Diagnosis and treatment of gastric cancer (2011 Edition)I. overviewGastric cancer is one of the most common malignant tumors in China. In 20
Diagnosis and treatment of gastric cancer (2011 Edition)
Gastric cancer is one of the most common malignant tumors in China. In 2010, the health statistics yearbook shows that in the year of 2005, the mortality rate of gastric cancer accounts for third of the mortality rate of malignant tumors in china. The occurrence of gastric cancer is the result of multiple factors. There are significant regional differences in the incidence of gastric cancer in China, and environmental factors play a dominant role in the occurrence of gastric cancer. Studies have shown that Helicobacter pylori (Helicobacter pylori, H.pylori) infection, diet, smoking and host genetic susceptibility is an important factor affecting the occurrence of gastric cancer.
In order to further standardize the diagnosis and treatment of gastric cancer in our country, improve the level of diagnosis and treatment of gastric cancer in medical institutions, improve the prognosis of patients with gastric cancer, and ensure the quality of medical care and medical safety, this code has been formulated. Mentioned in this specification refers to the gastric adenocarcinoma (hereinafter referred to as the gastric cancer), including adenocarcinoma of the esophagogastric junction.
The diagnosis and differential diagnosis of gastric cancer should be combined with the clinical manifestations, endoscopic and histopathological and imaging examinations.
(a) clinical manifestations. Gastric cancer is lack of specific clinical symptoms. The most common symptoms are abdominal discomfort or pain, loss of appetite, weight loss, fatigue, nausea, vomiting, hematemesis or melena, fever, diarrhea, constipation etc..
(two) signs. There were no obvious signs of early or partial advanced gastric cancer. Patients with advanced gastric cancer may be palpable abdominal mass, the occurrence of distant metastasis, according to the transfer site, there may be signs. When the upper digestive tract perforation, bleeding or obstruction of the digestive tract, etc., can appear corresponding signs.
(three) auxiliary examination.
(1) gastroscopy: the means of diagnosis of gastric cancer must be checked, the location of the tumor can be determined, and the pathological examination can be obtained. If necessary, select the use of pigment endoscopy or magnifying endoscopy.
(2) endoscopic ultrasonography (EUS) is helpful for evaluating the depth of gastric cancer invasion and judging the status of lymph node metastasis. It is necessary to carry out the examination of endoscopic mucosal resection (EMR) and endoscopic submucosal resection (ESD).
(3) laparoscopy: laparoscopy may be considered in patients with suspected peritoneal metastasis or peritoneal dissemination.
2 histopathological diagnosis.
Histopathological diagnosis is the basis for diagnosis and treatment of gastric cancer. Standardized treatment for patients with biopsy proven invasive carcinoma. As a result of biopsy limit, biopsy can not determine the depth of invasion, reported as precancerous lesions or suspected invasive patients suggest repeated biopsy or examination results combined with the image, further confirmed after treatment.
(1) gastroscope biopsy specimen processing.
The preliminary treatment of the specimen: after the specimen was taken out of the body, the specimen was immediately flattened, and the basal layer of the mucosa was attached to the filter paper.
The specimens were fixed in buffered formalin: 10%-13%. Before embedding the fixed time must be greater than 6 hours, less than 48 hours.
Paraffin embedding: remove the filter paper and embed the tissue vertically.
The HE production standards: dressing wax block, requiring continuous cut to 6 ~ 8 for organization, on the same slides. Routine HE staining, mounting.
(2) pathological diagnostic criteria.
Low grade intraepithelial tumor mucosa gland structure and morphology showed mild atypia, compared with the surrounding normal glands, glands densely arranged pseudostratified glandular cells appear, no or minimal mucus, strong nuclear staining, nuclear division phase.
High grade intraepithelial tumor mucosa gland structure and morphology showed severe atypia (epithelial carcinoma in situ), compared with the surrounding normal glands, gland gland cells arranged densely, and very significant to the disorder, common wall and cribriform structure further appear in the low level of intraepithelial tumor based on the lack of the secretion of mucus, mitotic activity, showing focal necrosis, but no interstitial infiltration.
Mucosal carcinoma: the infiltration of cancer in the mucosa, irregular glandular epithelial cell nests or isolated glandular epithelial cells infiltrated the lamina propria of the mucosa, confined to the muscularis mucosae.
