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1、当前胃癌的诊断和治疗,北京协和医院 基本外科肖 毅,Lung,Breast,Colorectal,Gastric,Prostate,Liver,Esophagus,Pancreatic,World cancer incidence and mortality,Female,40,30,20,10,0,10,20,30,40,Age-adjusted rate per 100,000,Mortality,Incidence,GLOBOCAN,IARC 2002,Male,Incidence of gastric cancer by region,ASR per 100,000 populatio
2、n,GLOBOCAN 2000:Cancer incidence,mortality and prevalence worldwide,IARC CancerBase No 5,IARCPress,2001,0,20,40,60,80,100,South Africa,Western Europe,Eastern Europe,North America,China,Japan,Korea,Male,Female,*Standardized to world population,Year,Gastric cancer:trend of age-adjusted mortality rate
3、but GE-junction incidence is rising,胃癌TNM分期T分期,Tis 原位癌T0 未发现肿瘤T1 肿瘤局限于粘膜层或粘膜下层T2 肿瘤侵及肌层或浆膜下层T2a 肿瘤侵及肌层T2b 肿瘤侵及浆膜下层T3 肿瘤穿透浆膜层（脏层腹膜），未侵及邻近结构T4 肿瘤侵及邻近结构,胃癌TNM分期N分期,N0 无淋巴结转移N1 1-6枚淋巴结转移N2 7-15枚淋巴结转移N3 16枚以上淋巴结转移,胃癌TNM分期M分期,M0 无远处转移M1 有远处转移,胃癌TNM分期,Ia期 T1N0M0Ib期 T1N1M0 T2N0M0II期 T1N2M0 T2N1M0 T3N0M0IIIa
4、期 T2N2M0 T3N1M0 T4N0M0IIIb期 T3N2M0IV期 T1-3N3M0 T4N1-3M0 TxNxM1,H1：肝转移；P1：腹膜转移；CY1：癌细胞；M1：除腹膜、肝或脱落细胞外的远处转移,胃癌大体类型 德国病理学家Borrmann于1926年提出,I型，肿块型：胃镜下和肉眼观察看见隆起粘膜表面的肿块。II型，溃疡型：界限清楚的溃疡形病灶。III型，溃疡浸润型：界限不清楚的溃疡性病灶，溃疡周围粘膜也有肿瘤细胞浸润。IV型，弥漫浸润型：界限不清楚，胃镜下确诊困难，钡餐可见胃挛缩，胃壁活动很少，称为“皮革胃”。,胃癌的诊断,胃镜钡餐腹部B超腹部CT,胃癌的分区,为适应胃癌根治
5、手术的需要，将胃大弯及胃小弯各分为三等分，连接各对应点，三部分各称近侧(C)、中部(M)和远侧(A)。D：十二指肠，E：食管如累及两个或三个区时，则先写主要分区，再写被浸润到的分区，如如MC、AM、MCAD等。,胃癌的淋巴结分组,No.1组：贲门右淋巴结No.2组：贲门左侧淋巴结No.3组：胃小弯淋巴结No.4组：胃大弯淋巴结No.5组：幽门上淋巴结No.6组：幽门下淋巴结No.7组：胃左动脉旁淋巴结No.8组：肝总动脉旁淋巴结No.9组：腹腔动脉周围淋巴结No.10组：脾门淋巴结No.11组：脾动脉干淋巴结No.12组：肝十二指肠韧带内淋巴结No.13组：胰头后淋巴结No.14组：肠系膜根部
6、淋巴结No.15组：结肠中动脉周围淋巴结No.16组：腹主动脉周围淋巴结,No.17组：胰头前淋巴结No.18组：胰下淋巴结No.19组：膈下淋巴结No.20组：食管裂孔淋巴结No.105组：胸上部食管旁淋巴结No.106组：胸部气管周围淋巴结No.107组：气管分叉周围的淋巴结No.108组：胸中部食管旁淋巴结No.109组：肺门周围淋巴结No.110组：胸下部食管旁淋巴结No.111组：膈上淋巴结No.112组：后纵膈淋巴结,胃癌淋巴结分站,A：胃远侧1/3；M：胃中部1/3；C：胃近侧1/3；D：十二指肠；*不清除，不影响判定清除程度；MA、M时不必清除，MC时必须清除；近侧胃切除时，不
7、充分清除，不影响判定清除程度,胃癌手术根治程度分级,A级手术DN；在切除的标本1cm内无癌细胞浸润。B级手术D=N；切缘1cm内有癌细胞浸润。C级手术切除原发灶和部分转移病灶；有肿瘤残余,当前胃癌治疗中的热点,胃癌的淋巴结清扫范围胃癌的辅助化疗胃癌的新辅助治疗,照片D4手术,胃癌淋巴结清扫范围,日本Sasako在2006年ASCO会议上报告的一项多中心前瞻性研究,比较了D2和D2加16组淋巴结清扫治疗局部进展期胃癌(包括期M0)的效果,结果显示两组虽然在术后死亡率、并发症等手术安全性方面无显著性差异,但D2加16组淋巴结清扫组亦未显示出延长患者生存期的优越性,因此认为应常规放弃此术式。经过东、
8、西方学者的反复论证,目前大家对于进展期胃癌较为统一的认识是将D2(淋巴结清除至第二站)手术作为标准术式。,胃癌扩大根治术,目前的胃癌扩大根治术包括联合脏器切除和腹主动脉旁淋巴结清扫术 扩大根治的原则是以所行手术是否会提高病人的生存时间，是否会改善病人的生存质量为标准。,早期胃癌的外科手术,缩小手术缩小胃切除面积缩小淋巴清扫范围定义：肿瘤局限于粘膜层或粘膜下层，不论有无淋巴结转移小胃癌：直径 1 cm微小胃癌：直径 0.5 cmD2手术仍是推荐手术,照片D2手术,胃癌围手术期处理,术前纠正酸碱平衡、低蛋白血症，补充水电解质，改善营养不良，输血；如合并幽门梗阻，用高渗盐水洗胃；术中开腹前常规预防使
9、用一次抗生素，视手术时间是否追加开腹前使用一次亚叶酸钙和5-Fu关腹前47C含10mg丝裂霉素的蒸馏水浸泡10分钟术后不常规使用抗生素5-6天开始进清流饮食，拔除引流管,胃癌术后治疗方式选择,胃癌辅助化疗,标准化疗方案ECF方案表阿霉素 50 mg/m2,顺铂60 mg/m2,5-FU 200 mg/m2/dMayo Clinic方案FOLFOX 4方案新化疗药物希罗达草酸铂（乐沙定，艾恒）紫杉类（泰索蒂，泰素）,胃癌辅助化疗现状,进展期疾病预后差，5年存活率10%；进展期疾病的化疗仍是姑息性；化疗的有效率较高，但是维持时间短，完全缓解率很低；没有理想的标准方案顺铂为基础药物的方案较常用(CF
