STOMACH CANCER

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1 STOMACH CANCER 위암 Nam Deuk Kim, Ph.D. 1

STOMACH Saccular organ Volume:1200-1500 ml Capacity : 3000 ml

2 STOMACH Saccular organ Volume: ml Capacity : 3000 ml Anatomic regions Cardia Fundus Body(or corpus) Antrum Pylorus 2

3 STOMACH Stomach wall mucosa submucosa muscularis subserosa serosa 0 Ⅰ Ⅱ Ⅲ Ⅳ 3

STOMACH (GASTRIC) CANCER In early stages, stomach cancer is treatable but, when the cancer has spread, the outlook isn't as good. The 5-year survival rate about 90% in earliest stages.

4 STOMACH (GASTRIC) CANCER In early stages, stomach cancer is treatable but, when the cancer has spread, the outlook isn't as good. The 5-year survival rate about 90% in earliest stages. only 3 percent in most advanced stage It is difficult to detect in its early stages when it usually doesn't cause any symptoms the only evidence may be microscopic internal bleeding Doctors diagnose about 22,000 cases of stomach cancer in the U.S. annually nearly 13,000 Americans with stomach cancer die annually. A suspicious stomach ulcer that was ultimately diagnosed as cancer on biopsy and resected. The surgical specimen was subsequently kept for educational purposes. 4

5 TYPES OF STOMACH CANCER Adenocarcinomas Most stomach cancers start from the glandular cells of the stomach lining Leiomyosarcoma Cancers which start from the cells of the muscle layer of the stomach a type of soft tissue sarcoma Carcinoid tumor A rare type of tumor can start in the stomach. Gastric lymphoma is the most common extranodal lymphoma - Primary lymphoma of the stomach: about 5% of all gastric malignancies and 20% of all extranodal lymphomas - Age at years 5

6 Epidemiology Stomach cancer is the fourth most common cancer worldwide with 930,000 cases diagnosed in It is a disease with a high death rate (~800,000 per year) making it the second most common cause of cancer death worldwide after lung cancer. It is more common in men and in developing countries. It represents roughly 2% (25,500 cases) of all new cancer cases yearly in the United States, but it is more common in other countries. It is the 3 rd leading cancer type in Korea, with 15.8% of malignant neoplasm (2011). Metastasis occurs in 80-90% of individuals with stomach cancer, with a six month survival rate of 65% in those diagnosed in early stages and less than 15% of those diagnosed in late stages. 6

평균수명까지생존시암발생확률 (%) 2005 31.9 25.5 29.6 2007 34.

7 평균수명까지생존시암발생확률 Male Female Total 평균수명 ( 통계청 ) 평균수명까지생존시암발생확률 (%) (3명중 1명 ) (10명중 3명 ) (3명중 1명 ) 7

8 8

9 Age Specific Cancer Incidence Female Male Korea Central Cancer Registry,

10 < 2010년주요암발생현황 : 남녀전체 > (2013년 8월현재 ) 순위암종 발생자수 분율 (%) 조발생률 표준화발생률 * 모든암 202, ( 갑상선암제외 ) (166,032) - (332.9) (242.9) 1 갑상선 36, 위 30, 대장 25, 폐 20, 간 15, 유방 14, 전립선 7, 담낭및기타담도 4, 췌장 4, 비호지킨림프종 3, ( 단위 : 명, 명 /10 만명 ) 10

11 < 성별 10 대암조발생률, 2010 년 > (2013 년 8 월현재 )( 단위 : 명 /10 만명 ) 위 (80.8) 대장 (62.5) 폐 (58.7) 간 (47.3) 전립샘 (31.4) 갑상샘 (24.9) 방광 (11.0) 담낭및기타담도 (10.1) 신장 (10.1) 췌장 (10.0) 갑상샘 (119.6) 유방 (57.1) 대장 (40.8) 위 (39.8) 폐 (24.3) 간 (16.5) 자궁경부 (15.5) 담낭및기타담도 (9.4) 췌 [ 장 (8.6) 난소 (8.0) 11

