胃癌根治术的外科策略

null胃癌根治术的外科策略 Strategy of radical surgery for advanced gastric cancer胃癌根治术的外科策略 Strategy of radical surgery for advanced gastric cancer陈 凛 普通外科胃肠病区 中国人民解放军总医院 北京 复兴路28号胃癌流行病学：亚太地区发病率高 全球每年: 934 000 新患者 ，700 000 死亡， 5年生存率 20% 胃癌流行病学：亚太地区发病率高 Parkin DM et al. CA Cancer J Clin 2005;55:74–108 Yang L. World J Gastroenterol. 2006;12;17–20 www.cancer.gov20 / 100 000 <10 / 100 000 10 20 / 100 000 胃癌发病率Incidence of gastric cancer worldwide in 2002(GLOBOCAN2002, 2004)Incidence of gastric cancer worldwide in 2002High incidenceDistrubution of gastric cancer patients in the worldwide -----2002years(GLOBOCAN 2002, 2004)Distrubution of gastric cancer patients in the worldwide -----2002yearsA great lot of casesSurvey of death cause in 1/10 national peoples in ChinaSurvey of death cause in 1/10 national peoples in ChinaMortality of male and female patients with gastric cancer are first position respectively in malignant diseases The death of gastric cancer patients are 37% in digestive tract malignant diseases （263 samples in 27 cities and provinces in China) (J Chines Oncology 2002-1） High mortalitynullMost of them are advanced gastric cancer (AGC) About 80% AGC in ChinaA data from 301 hospitalA data from 301 hospitalJan 1996 to Dec 2005 in 301 hospital ,2335 cases with gastric cancer were treated by surgical managementAGC: 77.34%null胃癌预后-5年生存率> 15 lymph nodes resectedCancer 2000, 88:921-32For AGC D2 operation is needed For AGC D2 operation is needed JGCA—胃癌治疗指南（81届胃癌大会）JGCA—胃癌治疗指南（81届胃癌大会）任何T，M1 Ⅳ 化疗，姑息性手术，放疗，支持治疗D2Surgical Strategy of advanced gastric cancer Surgical Strategy of advanced gastric cancer Surgical Strategy of advanced gastric cancer Surgical Strategy of advanced gastric cancer 1，Accurate staging 2，Evaluation of MDT (Multidisciplinary Team Model) 3，Standard gastrectomy with D2 lymphadenectomy 4，Effective perioperative therapy (postoperative adjvanctive chemo new adjvanctive chemo biotherapy) Clincal stagingClincal stagingAccurate stagingAccurate stagingTwo staging systems UICC and AJCC ---TNM staging JGCA --- guideline N stagingJACC、UICC—TNM分期JACC、UICC—TNM分期淋巴结巴数目分期 （1-6，7-15，＞ 15Sketch map of N stage by JGCASketch map of N stage by JGCAN1N2N3淋巴结的部位分站JGCA—胃癌治疗指南（81届胃癌大会）JGCA—胃癌治疗指南（81届胃癌大会）任何T，M1 Ⅳ 化疗，姑息性手术，放疗，支持治疗JGCA--- stagingJGCA--- stagingAJCC,UICC—TNM stagingAJCC,UICC—TNM stagingⅣⅣⅣⅣＭ１ⅣⅣⅣⅢAＴ４ⅣⅢBⅢAⅡＴ３ⅣⅢAⅡⅠBＴ２ⅣⅡⅠBⅠAＴ１Ｎ３Ｎ２Ｎ１Ｎ０1- 67- 15﹥15nullAccurate staging is key poit for accurate managementSurgical management for different stages of gastric cancerSurgical management for different stages of gastric cancer MDT Model MDT ModelStrategy of MDT evaluation in NCCN ChinaStrategy of MDT evaluation in NCCN ChinaMDT评估GCMDT研讨 GCMDT研讨 Strategy for Surgical skillStrategy for Surgical skillWhat is standard surgical management for AGCWhat is standard surgical management for AGCComplete dissection of primary tumor ( >3/4 gastrectomy ) D2 lymphadenectomy Cleanup of all of tumor cells in abdominal cavity null2/3 gastrectomy， enough edgenullInstruments usage shorten operation time、 Decrease of comtaminatednull5cmedgetumorEnough safe edge should be inspected during operationnullD2 lymphadenectomy for distal gastrectomyN7,8,9 N12a, N11pnull12a11p8D2 lymphadenectomy for distal gastrectomy nulln6n14D2 lymphadenectomy for distal gastrectomy nullN11\ N10 nodes dissectionProximal gastrectomy with D2 dissectionnullAccurate judging cut line for proximal gastrectomynullInspecting edge after stomach removednullD2 for distal gastrectomynullD2 for promxial gastrectomynullD2 for total gastrectomyJGCA— GI anastomose after