The submucosal carcinoma: intramucosal invasive cancer continue to penetrate deep infiltration, muscularis mucosa to submucosa, muscularis propria not invaded and stomach.
The early gastric cancer (T1N0/1M0): including mucosal and submucosal invasive carcinoma infiltrating carcinoma, with or without evidence of lymph node metastasis.
(3) pathological evaluation.
Standard for fixation of tissue specimens.
Fixed liquid: recommend the use of 10%-13% neutral formalin fixed, avoid the use of liquid containing heavy metals.
Fixed amount of liquid: must be greater than 10 times the volume of fixed specimens.
Fixed temperature: normal room temperature.
Fixed time: endoscopic biopsy specimens or mucosal resection specimens: greater than 6 hours, less than 48 hours. Gastric resection specimens: along the greater curvature of the stomach section to carry out level fixed, fixed time limit for more than 12 hours, less than 48 hours.
A. biopsy specimen.
Check the number of clinical specimens, from biopsy specimens must be drawn. Each wax block contains no more than 5 biopsy specimens. The specimens were wrapped in gauze or soft permeable paper to avoid loss.
B. endoscopic mucosal resection specimen.
Specimens by surgeons flat fixed range marker. The size of the tumor was recorded, and the distance from the incisal margin. Vertical to the wall, every 0.3cm specimens were cut into parallel, suitable block size of organization, recommended by the same embedding direction of all materials. Record the orientation of the tissue block.
C. gastrectomy specimens (gross examination records description see Appendix 1).
A. and tumor margin of tumor were fully considered, tumor size, infiltration depth, different texture and color areas are conventional materials, more than 4 blocks containing tumor, tumor infiltration depths 1-2 block the whole thickness of tumor, to determine the most deep-seated tumor invasion. The relationship between tumor and adjacent normal tissues was observed in the tumor adjacent to the 1-2 block. The distal and proximal surgical margins were cut, and at least 1. Based on principles of early cancer cut all surgical specimen producers shall be attached to organization Pictorial marking the location of the block, to visit or consultation reference.
B. lymph node: suggest surgeons according to the local anatomy and surgery, packet inspection lymph node, is conducive to the lymphatic drainage area of the location; before receiving the packet inspection orders or surgeon mark, pathologists in accordance with the following principles of specimens in lymph nodes: all lymph nodes were to be drawn, suggestions the total number of lymph nodes before surgery did not receive treatment cases should be more than 15 pieces. All visible negative lymph nodes should be complete submission, the naked eye positive lymph nodes can cut part inspection.
C. recommended tissue volume: not more than 2 x 1.5 x 0.3cm.
The principle and retention time of sample after D..
The remaining specimens were preserved A.: residual tissue preservation in fixed standard solution, and always maintain full fixed liquid volume and the concentration of formaldehyde, avoid dry specimens or because of insufficient or fixed liquid concentration decreased from decaying tissue for microscopic observation, according to the requirement of diagnosis at any time supplementary materials, or in pathological diagnosis after receiving the report issued by the clinical feedback information of specimen or supplementary materials review.
B. processing time: the rest were suggested in the pathological diagnosis report issued after 1 months, has not received the clinical feedback information, does not occur due to outside the hospital consultation opinions for review and other circumstances, can be handled by the hospital.
(4) pathological type.
General types of early gastric cancer.
Surface uplift type A
B: flat type
Surface depression type C
General types of advanced gastric cancer.
Bulge type: the main body of the tumor protruding into the lumen.
Ulcer type: tumor or through deep muscular layer with ulcer.
Infiltration type: the tumor infiltrating to the intestinal wall, so that the local intestinal wall thickening, but the surface is often no obvious ulcer or uplift.
A.WHO classification: the most common type of gastric cancer (2).
B.Lauren classification: intestinal type, diffuse type, mixed type.
(5) pathology report.
The pathological report of A. biopsy specimen must include the following:
A. basic information and submission of patient information;
B. intraepithelial neoplasia (dysplasia), grading report;
C. suspected invasion: repeat biopsy, if necessary, should be identified by immunohistochemical staining;
Early invasive carcinoma of D.: depth of invasion.
Clinicians should be aware of the depth of biopsy and biopsy may be difficult to determine the actual depth of invasion.
