Gastric Carcinoma

胃癌carcinoma of stomach，gastric carcinoma【流行病学】胃癌发病有明显地域性差别，日本、俄罗斯、智利等国家多发。

我国亦为高发地区，我国青海、甘肃、宁夏、辽东半岛、胶东半岛多发。

在我国胃癌在各种恶性肿瘤中居首位，多发生于40-60岁，男性多于女性，男：女约为2-3：1。

【病因】地域环境及饮食生活习惯：地域性差别显著，我国西北雨东部沿海多发；长期使用熏烤、食盐腌制食品地区多发，与食物中亚硝酸盐、真菌霉素、多环芳烃化合物有关；食物中缺乏新鲜蔬菜与水果也有一定关系；与吸烟有关；Hp感染：促使硝酸盐转化成亚硝酸盐及亚硝胺而致癌；引起胃粘膜慢性炎症加上环境致病因素加速黏膜上皮细胞的过度增殖，导致畸变致癌；Hp的毒性产物CagA、VacA可能具有促癌作用；癌前病变：慢性萎缩性胃炎伴肠化生与不典型增生；直径超过2cm的胃溃疡、胃腺瘤、胃大部切除术后残胃、恶性贫血胃体有显著萎缩者等；遗传和基因：胃癌的发生与抑癌基因P53、APC、DCC杂合性缺失有关；胃癌组织中癌基因c-met、K-ras有明显扩增和过度表达；胃癌的侵袭性和转移则与CD44基因的异常表达密切相关。

【病理】⑴大体分型：①早期胃癌：胃癌仅限于粘膜或粘膜下层者，不论病灶大小或有无淋巴结转移；小胃癌：癌灶直径在10mm以下；微小胃癌：癌灶直径在5mm以下；一点癌：癌灶更小尽在胃镜粘膜活检时诊断为癌，但切除后的胃标本虽经全粘膜取材未见癌组织；分为三型：Ⅰ型隆起型；Ⅱ型浅表型：Ⅱa浅表隆起型，Ⅱb浅表平坦型，Ⅱc浅表凹陷型；Ⅲ型凹陷型；②进展期胃癌：癌组织超出粘膜下层侵入胃壁肌层为中期胃癌，病变达浆膜下层或是超出浆膜向外浸润至邻近脏器或有转移为晚期胃癌，中晚期胃癌统称进展期胃癌。