12 2011 년암종별사망자수 : 남녀전체 대장암 7,721 췌장암 4,379 담낭및기타담도암 3,701 유방암 2,018 백혈병 1,557 식도암 1,507 비호지킨림프종 1,407 위암 9,719 간암 10,946 한국의사망원인 (2011) 1. Cancer (27.8%) 2. 뇌혈관질환 3. 심혈관질환 4. 자살 5. 당뇨병 6. 폐렴 7. 만성하기도질환 8. 간질환 9. 운수사고 10. 고혈압성질환 폐암 15,867 12

13 2011 년암종별사망자수 : 남자 폐암 11,503 대장암 4,377 췌장암 2,394 담낭및기타담도암 1,825 전립샘암 1,403 식도암 1,368 백혈병,904 방광암 853 위암 6,321 간암 8,226 13

14 2011 년암종별사망자수 : 여자 폐암 4,364 위암 3,398 대장암 3,344 자궁경부암 989 난소암 901 백혈병 653 간암 2,720 유방암 1,999 췌장암 1,985 담낭및기타담도암 1,876 14

15 암발생자의 10 대암에대한 5 년관찰생존율 암발생자의 10 대암에대한 5 년상대생존율 * 상대생존율 : 환자군의관찰생존율을동일한인구학적특성을가지는일반인구의생존율로나누어구한값 15

Changes of 5 year survival rate in Korea GC USA ( 99-06 ) 26% Canada (

16 Changes of 5 year survival rate in Korea GC USA ( ) 26% Canada ( 04-06) 22% Japan ( 97-99) 62.1% Korea ( 04-08) 63.1% Korea Cancer Registry

17 위암에서의 2 중암 Yonsei Cancer Center 2.3% (2000 년 1 월 년 12 월, 3,066 명 ) Female Male (%) (%) Colorectal Lung Liver (HCC) Head&Neck Kidney Gallbladder Esophagus Prostate Lymphoma Urinary bladder Pancreas Small intestine Breast Brain Thyroid 17

18 위암 _ 선암의일반적증상 ㆍ무증상ㆍ속쓰림 조기위암 80% 10% ㆍ체중감소ㆍ복통ㆍ오심, 구토ㆍ식욕감퇴ㆍ연하곤란ㆍ위장관출혈 진행성위암 60% 50% 30% 30% 25% 20% 18

19 위암의위험인자 위암은여러가지요인이복합적으로작용하여발생하게됩니다. 관련질병식이유전성기타 위수술의과거력 : 2~6 배의위험률만성위축성위염 : 저산증유발악성빈혈 : 약 10% 에서위암발생헬리코박터파이로리균 : 만성위축성위염유발용종성폴립 질산염화합물 ( 가공된햄, 소시지류 ) 짠음식, 저단백, 저비타민식이 가족력이있는경우위험도가약 4 배로증가 남자가여자보다 2 배정도높게발생 50~60 대에서호발음주흡연 19

20 RISK FACTORS Ⅰ Helicobacter pylori infection corkscrew-shaped bacteria H. pylori is a common cause of ulcers and infects over half the world's population at least 335,000 out of 800,000 annual new cases of gastric cancer can be attributed to H. pylori infection Diet starch, smoked fish and meat (benzopyrene), pickled vegetables in foods that are smoked, dried, salted or pickled ingest greater amounts of nitrates and nitrites potent carcinogens; nitrates/nitrites nitrosamines; V-C inhibits the nitrosation of secondary amines in vivo. can be converted inside your stomach into compounds that increase risk of stomach cancer Smoking and alcohol abuse particularly increase risk of cancer of the upper part of the stomach the portion closest to the esophagus 20

21 Helicobacter pylori Barry J. Marshall, M.D. 21

22 J. Robin Warren & Barry J. Marshall 2005 Nobel Laureate in Physiology or Medicine 2005 년노벨의학상수상자로호주의배리마샬과로빈워렌이선정. 스웨덴스톡홀름노벨상위원회의카롤린스카연구소는 3 일소화성궤양을일으키는파일로리균을발견한호주의배리마샬과로빈워렌을 2005 년노벨의학상수상자로선정. 이들에게는 100 만스웨덴크로네 (18 억원 ) 가수여. 22