B. endoscopic mucosal resection specimen pathology report must include the following:
A. basic information and submission of patient information;
B. tumor size;
C. intraepithelial neoplasia (dysplasia) classification;
D. should be used to report the histological type, grade, depth of invasion, margin and vascular invasion of invasive carcinoma.
PT1 should be treated with surgical resection to improve the extent of resection of the poorly differentiated carcinoma. In other cases, endoscopic resection is sufficient, but postoperative follow-up is required.
The histological features of poor prognosis include: low differentiation, vascular, lymphatic invasion, positive margin.
The positive incisal margin was defined as: the distance between the tumor and the resection margin was less than 1mm or the cutting edge could be seen in the cancer cells.
The pathological report of C. surgical resection specimens must include the following:
A. basic information and submission of patient information;
B.: tumor location, size, gross type, depth of invasion, the distance between the upper and lower margins and the tumor;
C. tumor differentiation (tumor type, grade);
D. depth of tumor invasion (T stage, T stage, or pT) was determined according to the morphological basis of the tumor cells. There was no cell mucus Lake in the newly treated specimens, and it was not considered to be residual tumor (TNM staging criteria see Annex 3);
E. detection of the number of lymph nodes and the number of positive lymph nodes (N stage);
The condition of proximal and distal margin of f.. If the tumor is close to the margin, the distance between the tumor and the margin should be measured under the microscope, and the margin of the tumor is within the margin of 1mm;
G. vascular and perineural invasion;
H. is helpful in the differential diagnosis and guidance of clinical treatment of special examination, including immunohistochemistry and molecular pathology detection, such as HER-2 detection.
The clinician must fill in the application form of pathological diagnosis in detail, describe the results of the operation and related clinical examination results, and make clear the lymph nodes.
3 laboratory examination.
(1) blood tests: blood routine, blood biochemistry, serum tumor marker examination.
(2) urine, stool, fecal occult blood test.
4 imaging examination.
(1) computed tomography (CT): CT scan and enhanced scan has important value in the evaluation of gastric cancer lesions, lymph node metastasis and distant metastasis status, should be used as the conventional method of preoperative staging of gastric cancer. In the absence of contrast agent contraindications, it is recommended to perform enhanced CT scanning in the presence of a good filling condition. The site should include the primary site and the site of metastasis.
(2) magnetic resonance imaging (MRI): MRI examination is one of the most important imaging methods. Recommended use of CT contrast agent allergy or other imaging tests for suspected metastases. MRI helps determine the status of peritoneal metastases, as appropriate.
(3) upper gastrointestinal contrast: it is helpful to determine the scope and function of primary gastric lesions, especially the double contrast radiography of air barium is one of the common imaging methods for the diagnosis of gastric cancer. Use of water-soluble contrast agents in patients with suspected pyloric obstruction.
(4) the chest X-ray examination should include: the positive side phase, can be used to evaluate whether the presence of lung metastases and other obvious pulmonary lesions, the lateral view is helpful to find the heart shadow lesions.
(5) ultrasonography: it is valuable for the evaluation of local lymph node metastasis and superficial metastasis of gastric cancer. Transabdominal ultrasonography can be used to understand the patient's abdominal cavity and pelvic cavity metastasis, especially contrast-enhanced ultrasound is helpful to identify the nature of the lesion.
(6) PET-CT: not recommended for routine use. Metastatic lesions that cannot be identified by conventional imaging studies may be used as appropriate.
(7) bone scan: not recommended for routine use. Bone scan may be considered in patients with suspected bone metastases.
Four, differential diagnosis
(a) benign diseases: gastric cancer has no characteristic symptoms and signs, and gastric ulcer, gastric polyps (adenomatous polyp or adenoma), giant gastric folds disease, hypertrophic gastritis, Verrucous Gastritis, gastric mucosa prolapse, gastric varices, granuloma and other benign lesions identified by.
(two) other malignant tumors of the stomach, which were mainly associated with gastric malignant lymphoma, gastric stromal tumor and gastric neuroendocrine tumor. Identification of primary liver cancer with liver metastasis.
(I) treatment principle.