Borrmann分型：Ⅰ型：结节型；Ⅱ型：溃疡限局型；Ⅲ型：溃疡浸润型；Ⅳ型：弥漫浸润型。

若全胃受累胃腔缩窄、胃壁僵硬如革囊状，称皮革胃，几乎都是低分化腺癌或印戒细胞癌引起，恶性度极高。

SPECIAL ARTICLEJapanese classification of gastric carcinoma:3rd English editionJapanese Gastric Cancer AssociationÓThe International Gastric Cancer Association and The Japanese Gastric Cancer Association 20111General principlesGastric cancer findings are categorized and recorded using the upper case letters T,H,etc.The extent of disease for each parameter is expressed by Arabic numerals following the letter (e.g.,T3H1);where the extent of disease is unknown,X is used.The clinical and pathological classi-fications are derived from information acquired from var-ious clinical,imaging,and pathological sources (listed in Table 1).The clinical classification (c)is derived at the conclusion of pretreatment assessment before a decision is made regarding the appropriateness of surgery.This clas-sification is an essential guide to treatment selection and enables the evaluation of therapeutic options.The patho-logical classification (p)is based on the clinical classifi-cation supplemented or modified by additional evidence acquired from pathological examination.This informs decision-making regarding additional therapy and provides prognostic information.Where there is doubt regarding the T,N,or M category,the less advanced category should be used.Histological tumor findings are recorded in the follow-ing order:tumor location,macroscopic type,size,histo-logical type,depth of invasion,cancer–stroma relationship,pattern of infiltration,lymphatic invasion,venous invasion,lymph node metastasis,and resection margins.For exam-ple:L,Less,Type 2,50920mm,tub1[tub2,pT2,int,INFb,ly1,v1,pN1(2/13),pPM0,pDM0(see subsequent text for an explanation of the abbreviations).2Anatomical extent and stage of gastric carcinoma 2.1Description of the primary tumor 2.1.1Size and number of lesionsThe two greatest dimensions should be recorded for each lesion.Where there are multiple lesions,the tumor with the most advanced T category (or the largest lesion where the T stage is identical)is classified.2.1.2Tumor location2.1.2.1The three gastric regions and the esophagogastric junction The stomach is anatomically divided into three portions,the upper (U),middle (M),and lower (L)parts,by the lines connecting the trisected points on the lesser and greater curvatures (Fig.1).Gastric tumors are described by the parts involved.If more than one part is involved,all involved portions should be recorded in descending order of degree of involvement,with the part containing the bulk of tumor first,e.g.,LM or UML.Tumor extension into the esophagus or duodenum is recorded as E or D,respectively.The online version of the prefatory article referred to in this article can be found under doi:10.1007/s10120-011-0040-6.English edition editors:Takeshi Sano (&),Yasuhiro Kodera.e-mail:takeshi.sano@jfcr.or.jpJapanese Gastric Cancer Association (&)Association office,First Department of Surgery,Kyoto Prefectural University of Medicine,Kawaramachi,Kamigyo-ku,Kyoto 602-0841,Japan e-mail:jgca@koto.kpu-m.ac.jpGastric CancerDOI 10.1007/s10120-011-0041-5The area extending2cm above to2cm below the esophagogastric junction(EGJ)is designated the EGJ area. Tumors having their epicenter in this area are designated EGJ carcinomas irrespective of histological type.The location of an EGJ carcinoma is described using the sym-bols E(proximal2cm segment)and G(distal2cm seg-ment),with the dominant area of invasion describedfirst, i.e.,E,EG,E=G(both areas equally involved),GE,or G. The distance between the tumor center and the EGJ is recorded.The EGJ is defined as the border between the esophageal and gastric muscles.Clinically this is identified by one of the following:(a)the distal end of the longitudinal pali-sading small vessels in the lower esophagus at endoscopy;(b)the horizontal level of the angle of His shown by bar-ium meal examination;(c)the proximal end of the longi-tudinal folds of the greater curve of the stomach shown at endoscopy or barium meal study;or(d)the level of the macroscopic caliber change of the resected esophagus and stomach.It is important to note that the squamocolumnar junction(SCJ)does not always coincide with the EGJ.Clinically,the tumor location is often expressed as cardia,fundus,body,incisura,and antrum.2.1.2.2Cross-sectional parts of the stomach The stom-ach’s cross-sectional circumference is divided into four equal parts:the lesser(Less)and greater(Gre)curvatures, and the anterior(Ant)and posterior(Post)walls(Fig.2). Circumferential involvement is recorded as Circ.2.1.2.3Carcinoma in the remnant stomach Carcinoma in the remnant stomach encompasses all carcinomas arising in the remnant