23 Helicobacter pylori Microbiology Epidemiology Associated with Upper GI dz. Diagnosis Treatment 23

24 Pathogenesis of Peptic Ulcer 24

25 Helicobacter pylori Peptic Ulcer 25

26 Helicobacter pylori -microbiology Microaerophilic, spiral, G(-) bacilli, multiple flagella Urease 생산 urea 로부터 NH 4 + 생성 위산으로부터보호, 위점막상피세포손상 VacA 생산 위점막상피세포에공포형성 CagA 생산 위점막상피로하여금인터루킨 -8 을분비케함 호중구를모아활성산소유리기생산 위상피세포표면과점액층밑부분사이에존재점막 invasion 은안함 Gastric mucosa or duodenal 의 metaplasia 부위에잘분포 26

27 H. pylori CagA 단백질의아미노산배열이동아시아와구미에서차이가남 (2002 년일본북해도대학연구팀발표 ) 일본인형 CagA 단백질 : 위세포증식과관여하는효소와강하게결합 암화촉진 인체위세포에 CagA 단백질주입결과 암세포와유사한형태로분화됨 일본은구미에비해위암발생률이 3~6 배높음 27

28 H. pylori PtprZ 단백질 (Nature, ) 뇌, 신경세포등에다량존재하는표면단백질 H. pylori 독소와결합할경우세포간접착력이떨어져위표면에서탈락되며결과적으로강한산성의소화액으로부터위벽을지키지못함. 28

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31 Helicobacter pylori -epidemiology 집단생활자들의감염이높음 선진국보다는후진국이감염률이높음 나이가들수록감염률이증가예 ) 우리나라에서 1~5 세에서약 6% 가관찰됨 20 세가되면 67% 가관찰됨 `CagA' 라는독소단백질을만들어내는헬리코박터균이한국인에게서특이하게위암의발생위험을 3.7 배높임 ( 06 AACR) 감염이되면 10~20% 에서궤양발생정상인에게서도발견됨 (60~70%) 31

32 Helicobacter pylori -epidemiology 잇몸질환자감염자많음 : American Journal of Public Health, November 2002 이와잇몸사이의간격이깊고큰경우에도간격이좁은사람에비해 50% 이상감염률높음 치아주위염증등이있을시도감염률이높음 32

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34 Helicobacter pylori - Associated with Upper GI dz. Chronic gastritis: > 95% Duodenal ulcer: >95% Gastric ulcer: 60~80% Causing agent for stomach cancer 34

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36 Helicobacter pylori-diagnosis Rapid urease test Culture ELISA Urea carbon breath test 36

37 Helicobacter pylori - 치료법 박멸요법이최우선 H. pylori 박멸전궤양재발율 -80~90% H. pylori 박멸후궤양재발율 -10% 이하 3 중요법 Rx: 오메프라졸 20mg bid or qd 10 day 아목사실린 1000mg bid 10 day 클래리쓰로마이신 500mg bid 10 day 치료종결 2 개월후적어도 2 가지이상검사에서음성이라야박멸된것으로봄 37

38 RISK FACTORS Ⅱ Previous stomach surgery Having had this surgery may result in higher of nitrate-producing bacteria and bile in stomach Genetics two to four times more common for immediate family members of people who have had the disease more than 90 % of people with stomach cancer have no family members with stomach cancer no significant, but hereditary nonpolyposis colorectal cancer (HNPCC) syndrome; 50% of gastric cancer patients are blood type A (38% of the general population) Country of origin Japan, Korea, parts of Eastern Europe and Latin America. However, people of Japanese ancestry who live in the United States have a much lower incidence of stomach cancer, suggesting environmental influences such as diet Gender : about two-thirds of cases are in men. Age : between age 50 and 70 Others: atrophic gastritis, pernicious anemia, subtotal gastrectomy, and gastric adenomatous polyps 38

SYMPTOMS Indigestion that does not go away Losing your appetite Difficulty in swallowing Losing weight A bloated feeling after eating Feeling sick (nausea)

39 SYMPTOMS Indigestion that does not go away Losing your appetite Difficulty in swallowing Losing weight A bloated feeling after eating Feeling sick (nausea) or vomiting (being sick) Heartburn Blood in the stools (bowel motion) or black stools Tiredness due to anemia (from bleeding from the wall of the stomach) 39