We should take comprehensive treatment principle, according to the pathological types and clinical stages, combined with the general condition of patients and organ function, take multidisciplinary treatment (multidisciplinary team MDT) mode, planning and reasonable application of surgery, chemotherapy, radiotherapy and targeted therapy, cured or greatly control of tumor, prolong the survival time of the patients, improve the quality of life for the purpose.
1 early gastric cancer and no evidence of lymph node metastasis, according to the depth of tumor invasion, consider endoscopic treatment or surgical treatment, postoperative adjuvant radiotherapy or chemotherapy.
2 patients with advanced gastric cancer or early gastric cancer with lymph node metastasis should be treated by surgery. According to the depth of tumor invasion and the presence of lymph node metastasis, radical surgery or neoadjuvant chemotherapy before surgery may be considered. The successful implementation of radical surgery for locally advanced gastric cancer should be based on the pathological staging of the tumor.
3 recurrent / metastatic gastric cancer drug treatment should be taken to comprehensive treatment means, given palliative surgery, radiation therapy, interventional therapy, radiofrequency treatment of local treatment at the right time, but also should be given pain, stenting, nutritional support and other supportive treatment.
(two) surgical treatment.
1 principles of surgical treatment.
Surgical resection is the main treatment for gastric cancer. The operation of gastric cancer is divided into radical operation and palliative operation. Radical gastrectomy for gastric cancer includes EMR, ESD, D0 and D1 resection for early gastric cancer, partial advanced gastric cancer (D2) and extended surgery (D2+). Gastric cancer palliative surgery including gastric cancer resection, palliative gastrojejunostomy, jejunal tube placement etc..
Surgical resection should be performed to completely remove the primary lesion and thoroughly clean the regional lymph nodes. For the localized growth of gastric cancer, the incisal margin of the lesion should be at least 3cm; for the invasive growth of gastric cancer, the incisal margin should be more than 5cm. The adjacent esophageal and duodenal carcinoma should be complete excision of the lesion, if necessary, intraoperative frozen pathological examination, in order to ensure the cutting edge of residual cancer. We still use the D (dissection) said the extent of lymphadenectomy, such as the D1 operation refers to the regional lymph node dissection to first stations, D2 operation refers to the clear regional lymph node to second stations, if not up to the first station lymph node dissection, as D0 surgery.
Laparoscopic surgery is a relatively rapid development of minimally invasive surgery, in the application of gastric cancer should be selected for patients with stage I is appropriate.
2 operation and indication.
(1) reduction surgery.
All types of radical resection with less than standard resection.
Endoscopic mucosal resection (endoscopic mucosa, resection, EMR) and endoscopic submucosal resection (andendoscopic submucosa, dissection, ESD) indications: high differentiation or differentiation, without ulcer, diameter less than 2cm, no lymph node metastasis of intramucosal carcinoma.
The indications of D1 resection of the stomach were: the diameter of the mucosal carcinoma was more than 2cm, and the invasion of the submucosa. Once lymph node metastasis occurs, D2 resection should be performed.
(2) standard operation.
D2 radical resection is the standard surgical procedure for gastric cancer, and the depth of tumor invasion is more than that of submucosa (muscular layer or above), or with lymph node metastasis but has not yet invaded adjacent organs. All patients should be treated with standard surgery (D2).
Table 1 lymph node dissection of D1 and D2 (standard radical resection) in different sites of gastric cancer
1, 4Sb, 4D, 5, 6, 7, 3
1, 2,, 4sa, 4Sb, 7
D1+8a, 9, 11p, 12a
D1+8a, 9, 10, 11
D1+8a, 9, 10, 11, 12a
(3) standard surgery + combined organ resection: tumor invasion of adjacent organs.
(4) palliative surgery: it is only suitable for patients with distant metastasis or tumor invasion of the important organs can not be removed at the same time with bleeding, perforation, obstruction and so on. Palliative surgery to relieve symptoms and improve quality of life for the purpose of.
3 radical operation contraindication.
(1) the whole body can not tolerate surgery;
(2) local infiltration cannot be completely removed;
(3) the exact evidence of distant metastasis, including distant lymph node metastasis, peritoneal dissemination, and more than 3 metastases in the liver;
(4) there are obvious defects in heart, lung, liver, kidney and other important organs, severe hypoproteinemia, anemia, malnutrition and so on.
4 lymph node grouping, sub standard (Annex 4).