stomach following a gastrectomy,irrespective of the histology of the primary lesion(benign or malignant)or its risk of recurrence,the extent of resection,or method of reconstruction.The following information should be recorded, as well as,if available,information on the extent of resection and type of reconstruction of the previous gastrectomy.a.The primary lesion at the previous gastrectomy:benign(B),malignant(M),or unknown(X).b.The time interval elapsed between the previous gastrec-tomy and the current diagnosis,in years(unknown:X).c.Tumor location in the remnant stomach:anastomoticsite(A),gastric suture line(S),other gastric site(O),or total remnant stomach(T).Extension into the esoph-agus(E),duodenum(D),or jejunum(J)is recorded. Examples:B-20-S,M-09-AJ.2.1.3Macroscopic types2.1.3.1Basic classification Gross tumor morphology is categorized as either superficial or advanced type.Super-ficial type is typical of T1tumors while T2–4tumors usually manifest as advanced types(Fig.3).Viewed from the mucosal surface,gross tumor appearance is categorized into six types(Table2).Type0is subdivided according to the Macroscopic Classification of Early Gastric Cancer (Sect.2.1.3.2).Although macroscopic type is determined regardless of the depth of tumor invasion,the T category should also be recorded.2.1.3.2Subclassification of Type0(Fig.4,modified from the Japanese Endoscopy Society Classification of1962)Super-ficial tumors with two or more components should have all components recorded in order of the surface area occupied,e.g.0-IIc?III(Table3).2.1.3.3Description of macroscopic type The macro-scopic tumor type should be recorded in both the clinical and pathologicalclassifications.Table1Clinical and pathological classificationClinical classification(c)Pathological classification(c)Physical examination,imagingstudies,endoscopic,laparoscopicand surgicalfindings,biopsy,cytology,biochemical andbiological investigations.Histological examination ofsurgically or endoscopicallyresected specimens;peritoneallavage cytology.Japanese Gastric Cancer Association2.1.4Histological classification(Table4)Where a malignant epithelial tumor consists of more than one histological subtype,the different histological com-ponents should be recorded in descending order of the surface area occupied,e.g.,tub1[pap(see table below).2.1.5Depth of tumor invasion(T)The depth of tumor invasion is recorded as the T-category. Conventional characters denoting depth of tumor invasion are also recorded:M,SM,MP,SS,SE,SI(see below).The prefixes‘‘c’’and‘‘p’’are used in conjunction with the T-category and not with the characters M,SM,etc.(e.g.,a pathologically diagnosed mucosal tumor should be recor-ded as pT1a,not pM).Tumor invasion into the muscularis mucosa is included in the M category.Early gastric cancer comprises of T1tumors irrespective of lymph node metastasis.TX Depth of tumor unknownT0No evidence of primary tumorT1Tumor confined to the mucosa(M)or submucosa (SM)T1a Tumor confined to the mucosa(M)T1b Tumor confined to the submucosa(SM)1T2Tumor invades the muscularis propria(MP)Table3Subclassification of Type0Type0-I(protruding)a Polypoid tumors.Type0-II(superficial)Tumors with or without minimal elevation ordepression relative to the surroundingmucosa.Type0-IIa(superficial elevated)aSlightly elevated tumors.Type0-IIb(superficialflat)Tumors without elevation or depression.Type0-IIc(superficial depressed)Slightly depressed tumors.Type0-III(excavated)Tumors with deep depression.a Tumors with less than3mm elevation are usually classified as0-IIa,with more elevated tumors being classified as0-IType 1MassType 2UlcerativeType 3InfiltrativeulcerativeType 4DiffuseinfiltrativeFig.3Macroscopic types of advanced gastric cancerTable2Macroscopic typesType0(superficial)Typical of T1tumors.Type1(mass)Polypoid tumors,sharply demarcated from thesurrounding mucosa.Type2(ulcerative)Ulcerated tumors with raised marginssurrounded by a thickened gastric wall withclear margins.Type3(infiltrative ulcerative)Ulcerated tumors with raised margins, surrounded by a thickened gastric wall without clear margins.Type4(diffuse infiltrative)Tumors without marked ulceration or raised margins,the gastric wall is thickened and indurated and the margin is unclear.Type5 (unclassifiable)Tumors that cannot be classified into any of theabove types.Type 0-IProtrudingType 0-IISuperficialType 0-IIIExcavatedType 0Superficial, flatType 0-IIaSup. elevatedType 0-IIbSup. flatType 0-IIcSup. depressedFig.4Subclassification of Type01SM may be subclassified as SM1or T1b1(tumor invasion is within0.5mm of the muscularis mucosae)or SM2or T1b2(tumor invasionis0.5mm or more deep into the muscularis mucosae).Japanese classification of