40 Signs and symptoms Stage 1 (Early) - Indigestion or a burning sensation (heartburn) - Loss of appetite, especially for meat - Abdominal discomfort or irritation Stage 2 (Middle) - Weakness and fatigue - Bloating of the stomach, usually after meals Stage 3 (Late) - Abdominal pain in the upper abdomen - Nausea and occasional vomiting - Diarrhea or constipation - Weight loss - Bleeding (vomiting blood or having blood in the stool) which will appear as black. This can lead to anemia. - Dysphagia; this feature suggests a tumor in the cardia or extension of the gastric tumor in to the esophagus. Note that these can be symptoms of other problems such as a stomach virus, gastric ulcer or tropical sprue. 40

41 DIAGNOSIS Diagnosis Involves you undergoing a general physical examination Discussion with your doctor of your medical history Undergo one or more of the following diagnostic procedures Autodiagnosis Unintended weight loss and lack of appetite Abdominal pain Vague discomfort in the abdomen, often above the navel A sense of fullness just below the chest bone after eating a small meal Heartburn, indigestion or ulcer-type symptoms Nausea Vomiting, with or without blood Swelling of the abdomen 41

DIAGNOSIS Ⅰ Upper endoscopy Inserts a thin, flexible tube (endoscope) equipped with a light through your mouth and into your esophagus, stomach and small intestine.

This procedure also allows your doctor to remove a small sample (biopsy) of any tissue that appears abnormal for further assessment Stomach X-ray After fasting overnight,

42 DIAGNOSIS Ⅰ Upper endoscopy Inserts a thin, flexible tube (endoscope) equipped with a light through your mouth and into your esophagus, stomach and small intestine. See the upper part of your digestive tract. This procedure also allows your doctor to remove a small sample (biopsy) of any tissue that appears abnormal for further assessment Stomach X-ray After fasting overnight, you'll drink a barium mixture, a chalky liquid that will coat your upper gastrointestinal tract and small bowel to enhance viewing on an X-ray Endoscopic image of linitis plastica, a type of stomach cancer where the entire stomach is invaded, leading to a leather bottle-like appearance with blood coming out of it. 42

43 DIAGNOSIS Ⅱ Blood test A test called a complete blood count (cbc) can indicate anemia Stool test for occult blood Detect microscopic amounts of blood in your stool. Once a diagnosis of gastric cancer is made, your doctor may recommend additional tests to determine the extent of the disease and the best course of treatment. These tests may include 43

This procedure may help your doctor determine the extent of the cancer.

44 DIAGNOSIS Ⅲ Endoscopic ultrasound Using a small flexible tube with a light (endoscope) your doctor can thread a small ultrasound device into your stomach to generate a close-up image of your stomach on a computer screen. This procedure may help your doctor determine the extent of the cancer. Computerized tomography (CT) scan To see if the cancer has spread to nearby organs, such as the lymph nodes, pancreas and liver, your doctor may have you undergo a CT scan. A CT scan allows your doctor to see your internal organs. 44

45 [ 조기위암의육안분류 ] [ 진행위암의보우만 (Borrmann) 분류 ] 45

46 STAGE INFORMATION The American Joint Committee on Cancer (AJCC) has designated staging by TNM classification TNM definitions Primary tumor (T) TX: Primary tumor cannot be assessed T0: No evidence of primary tumor Tis: Carcinoma in situ: intraepithelial tumor without invasion of the lamina propria T1: Tumor invades lamina propria or submucosa T2: Tumor invades the muscularis propria or the subserosa T3: Tumor penetrates the serosa (visceral peritoneum) without invading adjacent structures T4: Tumor invades adjacent structures 46

47 STAGE INFORMATION Regional lymph nodes (N) The regional lymph nodes are the perigastric nodes, found along the lesser and greater curvatures, and the nodes located along the left gastric, common hepatic, splenic, and celiac arteries. For pn, a regional lymphadenectomy specimen will ordinarily contain at least 15 lymph nodes. Involvement of other intra-abdominal lymph nodes, such as the hepatoduodenal, retropancreatic, mesenteric, and para-aortic, is classified as distant metastasis. NX: Regional lymph node(s) cannot be assessed N0: No regional lymph node metastasis N1: Metastasis in 1 to 6 regional lymph nodes N2: Metastasis in 7 to 15 regional lymph nodes N3: Metastasis in more than 15 regional lymph nodes Distant metastasis (M) MX: Distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis 47