The main purpose of radiotherapy or radiotherapy and chemotherapy for gastric cancer is to perform preoperative or postoperative adjuvant therapy, palliative care and improve the quality of life. Postoperative radiotherapy and chemotherapy indications mainly for T3-4 or N+ (positive lymph nodes) of gastric cancer; preoperative chemoradiotherapy indications for unresectable locally advanced or advanced gastric cancer; palliative radiotherapy indications for local recurrence and / or metastasis.
(1) patients with gastric cancer after radical resection (R0), pathological stage of T3-4 or lymph node positive (T3-4N+M0), such as not standard D2 operation, and did not receive preoperative radiotherapy and chemotherapy, postoperative radiotherapy and chemotherapy is recommended;
(2) locally advanced resectable gastric cancer (T4NxM0) may be treated with preoperative concurrent chemoradiotherapy and re evaluation after treatment for radical surgery;
(3) non radical resection of gastric cancer, there are patients with residual tumor (R1 or R2 resection), it is recommended that postoperative concurrent chemoradiotherapy;
(4) local recurrence of gastric cancer, radiotherapy or chemoradiotherapy;
(5) metastatic carcinoma of the stomach, which is relatively limited in the extent of the lesion, bone metastasis and pain, and brain metastasis.
2 radiation therapy technology.
(1) irradiation technique.
According to the radiotherapy equipment in the hospital, different radiotherapy techniques, such as conventional radiotherapy, three-dimensional conformal radiotherapy, intensity modulated radiotherapy, image guided radiotherapy, etc.. Recommend the use of three-dimensional conformal radiotherapy and intensity-modulated radiotherapy and other advanced technology, to better protect the surrounding normal tissues such as liver, spinal cord, dose of kidney and intestine, reduce the adverse effect of normal tissue, improve the tolerance of radiotherapy.
Analog positioning: recommended CT simulation positioning. If there is no CT simulation positioning, must be simulated conventional positioning. Postural fixation, supine position. 3 hours before positioning to avoid eating, oral contrast agent or intravenous angiography is helpful for CT positioning and target delineation;
Sanye and more than the recommended field irradiation;
If the intensity modulated radiotherapy, the plan must be verified;
The amount of local radiotherapy or external irradiation technique can be used in operation;
The radioactive particles implantation therapy is not recommended for routine use.
(2) target definition.
The target area after radical resection of gastric cancer includes the risk of recurrence of primary tumor and lymph node irradiation in high-risk areas.
A high risk of recurrence of primary tumors: including anastomotic sites and adjacent invasive organs or sites;
Lymph node of high risk area: according to the location of primary tumor, the depth of tumor invasion and lymph node metastasis;
Adjacent organs: the pancreas or part of the pancreas.
(3) normal tissue limited dose.
Dose limits for normal tissue: 60% liver < Gy = 2/3; < = 20 Gy, < of the spinal cord; Gy of the heart, 1/3, 45; <, of 50 Gy, minimizing the amount of irradiation of the bowel and duodenum.
(4) irradiation dose.
Three dimensional conformal radiation therapy and intensity modulated radiotherapy using volume dose definition method, conventional irradiation application isocenter dose definition model.
After radical resection of primary tumor, the risk of recurrence of regional and regional lymphatic drainage area of radiation dose, recommended DT45-50.4 Gy, 1.8 Gy each time, a total of 25-28;
The tumor and / or residual, Ono Teru after local irradiation DT 5-10 Gy reduce the field.
3 concurrent chemotherapy and radiotherapy.
Synchronous radiotherapy with 5- fluorouracil (5-FU) or capecitabine based chemotherapy should be adopted.
(four) chemotherapy. It is divided into palliative chemotherapy, adjuvant chemotherapy and neoadjuvant chemotherapy, and the clinical indications should be strictly controlled. Chemotherapy should fully consider the patient's physical condition, physical condition, adverse reactions, quality of life and patients' wishes, to avoid excessive treatment or inadequate treatment. To assess the efficacy of chemotherapy in a timely manner, closely monitor and control adverse reactions, and to adjust the drug and / or dose as appropriate. The therapeutic effect was evaluated according to the standard of curative effect evaluation (Annex 5) or the reference of WHO solid tumor efficacy evaluation criteria. Adverse reaction evaluation criteria refer to NCI-CTC standard.