gastric carcinomaTable4Histological classification of gastric tumorsBenign epithelial tumor ICD-O code Adenoma8140/0 Malignant epithelial tumorCommon typePapillary adenocarcinoma(pap)8260/3 Tubular adenocarcinoma(tub)8211/3 Well-differentiated(tub1)Moderately differentiated(tub2)Poorly differentiated adenocarcinoma(por)Solid type(por1)Non-solid type(por2)Signet-ring cell carcinoma(sig)8490/3 Mucinous adenocarcinoma(muc)8489/3 Special typeCarcinoid tumor8240/3 Endocrine carcinoma8401/3 Carcinoma with lymphoid stromaHepatoid adenocarcinomaAdenosquamous carcinoma8560/3 Squamous cell carcinoma8070/3 Undifferentiated carcinoma8020/3 Miscellaneous carcinomaNon-epithelial tumorGastrointestinal stromal tumor(GIST)8396/0,1,3 Smooth muscle tumor8890/0,3 Neurogenic tumor9560/9580/0 Miscellaneous non-epithelial tumorsLymphomaB-cell lymphomaMALT(mucosa-associatedlymphoid tissue)lymphoma9699/3 Follicular lymphoma9690/3 Mantle cell lymphoma9673/3 Diffuse large B-cell lymphoma9680/3 Other B-cell lymphomasT-cell lymphomaOther lymphomasMetastatic tumorTumor-like lesionHyperplastic polypFundic gland polypHeterotopic submucosal glandHeterotopic pancreasInflammatoryfibroid polyp(IFP)Gastrointestinal polyposisFamilial polyposis coli,Peutz–Jegherssyndrome,juvenile polyposis,Cowden’s diseaseOthers Table5Anatomical definitions of lymph node stationsNo.Definition1Right paracardial LNs,including those along thefirst branch of the ascending limb of the left gastric artery.2Left paracardial LNs including those along theesophagocardiac branch of the left subphrenic artery3a Lesser curvature LNs along the branches of the left gastric artery3b Lesser curvature LNs along the2nd branch and distal part of the right gastric artery4sa Left greater curvature LNs along the short gastric arteries (perigastric area)4sb Left greater curvature LNs along the left gastroepiploic artery (perigastric area)4d Rt.greater curvature LNs along the2nd branch and distal part of the right gastroepiploic artery5Suprapyloric LNs along the1st branch and proximal part of the right gastric artery6Infrapyloric LNs along thefirst branch and proximal part of the right gastroepiploic artery down to the confluence of the rightgastroepiploic vein and the anterior superiorpancreatoduodenal vein7LNs along the trunk of left gastric artery between its root and the origin of its ascending branch8a Anterosuperior LNs along the common hepatic artery8p Posterior LNs along the common hepatic artery9Celiac artery LNs10Splenic hilar LNs including those adjacent to the splenic artery distal to the pancreatic tail,and those on the roots of the shortgastric arteries and those along the left gastroepiploic arteryproximal to its1st gastric branch11p Proximal splenic artery LNs from its origin to halfway between its origin and the pancreatic tail end11d Distal splenic artery LNs from halfway between its origin and the pancreatic tail end to the end of the pancreatic tail12a Hepatoduodenal ligament LNs along the proper hepatic artery, in the caudal half between the confluence of the right and lefthepatic ducts and the upper border of the pancreas12b Hepatoduodenal ligament LNs along the bile duct,in the caudal half between the confluence of the right and lefthepatic ducts and the upper border of the pancreas12p Hepatoduodenal ligament LNs along the portal vein in the caudal half between the confluence of the right and lefthepatic ducts and the upper border of the pancreas13LNs on the posterior surface of the pancreatic head cranial to the duodenal papilla14v LNs along the superior mesenteric vein15LNs along the middle colic vessels16a1Paraaortic LNs in the diaphragmatic aortic hiatus16a2Paraaortic LNs between the upper margin of the origin of the celiac artery and the lower border of the left renal vein16b1Paraaortic LNs between the lower border of the left renal vein and the upper border of the origin of the inferior mesentericarteryJapanese Gastric Cancer AssociationT3Tumor invades the subserosa(SS)T4Tumor invasion is contiguous to or exposed beyond the serosa(SE)or tumor invades adjacent structures(SI)T4a Tumor invasion is contiguous to the serosa or penetrates the serosa and is exposed to theperitoneal cavity(SE)2T4b Tumor invades adjacent structures(SI).32.1.6Cancer stromal volume,infiltrative pattern,and capillary invasion2.1.6.1Cancer stromal volume(to be recorded for T1b or deeper tumors)Medullary type(med):Scanty stromaScirrhous type(sci):Abundant stromaIntermediate type(int):The quantity of stroma is intermediate between the two above types.2.1.6.2Tumor infiltrative(INF)pattern into the surrounding tissues(to be recorded in T1b or deeper tumors;Fig.5) INFa Tumor displays expanding growth with a distinct border