48 AJCC stage groupings Stage 0 Tis, N0, M0 Stage IA T1, N0, M0 Stage IB T1, N1, M0 T2, N0, M0 Stage II T1, N2, M0 T2, N1, M0 T3, N0, M0 Stage IIIA T2, N2, M0 T3, N1, M0 T4, N0, M0 Stage IIIB T3, N2, M0 Stage IV T4, N1, M0 T1, N3, M0 T2, N3, M0 T3, N3, M0 T4, N2, M0 T4, N3, M0 Any T, Any N, M1 48

49 STAGE 0 STAGE Ⅰ STAGE Ⅱ STAGE Ⅲ STAGE Ⅳ The cancer is located in the inner layer of the stomach (epithelium) but has not yet spread to the second layer (lamina propria). The cancer has started to penetrate toward the outer layer of the stomach (lamina propria, submucosa, muscularis propria or subserosa), and nearby lymph nodes may be involved. The cancer has penetrated the lining of the abdominal cavity but has not invaded adjacent organs, or more distant lymph nodes may be involved. The cancer has spread to nearby organs such as the liver or kidney, or more distant lymph nodes may be involved. The cancer has spread to nearby organs or metastasized to more distant places in the body. 49

50 [ 위암의병기별생존율 ] 병기 5 년생존율 0 기 100% 대표적인예 선종이나고등급이형성증등위암의전구병변을내시경점막절제술로제거한경우 1A 기 95% 점막, 점막하층에국한되고림프절전이가없는경우 1B 기 85% 2 기 70% 3A 기 50% 점막, 점막하층까지침윤하고림프절 1 군에전이가있는경우근육층이나장막하층까지침윤하고, 림프절전이가없는경우 장막침윤이있고림프절전이가없거나, 장막침윤없이림프절 1 군에전이가있는경우 장막침윤이있고, 림프절전이가 1 군에있는경우나, 장막침윤없이림프절 2 군에전이가있는경우 3B 기 30% 장막침윤이있고림프절전이가 2 군이상에있는경우 4 기 10% 대동맥주위의림프절전이가있거나, 뼈, 폐, 간등의전신전이가동반된경우 50

51 TREATMENT Surgery taking out the cancer in an operation Chemotherapy using drugs to kill cancer cells Radiotherapy 51

52 SURGERY Surgery is the most important treatment for most stomach cancers. The results of surgery have improved in the last 10 years, because nowadays the cancer is often found and treated earlier, and because better surgical methods have been developed. If the cancer is caught at an early stage, a surgical operation may be all that is needed to cure it. Usually all that is needed is to remove part of the stomach (a partial gastrectomy). Often the lymph glands (nodes) close to the stomach are removed at the same time to see whether the cancer cells have spread into them. Depending on the extent of the cancer some other organs in the area of the stomach may be removed at the same time, such as the lower part of the gullet (esophagus) and the upper part of the small bowel (duodenum), the spleen or part of the pancreas. 52

53 SURGERY Partial gastrectomy Total gastrectomy 53

내시경적점막절제술 [(Endoscopic mucosal resection (EMR)] 조기위암중에서위주변림프절전이가없는암은내시경을이용한절제로완치시킬수있음. 암의위치가가장안쪽인점막층에국한되어있고, 암의크기가 2cm 이내로작으며, 세포의분화도가좋은위암은림프절전이가없다고알려져있음.

54 내시경적점막절제술 [(Endoscopic mucosal resection (EMR)] 조기위암중에서위주변림프절전이가없는암은내시경을이용한절제로완치시킬수있음. 암의위치가가장안쪽인점막층에국한되어있고, 암의크기가 2cm 이내로작으며, 세포의분화도가좋은위암은림프절전이가없다고알려져있음. 이러한경우에는내시경으로위암부위만도려내는시술을하여수술을한것과마찬가지로완치시킬수있음. 내시경적점막절제술은약 30 분정도수면내시경을하면서치료하는데, 위암바로아래에생리식염수를주사하여위점막을부풀리고, 전기올가미를이용하여잘라냄. 암을도려내어서생긴위궤양은한달정도위궤양약을복용하면아물게되고, 치료후에는 2~3 일만에퇴원할수있음. 이치료법은계속정상적인위를갖고생활을할수있어서삶의질이향상되는장점이있음. 54