1 palliative chemotherapy.
Objective to relieve the clinical symptoms, improve the quality of life and prolong the survival time. The utility model is suitable for patients with the condition that the body is in good condition and the function of the main organs is basically normal, and the patients can not be resected, recurrent or palliative.
The system of chemotherapy drugs used include: 5- fluorouracil (5-FU), capecitabine, Tizio, cisplatin, epirubicin, paclitaxel, docetaxel, oxaliplatin and irinotecan etc..
The chemotherapy regimen consisted of two drugs or three drugregimen, including two drug regimen: 5-FU/LV+ cisplatin (FP), capecitabine plus cisplatin, S-1 plus cisplatin and capecitabine plus oxaliplatin (XELOX), FOLFOX, capecitabine plus paclitaxel, FOLFIRI etc.. The three drug regimen is suitable for patients with advanced gastric cancer with good physical condition, including ECF and its derivatives (EOX, ECX, EOF), and the improvement of DCF. For patients with poor physical status and elderly patients, consider the use of oral fluorouracil or paclitaxel monotherapy.
The positive expression of HER-2 (+ + + in immunohistochemical staining, or immunohistochemistry staining with FISH + + and positive) of the patients with advanced gastric cancer, can be considered in chemotherapy on the basis of the combined use of molecular target drugs to inhibit monoclonal antibody trastuzumab.
2 adjuvant chemotherapy.
The objects of adjuvant chemotherapy include: postoperative pathological stage was Ib stage with lymph node metastasis, postoperative pathological stage was II stage and above. Adjuvant chemotherapy began after the patient's physical condition returned to normal, usually in 3-4 weeks after the start of surgery, combined chemotherapy in 6 months to complete, single drug chemotherapy should not be more than 1 years. Adjuvant chemotherapy regimens recommended by the combination of 5-fluorouracil and platinum in combination with two drugs. For the clinical pathological stage Ib stage, poor physical condition, old age, intolerance of two drug combination program, consider the use of oral fluorouracil single drug chemotherapy.
3 neoadjuvant chemotherapy.
For locally advanced gastric cancer (T3/4, N+) without distant metastasis, neoadjuvant chemotherapy should be recommended, and two or three drugs should be used in combination with chemotherapy. Neoadjuvant chemotherapy for gastric cancer: ECF and its improvement. The time limit of neoadjuvant chemotherapy should not be more than 3 months, so we should evaluate the curative effect in time, and pay attention to the judgment of adverse reactions, so as to avoid the complications.
Postoperative adjuvant therapy should be based on preoperative staging and neoadjuvant chemotherapy efficacy, the effective continuation of the original program or according to the patient's tolerance to adjust the treatment plan, invalid replacement program.
(five) support treatment. Objective to relieve symptoms, reduce pain, improve the quality of life, should determine the efficacy of the treatment options, and consider, including correction of anemia and improve nutrition, improve appetite, relieve obstruction, analgesia, psychological treatment etc.. Specific measures include stent placement, enteral and parenteral nutritional support, control ascites, Chinese medicine treatment, etc..
Six, gastric cancer diagnosis and treatment process
The general flow of diagnosis and treatment of gastric cancer is shown in figure 1.
Seven, follow up
Patients with gastric cancer should be followed up regularly by monitoring symptoms, signs and auxiliary examinations. The purpose of follow-up was to monitor the recurrence of the disease or the treatment related adverse reactions, and to evaluate the improvement of nutritional status. Follow up should include hematology, imaging, endoscopy and other items.
The frequency of follow-up was 3 -6 months after treatment, once every for 3 - 5 years, every year in June, once a year after 5 years. Endoscopy once a year. The total gastrectomy, large cell anemia, should add vitamin B12 and folic acid.