from the surrounding tissueINFb Tumor shows an intermediate pattern between INFa and INFcINFc Tumor displays infiltrative growth with no distinct border with the surrounding tissue.2.1.6.3Capillary invasion42.1.6.3.1Lymphatic invasion(ly)ly0:No lymphatic invasionly1:Minimal lymphatic invasionly2:Moderate lymphatic invasionly3:Marked lymphatic invasion2.1.6.3.2Venous invasion(v)v0:No venous invasionv1:Minimal venous invasionv2:Moderate venous invasionv3:Marked venous invasion2.2Lymph node metastasis2.2.1Anatomical definition of lymph nodes and lymphnode regions(Figs.6,7)The lymph nodes(LNs)of the stomach are defined and given station numbers,as shown in Table5and Figs.7,8,9.Lymph node stations1–12and14v are defined as regional gastric lymph nodes;metastasis to any other nodes is classified as M1. In tumors invading the esophagus,lymph node numbers19, 20,110,and111are included as regional lymph nodes.For carcinomas arising in the remnant stomach with a gastroje-junostomy,jejunal lymph nodes adjacent to the anastomosis are included as regional lymph nodes.Please refer to the ‘‘Gastric Cancer Treatment Guidelines’’[1]for a detailed account of which lymph nodes are to be dissected in gastric resection with curative intent.2.2.2Recording of lymph node metastasisFor surgical resection specimens,the total number of lymph nodes and the number of involved lymph nodes at each nodal station are recorded.When a tumor nodule without histological evidence of lymph node structure is found in the lymphatic drainage area of the primary tumor, it is recorded as extranodal metastasis and counted as a metastatic lymph node in the pNdetermination.Fig.5Tumor infiltrative(INF)patternTable5continuedNo.Definition16b2Paraaortic LNs between the upper border of the origin of the inferior mesenteric artery and the aortic bifurcation17LNs on the anterior surface of the pancreatic head beneath the pancreatic sheath18LNs along the inferior border of the pancreatic body19Infradiaphragmatic LNs predominantly along the subphrenic artery20Paraesophageal LNs in the diaphragmatic esophageal hiatus 110Paraesophageal LNs in the lower thorax111Supradiaphragmatic LNs separate from the esophagus112Posterior mediastinal LNs separate from the esophagus and the esophageal hiatus2Tumor extending into the greater or lesser omentum without visceral peritoneal perforation is classified as T3.3Invaded adjacent structures should be recorded.The adjacent structures of the stomach are the liver,pancreas,transverse colon, spleen,diaphragm,abdominal wall,adrenal gland,kidney,small intestine,and retroperitoneum.Serosal invasion with involvement ofthe greater and lesser omentum is classified as T4a,not T4b.Invasion of the transverse mesocolon is not T4b unless it extends to the colic vessels or penetrates the posterior surface of the mesocolon.4In endoscopically resected specimens,capillary invasion is recorded as ly(-)or ly(?),and v(-)or v(?).Japanese classification of gastric carcinoma2.2.2.1Lymph node metastasis (N)NX:Regional lymph nodes cannot be assessed N0:No regional lymph node metastasis N1:Metastasis in 1–2regional lymph nodes N2:Metastasis in 3–6regional lymph nodesN3:Metastasis in 7or more regional lymph nodes N3a:Metastasis in 7–15regional lymph nodesN3b:Metastasis in 16or more regional lymph nodes Although it is not a prerequisite,the examination of 16or more regional lymph nodes is recommended for N status determination.2.2.2.2Metastatic ratio of lymph nodes The metastatic ratio is the ratio of metastatic nodes to the total number ofACM A. colica mediaAGB Aa. Gastricae brevesAGES A. gastroepiploica sinistra AGP A. gastrica posterior AHC A. hepatica communis AJ A. jejunalisAPIS A. phrenica inferior sinistra TGC Truncus gastrocolicus VCD V. colica dextraVCDA V. colica dextra accessoria VCM V. colica mediaVGED V. gastroepiploica dextra VJ V. jejunalis VL V. lienalisVMS V. mesenterica superior VPV. portaeVPDSAV. pancreaticoduodenalissuperior anteriorFig.6Location of lymph nodestationsFig.7Location of lymph nodes in the esophageal hiatus and in the infradiaphragmatic and paraaortic regionsJapanese Gastric Cancer Associationdissected nodes and is recorded for each nodal station for all regional lymph nodes.2.3Distant metastasisMetastasis to sites other than regional lymph nodes (distant metastasis)is M1disease.In addition,perito-neal metastasis,peritoneal lavage cytology,and hepatic metastasis may be described by the conventional sym-bols P,CY,and H,respectively (see below).Positive peritoneal lavage cytology is recorded as cy ?by the International Union Against Cancer (UICC)/TNM system.2.3.1Presence or absence and sites of distantmetastasis (M)MX:Distant metastasis status unknown