other functional disorders related to recurrence.7373*Suggested protocolsThere is no evidence that intensive follow-up after the initial treatment may improve outcome of patients.Careful physical examination of symptomatic patients should be performed,together with blood tests including CEA and CA19.9 determinations.In the presence of signs and symptoms of relapse,radiological investigations should be performed for patients who are candidate for palliative chemotherapy.*7474*ConclusionGastric cancer is one of the most common cancers with great geographic variation of the incidence and have complex causes and many risk factors.Gastric cancer can spread directly,via lymphatic,or hematogenously.Patients may present with a wide variety of symptoms,or they may remain completely asymptomatic.Surgical resection of the primary tumour and regional lymph nodes is the treatment of choice for gastric cancer.The extent of disease,the operative procedure,and patient selection are crucial in optimizing outcome.Adjuvant therapy(mainly,chemotherapy radiotherapy)still warrants further evaluation for high-risk(T3-4,N+)gastric cancer patients.Neoadjuvant therapy may reduce tumour mass enabling resection with potentially curative intent.When the disease is metastatic,treatment of gastric cancer is exclusively palliative or symptomatic.*http:/dx.doi.org/10.1016/j.critrevonc.2009.01.00475757676*Testing1.What is the TNM classification of gastric cancer?2.What is the borrmanns type of gastric cancer?3.How to make a diagnosis for gastric cancer patients?7777*
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