Attachment: 1 gastric cancer pathology report standard template
2 histological classification of gastric cancer
3 TNM staging criteria for gastric cancer
4 lymph node grouping, sub standard
5 basic criteria for determining the efficacy of radiotherapy and chemotherapy for gastric cancer
Gastric cancer pathology report standard template
Specimens of gastric and cardiac carcinoma were examined routinely
(full stomach, subtotal or resected specimens of gastric stump): long long cm, small bending length cm, with quiet knocker / duodenum / lower esophagus, length (cm; in gastric cardia / stomach / body / antrum; small bending / greater curvature) type (early and advanced) tumor (including appearance description): from the upper margin from cm, margin size * * cm - - - cm section characters; depth of invasion; involving / not involving the lower esophagus / pyloric ring. Around the esophageal mucosa adjacent to tumor or tumor / muscle wall findings (erosion / rough / granular / SAG / plaque / necessary negative findings). Big bend to find lymph nodes (number / / 10 / 14), to find a small bending diameter cm; lymph node (number / / 10 / 14), to cm diameter. Omentum, size - X - X - cm, with tumor and lymph nodes.
Pathological diagnosis of gastric cancer
(1) tissue typing
(2) tissue classification
(3) infiltration depth
(4) infiltration of the esophagus or duodenum (if cut)
(5) vascular infiltration
(6) perineural invasion
2 incisal margin
3 other pathological findings
(1) chronic gastritis
(2) intestinal metaplasia
(3) atypical hyperplasia
(7) Helicobacter pylori
4 regional lymph nodes (including small bend, bend, omentum and separately examined lymph nodes)
(2) the number of affected
5 distant metastasis
6 other tissues / organs
7 special auxiliary examination results (histochemical staining, immunohistochemical staining, etc.)
Pathology difficult to submit the hospital consultation (the right to reduce the error, the original pathology reports to check the inspection section to provide full lesion slice or wax block, and intraoperative findings).
Histological classification of stomach neoplasms
Intraepithelial neoplasm adenoma 8140/0
Intestinal type 8144/3
Papillary adenocarcinoma 8260/3
Tubular adenocarcinoma 8211/3
Mucinous adenocarcinoma 8480/3
Signet ring cell carcinoma 8490/3
Squamous cell carcinoma 8070/3
Small cell carcinoma 8041/3
Undifferentiated carcinoma 8020/3
Carcinoid tumor (8240/3)
Non epithelial tumor
Granular cell tumor 9580/0
Glomus tumor 8711/0
Gastrointestinal stromal tumor 8936/1
Uncertain malignant potential 8936/1
Kaposi sarcoma 9140/3
Marginal zone B cell lymphoma, type 9699/3 MALT
Mantle cell lymphoma 9673/0
Diffuse large B cell lymphoma 9680/3
TNM staging criteria for gastric cancer
Primary tumor (T)
TX: primary tumor cannot be evaluated
T0: no tumor was found in the resected specimen
Tis: in situ carcinoma: the tumor is located in the epithelium and does not invade the lamina propria
T1a: tumor invasion of the lamina propria or muscularis mucosae
T1b: tumor invades submucosa
T2: tumor invasion of the muscularis propria
T3: the tumor penetrated the submucosa connective tissue, did not encroach on the peritoneum or adjacent structures
T4a: tumor invasion of serous membrane (visceral peritoneum)
T4b: tumor invasion adjacent tissue structure
Regional lymph node (N)
NX: regional lymph nodes cannot be evaluated
N0: regional lymph node metastasis
N1:1-2 regional lymph node metastasis
N2:3-6 regional lymph node metastasis
N3:7 and more than 7 regional lymph node metastasis
N3a:7-15 regional lymph node metastasis
N3b:16 (or more) lymph node metastasis
Distant metastasis (M)
M0: no distant metastasis
M1: distant metastasis
0 phase TisN0M0
Phase T1N0M0 IA
IB phase T1N1M0, T2N0M0
IIA phase T1N2M0, T2N1M0, T3N0M0
IIB phase T1N3M0, T2N2M0, T3N1M0, T4aN0M0
IIIA phase T2N3M0, T3N2M0, T4aN1M0
IIIB phase T3N3M0, T4aN2M0, T4bN0M0, T4bN1M0
IIIC phase T4aN3M0, T4bN2M0, T4bN3M0
IV any T any NM1
Lymph node in gastric cancer group, sub standard
The greater curvature of the stomach and gastric were divided into three parts, connecting the corresponding points after the stomach is divided into upper, middle and lower three parts, respectively by U (upper), M (central), L (lower) said in different parts of gastric cancer, E (esophagus) and D (duodenum) expressed in gastric cancer the upward or downward infiltration. In the case of a tumor that reaches or exceeds two parts, the main part is represented by a number of letters before the principle.