M0:No distant metastasis M1:Distant metastasisSites of metastasis are recorded using the follow-ing notation:LYM (lymph nodes),SKI (skin),PUL (lung),MAR (bone marrow),OSS (bone),PLE (pleura),BRA (brain),MEN (meninx),ADR (adrenal),OTH (others)52.3.2Peritoneal metastasis (P)PX:Peritoneal metastasis is unknown P0:No peritoneal metastasis P1:Peritoneal metastasis.2.3.3Peritoneal lavage cytology (CY)CYX:Peritoneal cytology not performedCY0:Peritoneal cytology negative for carcinoma cells CY1:Peritoneal cytology positive for carcinoma cells A macroscopically curative resection with CY1is R1.2.3.4Hepatic metastasis (H)HX:Hepatic metastasis is unknown H0:No hepatic metastasis H1:Hepatic metastasis.2.4StagegroupingFig.8Histological evaluation criteria of tumor response after preoperative therapy5Other sites include retroperitoneal carcinomatosis and the ovaries (Krukenberg).Japanese classification of gastric carcinoma3Treatment evaluation3.1Evaluation after surgical or endoscopic resection3.1.1Surgical specimen resection margin3.1.1.1Proximal margin(PM)PMX Involvement of the proximal margin cannot be assessedPM0No involvement of the proximal marginPM1Involvement of the proximal margin.3.1.1.2Distal margin(DM)DMX Involvement of the distal margin cannot be assessed DM0No involvement of the distal marginDM1Involvement of the distal margin.3.1.2Resection margin of the endoscopic resection specimen 3.1.2.1Horizontal margin(HM)HMX Involvement of the horizontal margin cannot be assessedHM0No involvement of the horizontal marginHM1Involvement of the horizontal margin.3.1.2.2Vertical margin(VM)VMX Involvement of the vertical margin cannot be assessed VM0No involvement of the vertical marginVM1Involvement of the vertical margin.3.1.3Residual tumor(R)The presence or absence of residual tumor after surgery is described as the R status;R0is a curative resection with neg-ative resection margins;R1and R2are non-curative resections. RX Presence of residual tumor cannot be assessedR0No residual tumorR1Microscopic residual tumor(positive resection margin or CY1)R2Macroscopic residual tumor.3.2Tumor evaluation after preoperative treatment3.2.1Description of tumor classificationafter preoperative treatmentTumor classification after preoperative chemotherapy or chemoradiotherapy is designated by the prefix‘y’.The clinical classification following preoperative treatment is designated ycTNM and the pathological classification yp-TNM.The ycTNM and ypTNM classification describes the extent of tumor actually present at the time of that exam-ination;it is not an estimate of the extent of tumor prior to preoperative therapy.Only viable tumor cells are taken into account when calculating ypTNM.Signs of tumor regres-sion,including scars,areas offibrosis,granulation tissue,or mucin lakes are not taken into consideration.For example:A large adenocarcinoma with computed tomography(CT)evidence of serosal irregularity and lymph node metastasis was classified as cT4aN1M0.Pre-operative chemotherapy achieved significant tumor regression,with the tumor being undetectable by endos-copy and CT(ycT0N0M0).Gastrectomy was performed and histological examination revealed viable carcinoma cells in the muscularis propria and in two regional lymph nodes;granulation tissue with mucin lakes was present in five other lymph nodes(ypT2N1M0).3.2.2Histological evaluation criteria of tumor responseafter preoperative therapy(Fig.8)The histological response of the primary tumor should be evaluated in the section where the tumor is thought to have been located at the pretreatment assessment and in the sec-tions where tumor cells are likely to remain.Viable tumor cells are defined as cells which are judged to be capable of proliferation.Grade0(no effect)No evidence of effectGrade1(slight effect)Grade1a(very slight effect)Viable tumor cellsoccupy more than2/3of the tumorous areaGrade1b(slight effect)Viable tumor cells remain inmore than1/3but less than2/3of the tumorous areaGrade2(considerable effect)Viable tumor cells remainin less than1/3of thetumorous areaGrade3(complete response)No viable tumor cellsremain.It is recommendedthat thefinding is confirmedon additional sectioning.3.3Response evaluation of chemotherapyand radiotherapyTumor response to chemotherapy and/or radiotherapy is assessed using the Response Evaluation Criteria in Solid Tumors(RECIST)version1.1[2].Japanese Gastric Cancer AssociationThe Japanese Gastric Cancer Association(JGCA) developed an original method to evaluate the response of the primary gastric lesion to chemotherapy or radiotherapy [3],but it was not widely used,mainly because of technical difficulties.In the RECIST,primary gastric tumors are regarded as non-target lesions