distal gastrectomyJGCA— GI anastomose after distal gastrectomynullB 1—anastomose after distal gastrectomyJGCA— GI anastomose after proximal gastrectomyJGCA— GI anastomose after proximal gastrectomynullJGCA— GI anastomose after total gastrectomynullOP TeamA data from 301 hospital (general hospital of China PLA)A data from 301 hospital (general hospital of China PLA)Jan 1996 to Dec 2005 in 301 hospital ,2335 cases with gastric cancerAGC: 77.34%EGC:22.66%Characteristics of 2335 cases with gastric caner in 301 hospital Characteristics of 2335 cases with gastric caner in 301 hospital Characteristics of 2335 cases of GC in 301 hospitalCharacteristics of 2335 cases of GC in 301 hospital Overall Survival Overall Survivalsurvival curve for different surgerysurvival curve for different surgerysurvival curve for different TNM stagesurvival curve for different TNM stagesurvival curve for different gross featuressurvival curve for different gross features survival curve for different combined therapy survival curve for different combined therapy multivariate regression analyses multivariate regression analyses perioperative therapyperioperative therapyPerioperative adjunctive therapyPerioperative adjunctive therapyMore and more clincal trials suggeste evidence Postoperative adjunctive chemotherapy improving survival New adjunctive chemotherapy gave AGC patients advantages, need more clinical evidence null病例: 23 trials， 4919 pts 方法: 术后辅助化疗组: 2441 术后观察组 (单纯手术): 2478 结果: 3年总生存率: 化疗组60.6%,单纯手术组 53.4% (RR: 0.85,95%CI: 0.80–0.90 ) DFS: 化疗组更优 (RR: 0.88, 95%CI: 0.77–0.99) 复发率: 化疗组复发率更低 (RR: 0.78, 95%CI: 0.71-0.86) 3~4级毒副反应 (骨髓抑制、胃肠道反应): 化疗组更多 其中有10个试验出现化疗相关性死亡，共15人，发生率1.58% 结论: 胃癌根治术后进行辅助化疗 能提高生存率和无病生存期，减少复发率An updated meta-analysis of adjuvant chemotherapy after curative resection for gastric cancerEuropean Journal of Surgical Oncology (EJSO) 2008.02.    NCCN----postoperative chemotherapyNCCN----postoperative chemotherapy2008年：2篇Meta-analysis 显示术后辅助化疗的3年生存率、无进展生存期和复发率有改善趋势临床究结果将进一步提供循证医学证据null新辅助与单纯手术组比较nullACTS-GC study ：Randomized phase III trial comparing S-1 monotherapy versus surgery alone for stage II/III gastric cancer patients after curative D2 gastrectomy （S-1 as adjuvant therapy vs surgery alone）1059 cases stage II/III ，D2,3 years follow up*Randomized phase III trial comparing S-1 monotherapy versus surgery alone for stage II/III gastric cancer patients (pts) after curative D2 gastrectomy (ACTS-GC study). 2007Gastrointestinal cancer symposium, sasako M*12/2005 showed that HR of death for S-1 to C was 0.57, trial was recommended to stop. 09/2006 HR of death for S-1 was 0.68. Conclusions: Adjuvant chemotherapy with S-1 for gastric cancer is feasible and effective. This regimen can be the standard treatment for stage II/III gastric cancer pts after curative D2 dissection. Our exeperience in perioperative therapy for AGC with metastasisOur exeperience in perioperative therapy for AGC with metastasisNew adjunct chemoth Chemoth intraoperative Biotherapy : DC induced immunotherapy Surgical therapy for AGC with hepatic metastasisnullCase1: Surgical treatment after 8 cycles chemo for patients with AGC with hepatic metastasis Case2: surgical treatment after 4 cycles chemo for AGC patients with metastasisConclusionsConclusionsHigh incidence and mortality of gastric cancer in China was revealed by epidemiology survey Standard surgical treatment is most important for AGC Perioperative adjunctive therapy may be a role for imprving treatment results of AGC MDT is a good model for AGC treatment nullTHANKS FOR YOUR ATTENTION !!