Grouping of gastric cancer lymph nodes
The first group (No. 1) had right gastric lymph nodes
Second groups (No. 2) left gastric lymph nodes
Third groups (No. 3) small curved lymph node
Group 4sa (No. 4sa) large lymph node group (left along the short gastric artery)
Group 4Sb (No. 4Sb) large lymph node group (left along the left gastroepiploic artery)
Group 4D (No. 4D) large lymph node group (right along the right gastroepiploic artery)
Fifth groups (No. 5) lymph nodes
Sixth groups (No. 6) lymph nodes
Seventh groups (No. 7) left gastric artery lymph nodes
Group 8A (No. 8a) of the common hepatic artery
Group 8b (No.8b) posterior lymph nodes of common hepatic artery
Ninth groups (No. 9) celiac lymph nodes
Tenth groups (No. 10) splenic hilar lymph nodes
Group 11p (No. 11p) splenic artery proximal lymph node
Group 11d (No. 11d) splenic artery distal lymph node
Group 12a (No. 12a) of the hepatic ligament (along the hepatic artery)
Group 12b (No. 12b) of the hepatic ligamentum lymph node (along the bile duct)
Group 12p (No. 12p) of the hepatic ligamentum lymph node (along the portal vein)
The thirteenth group (No. = 13) of the posterior pancreatic lymph node
Group 14V (No. 14V) along the superior mesenteric vein lymph node
Group 14a (No. 14a) along the superior mesenteric artery lymph node
Fifteenth groups (No. 15) of the middle colic lymph nodes
Group 16a1 (No. 16a1) abdominal aortic lymph nodes A1
Group 16a2 (No. 16a2) abdominal aortic lymph nodes A2
Group 16b1 (No. 16b1) abdominal aortic lymph nodes B1
Group 16b2 (No. 16b2) abdominal aortic lymph nodes B2
The seventeenth group (No. 17) of pancreatic head lymph node
The Eighteenth Group (No. 18) of the inferior pancreatic lymph node
The nineteenth group (No. 19) had inferior phrenic lymph nodes
Twentieth groups (No. 20) esophageal hiatus lymph nodes
110th groups (No. 110) of the lower thoracic lymph nodes
The 111st group (No. 111) was superior to the diaphragm
Posterior mediastinal lymph nodes in 112nd groups (No. 112)
Two, different parts of gastric cancer lymph node station standard
* gastric cancer
* * * M
Basic criteria for determining the efficacy of radiotherapy and chemotherapy for gastric cancer
Solid tumor efficacy evaluation criteria
Complete remission (CR), tumors completely disappeared for more than 1 months.
Partial remission (PR), the maximum diameter of the tumor and the maximum vertical diameter of the product reduced by 50%, no increase in other lesions, continued for more than 1 months.
Stable disease (SD) lesions, the second product reduced less than 50%, increase of not more than 25%, lasting more than 1 months.
The disease progression (PD) lesions, the second product increased more than 25%.
Two, 2 RECIST curative effect evaluation standard
(1) evaluation of target lesions.
1 complete remission (CR). All target lesions disappeared.
2 part remission (PR). The maximum diameter of the target lesion was reduced by 30% compared with baseline.
3 disease progression (PD). The sum of the longest diameter of the target lesion was increased by 20% compared with the maximum length of the target lesion recorded after the start of treatment, or one or more new lesions appeared.
4 pathological changes (SD). Between partial remission and disease progression.
(two) evaluation of non target lesions.
1 complete remission (CR). All non target lesions disappeared and tumor markers returned to normal.
2 incomplete remission / stability (IR/SD). The presence of one or more non target lesions and / or tumor markers was consistently higher than normal values.
3 disease progression (PD). Progress in the development of one or more new lesions and / or existing non target lesions.
(three) evaluation of the best total efficacy.
The evaluation of the best overall efficacy is the minimum measured from the beginning of the treatment to the progression or recurrence of the disease. The classification of patients with the best efficacy is usually determined by lesion measurement and confirmation.
Diagnosis and treatment of gastric cancer (2011 Edition)
Writing expert group
(sort by surname)
Wang Fenghua, Wang Pengyuan, Bai Ming Yin, and she, by the order of the words of the words of
Li Yexiong Zhang Jun,, Xu Huimian,, and
Pan Hongming Yan Min