and endoscopic diagnosis is not recommended as an objective evaluation.However,the response of the primary tumor is clinically important and the JGCA methods may provide useful information in future neoadjuvant trials.The results of response evalua-tion of the primary tumor made by the following methods can be recorded and used as information that is additional to the RECIST results in some trial settings.3.3.1JGCA response evaluation of primary tumorTumor response,morphological changes,and efficacy are evaluated by double-contrast barium meal study and/or endoscopic examination of the following three types of primary lesions.3.3.1.1Measurable lesions(a-lesions)Reduction rate= (longest diameter before therapy-longest diameter after therapy)/longest diameter before therapy.3.3.1.2Evaluable but not measurable lesions(b-lesions)(i)Describe changes in protruded lesions as follows:Progression,no change,regression,flattening,or disappearance (ii)Describe changes in excavated lesions as follows:•Raised margin:progression,no change,regres-sion,flattening,or disappearance•Crater:progression,no change,regression,flat-tening,or disappearance.3.3.1.3Diffusely infiltrating lesions(c-lesions)[3]In diffusely infiltrating tumors(type4),treatment response may be evaluated by expansion of the gastric lumen.In principle,the squares of the lesion shown with standing barium X-ray examination are compared before and after therapy,at the same position with the same volume of barium,and the enlargement rate is calculated.Enlargement rate=(product calculated before ther-apy)-(product calculated after therapy)/(product calcu-lated before therapy)9100%3.3.1.4Definition of response in primary lesion •Complete response(CR)Disappearance of all tumor lesions and no diagnosis of carcinoma.Biopsy specimens are negative for carcinoma.•Partial response(PR)a-lesions:At least a30%decrease in total sizeb-lesions:Remarkable regression andflattening of atumor on X-ray/endoscopic examinations,whichroughly corresponds to at least a50%decrease intumor size.c-lesions:At least50%enlargement of the gastriclumen in the area of the lesions by X-ray examination.•Stable disease(SD)Changes in tumor size or shape are less than PR,but are not progressive disease(PD). Japanese classification of gastric carcinoma•Progressive disease(PD)Increase in tumor size and/or worsening of the shape (20%or more increase in a-lesions),or new intragastric lesions.4Handling of the resected specimen4.1Description offindingsPathologicalfindings are recorded when the following conditions are met.(a)The whole resected stomach is macroscopicallyobserved.(b)The representative sections of the whole resectedstomach including the carcinoma are microscopically examined.4.2Preparation of the resected stomachAfter gross inspection and measurement of any serosal tumor involvement(Fig.9),the stomach is,in principle,opened along the greater curvature.On examination from the mucosal side,the tumor size and the length of the proximal and distal resection margins are measured(Fig.10).4.3Fixation of the resected stomachAfter dissection of the lymph nodes from the specimen,the stomach is placed on aflat board with the mucosal side up, pinned at the edges with stainless steel pins,andfixed in a 10%buffered formalin solution.A relatively shortfixation time(48h)is recommended for additional immunohisto-chemical or genetic examinations in the future.4.4Sectioning of the stomachFirstly a section is taken along the lesser curvature as a reference line to assess background mucosal changes.In Type0superficial tumors,a set of sections parallel to the reference line should be made at5-to7-mm intervals (Fig.11).In advanced tumors,the area of deepest invasion should be sectioned parallel to the reference line.If there is concern about tumor margins,additional sections should be taken(Fig.12).In multiple tumors or tumors of unusual configuration,suitable sectioning to obtain accuratefind-ings must be devised on a case-by-case basis.The carci-noma in a remnant stomach should be sectioned taking into account its relationship with the suture line and anastomosis.4.5Sectioning of lymph nodesEach dissected lymph node should be studied individually. The plane of largest dimension of the node including the hilus should be sectioned.4.6Handling of endoscopically resected specimensA single resection procedure performed for a single lesion is defined as‘‘en-bloc resection’’,and multiple resection procedures for a single lesion are defined as‘‘piecemeal resection’’.4.6.1Fixation,inspection,and sectioningThe specimen is spread out,pinned on aflat board,and fixed in10%buffered formalin solution.The size ofthe Japanese Gastric Cancer Association。