10、,ECF,PELF),SWOG 9008/INT 0116:总存活率,0,20,40,60,80,100,0,24,48,72,96,120,Months after registration,Percentage survival,p=0.01,Macdonald J et al.N Engl J Med 345:725730;updated ASCO GI 2004;Abstract 6,SWOG 9008/INT 0116,D1=54%D1=36%D2=10%,Surgical procedures(based on 551 cases),Macdonald J et al.N Engl
11、 J Med 345:725730;updated ASCO GI 2004;Abstract 6,3 preoperative plus 3 postperative cycles of ECF,MAGIC trial:design,Eligible patients,R,S armSurgery alone,CSC armPreoperative chemoSurgeryPostoperative chemo,Cunningham et al.ASCO 2005;Abstract 4001,MAGIC trial:overall survival,Months from randomiza
12、tion,0,0.1,0.2,0.3,0.4,0.5,0.6,0.7,0.8,0.9,1.0,0,12,24,36,48,60,72,Survival rate,Logrank p-value=0.009,Hazard ratio=0.75,(95%CI 0.600.93),Events,Total,149,170,250,253,CSC,S,Cunningham et al.ASCO 2005;Abstract 4001,On multivariate analysis,treatment effect unchanged after adjustment for age,performan
13、ce status,site of primary and genderHazard ratio for deathAdjusted:0.74(95%CI:0.590.93)Unadjusted:0.75,MAGIC trial:overall survival,Cunningham et al.ASCO 2005;Abstract 4001,MAGIC trial:conclusions,Effective downsizing Increased R0 resection rate PFS significantly improved Survival significantly impr
14、oved,Cunningham et al.ASCO 2005;Abstract 4001,31,TCFDocetaxel 75 mg/m2 iv over 1 hr,D1Cisplatin 75 mg/m2 iv over 13 hrs,D1 5-FU 750 mg/m2/day by civ over 5 daysq3w 227 patients,CFCisplatin 100 mg/m2 iv over 13 hrs,D1 5-FU 1000 mg/m2/day by civ over 5 daysq4w 230 patients,Measurable or evaluable meta
15、static or measurable locally recurrent gastric adenocarcinoma Age 18 years oldKPS 70Adequate hematological and biochemical parameters,Stratification factors:Liver involvement;prior gastrectomy;measurable/evaluable disease;weight loss in prior 3 months;centreTumour assessments planned every 8 weeks i
16、n both armsPrimary endpointTime to progression in Full Analysis Population(FAP),Moiseyenko VM et al.Proc ASCO 2005;23:308s,RANDOMIZATION,TAX325:Phase III study design,TAX325:overall survival,0,10,20,30,40,50,60,70,80,90,100,RR:TCF 37%;CF 25%;p=0.016,p=0.0201HR:1.29(95%CI:1.041.61)Risk reduction:22.7
17、%,Months,Probability(%),TCF,CF,Moiseyenko VM et al.Proc ASCO 2005;23:308s,This study shows the benefit of adding docetaxel to cisplatin/5-FU in first-line metastatic and locally recurrent gastric cancer:,Docetaxel is a new therapeutic option in this diseaseTrials are ongoing to optimize its use in this setting,TAX325:conclusions,Moiseyenko VM et al.Proc ASCO 2005;23:308s,