【疾病名】胃癌【英文名】gastric cancer【缩写】【别名】carcinoma of stomach；stomach cancer【ICD号】C16.9【概述】胃癌是源自胃黏膜上皮的恶性肿瘤，占全部恶性肿瘤的第3位，占消化道恶性肿瘤的首位，占胃恶性肿瘤的95%。

可见胃癌是威胁人类健康的一种常见病。

【流行病学】胃癌的发病情况在不同国家和不同地区相差悬殊，高的可超过100/10万，低的则不足10/10万。

在世界各国中，日本、智利、哥斯达黎加和匈牙利为高发地区，而非洲、北美洲许多地区以及印度和印度尼西亚等国，胃癌的发病率较低。

近年来许多资料表明，世界各国包括日本在内的许多高发区国家的胃癌发生率及病死均有下降的趋势，随着经济的发展、人们生活水平的提高、饮食结构的改善，胃癌的发病率及病死率仍将进一步下降。

我国胃癌男女性病死率为20.9/10万和10.2/10万，分别占所有恶性肿瘤死亡的26.1%和18.7%，在世界范围内属于高发水平地区。

西北地区发病率最高，青海、宁夏、甘肃三省的胃癌病死率均超过35/10万，病死率为20/10万～30/10万的则有西藏、辽宁、吉林、江苏、上海、浙江和福建等地区。

四川、湖南、云南、贵州、广东和广西等地的胃癌病死率则不足10/10万。

1998年上海胃癌的男女性发病率分别为50.59/10万和31.98/10万，占所有恶性肿瘤死亡的16.68%和13.95%。

胃癌的发病年龄符合于癌肿的一般规律，即大多数发生在中年以后，多见于40～60岁，平均年龄约为50岁，仅5%的患者年龄是在30岁以下。

以性别而论，胃癌在男性较女性为常见，国外男女胃癌的发病比例不到2∶1，而我国为1.5∶1～2.5∶1。

【病因】胃癌的病因迄今尚未完全阐明，有些因素对胃癌的发生可能有一定影响，系综合因素所致。

1.遗传因素 临床工作者多曾遇到一个家族中两个以上的成员患有胃癌的情况，这种好发胃癌的倾向。

胃癌诊疗规范（2018年版）一、概述胃癌（Gastric Carcinoma）是指原发于胃的上皮源性恶性肿瘤。

在我国胃癌发病率仅次于肺癌居第二位，死亡率排第三位。

全球每年新发胃癌病例约120万，中国约占其中的40%。

我国早期胃癌占比很低，仅约20%，大多数发现时已是进展期，总体5年生存率不足50%。

近年来随着胃镜检查的普及，早期胃癌比例逐年增高。

胃癌治疗的总体策略是以外科为主的综合治疗，为进一步规范我国胃癌诊疗行为，提高医疗机构胃癌诊疗水平，改善胃癌患者预后，保障医疗质量和医疗安全，特制定本规范。

本规范所称的胃癌是指胃腺癌（以下简称胃癌），包括胃食管结合部癌。

二、诊断应当结合患者的临床表现、内镜及组织病理学、影像学检查等进行胃癌的诊断和鉴别诊断。

（一）临床表现早期胃癌患者常无特异的症状，随着病情的进展可出现类似胃炎、溃疡病的症状，主要有：①上腹饱胀不适或隐痛，以饭后为重；②食欲减退、嗳气、返酸、恶心、呕吐、黑便等。

进展期胃癌除上述症状外，常出现：①体重减轻、贫血、乏力。

②胃部疼痛，如疼痛持续加重且向腰背放射，则提示可能存在胰腺和腹腔神经丛受侵。

胃癌一旦穿孔，可出现剧烈腹痛的胃穿孔症状。

③恶心、呕吐，常为肿瘤引起梗阻或胃功能紊乱所致。

贲门部癌可出现进行性加重的吞咽困难及反流症状，胃窦部癌引起幽门梗阻时可呕吐宿食。

④出血和黑便，肿瘤侵犯血管，可引起消化道出血。

小量出血时仅有大便潜血阳性，当出血量较大时可表现为呕血及黑便。

⑤其他症状如腹泻（患者因胃酸缺乏、胃排空加快）、转移灶的症状等。

晚期患者可出现严重消瘦、贫血、水肿、发热、黄疸和恶病质。

（二）体征一般胃癌尤其是早期胃癌，常无明显的体征，进展期乃至晚期胃癌患者可出现下列体征：①上腹部深压痛，有时伴有轻度肌抵抗感，常是体检可获得的唯一体征。

②上腹部肿块，位于幽门窦或胃体的进展期胃癌，有时可扪及上腹部肿块；女性患者于下腹部扪及可推动的肿块，应考虑Krukenberg瘤的可能。

重庆医科大学附属第一医院The First Affiliated Hospital, Chongqing Medical University手术记录姓名：刘圣文住院号601833日期 2009年 5月 11日 16：00时术前诊断：胃癌（gastric carcinoma）术后诊断：胃癌（gastric carcinoma）手术名称：胃癌根治术（远端胃大部切除＋D2），毕Ⅰ氏吻合。

手术人员：主刀：朱明才二助手：邓宁洗手护士：秦艳一助手：吴松三助手：万幸麻醉师：王萍麻醉方式：静脉复合麻醉。

麻醉效果：好。

更改麻醉情况：无术中所见：肿瘤位于幽门后壁，约3.5*3.5*3.0cm大小，6组淋巴结数枚肿大，大小不等，最大约2.0*1.5cm。

肝脏、十二指肠、结肠、胰腺、腹主动脉旁、腹壁及盆腔等无转移性结节。

手术经过：1.全麻下，常规消毒铺巾。

取上腹部正中由剑突至脐下2cm切口，逐层进腹,探查腹腔，如术中所见。

拟行根治性远端胃大部切除术。

2．在横结肠上缘锐性切开胃结肠韧带，将横结肠系膜前叶剥离至胰腺下缘，清除14V淋巴结。

再分离胰腺包膜至胰腺上缘。

3．游离胃网膜右血管根部，于胃网膜右动脉、静脉根部离断结扎，清除第6组淋巴结。

4．沿幽门上分离胃右动脉，于其根部离断，清除周围淋巴结。

游离十二指肠上段约3cm，切断十二指肠后，十二指肠残端予丝线间断缝合浆肌层缝合包埋完好。

5.在肝下缘切开小网膜，裸化肝动脉、肝总动脉、脾动脉、腹腔动脉、胃左动脉根部，清除血管旁淋巴结,于胃左动脉根部切断，其残端予以结扎＋缝扎；同法处理胃左静脉。

6.沿食道右侧向下清除食道右侧及胃底体小弯侧组织。

沿胃大弯侧脾门处离断胃网膜左血管，残端予以结扎。

距肿瘤上缘5cm切断胃体移出标本，小弯侧用闭合器闭合。

7．十二指肠残端缝荷包，吻合器经胃残端置入从胃后壁与十二指肠吻合完好，并加浆肌层缝合数针加强，胃管放过吻合口。

胃残端用闭合器关闭，并加浆肌层缝合。