55 CHEMOTHERAPHY 1. Central line is inserted into your chest here 2. The line is tunneled under your skin 3. It comes out here 55

56 CHEMOTHERAPHY Fluorouracil(5-Fu) Most common drug for stomach cancer Combine with radiotheraphy or other drugs Doxorubidicin (arriamycin) Methotrexate Etoposide Cisplatin 선플라 Cafecitabin- 젤로다 Gleevec 56

57 Taxotel ( 탁소텔 ) constituent : Docetaxel 한독약품-아벤티스파마 Oral anticancer drug For metastatic breast cancer, ovarian cancer Recognized for metastatic stomach cancer (2001) Single theraphy : about 17~24% effective Combined with cisplatin : 56% 57

58 Zeloda ( 젤로다 ) constituent : cafecitabin Roche Korea Ltd. Oral anticancer drug For metastatic breast cancer Recognized for metastatic stomach cancer ( ) Single theraphy : about 70% effective for patients Relative safe side effect : 수족증후군 (68.2%), retching (27.3%), diarrhea (27.3%), loss of appetite 58

RADIOTHERAPY Radiotherapy is not usually used to treat cancer of the stomach. This is because the stomach is so close to other major organs that it is difficult to give effective treatment.

59 RADIOTHERAPY Radiotherapy is not usually used to treat cancer of the stomach. This is because the stomach is so close to other major organs that it is difficult to give effective treatment. The doses that would be necessary to try to cure the cancer would cause many side effects. In the situation where the cancer has spread beyond the stomach and may be causing pain, a small dose of radiotherapy may be very helpful to relieve pain. 59

60 TREATMENT BY STAGE Stage 0 Stage 0 is gastric cancer confined to mucosa. Experience in Japan where stage 0 is diagnosed frequently, indicates that greater than 90% of patients treated by gastrectomy with lymphadenectomy will survive beyond 5 years. An American series has confirmed these results Stage Ⅰ One of the following surgical procedures: distal subtotal gastrectomy (if the lesion is not in the fundus or at the cardioesophageal junction) proximal subtotal gastrectomy or total gastrectomy, both with distal esophagectomy (if the lesion involves the cardia). These tumors often involve the submucosal lymphatics of the esophagus. total gastrectomy (if the tumor involves the stomach diffusely or arises in the body of the stomach and extends to within 6 centimeters of the cardia or distal antrum) Postoperative chemoradiation therapy for patients with node-positive (T1 N1) and muscle-invasive (T2 N0) disease 60

61 TREATMENT BY STAGE Stage Ⅱ One of the following surgical procedures: distal subtotal gastrectomy (if the lesion is not in the fundus or at the cardioesophageal junction) proximal subtotal gastrectomy or total gastrectomy (if the lesion involves the cardia) total gastrectomy (if the tumor involves the stomach diffusely or arises in the body of the stomach and extends to within 6 centimeters of the cardia) Postoperative chemoradiation therapy Stage Ⅲ Radical surgery: Curative resection procedures are confined to patients who at the time of surgical exploration do not have extensive nodal involvement. Postoperative chemoradiation therapy. 61

62 TREATMENT BY STAGE Stage Ⅳ Patients with no distant metastases(m0) Radical surgery if possible, followed by postoperative chemoradiation Patients with distant metastases (M1) Palliative chemotherapy Endoscopic laser therapy or endoluminal stent placement may be helpful to patients whose tumors have occluded the gastric inlet. Palliative radiation therapy may alleviate bleeding, pain, and obstruction. Palliative resection should be reserved for patients with continued bleeding or 62

63 RECURRENT GASTRIC CANCER Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the stomach or in another part of the body such as the liver or lymph nodes. Treatment Chemotherapy to relieve symptoms. Surgery to relieve symptoms, reduce bleeding, or remove a tumor that is blocking the stomach. Radiation therapy to relieve symptoms, reduce bleeding, or shrink a tumor that is blocking the stomach. 63

64 STANDARD TREATMENT OPTIONS Palliative chemotherapy with: Fluorouracil (5-Fu) FAM: fluorouracil + doxorubicin + mitomycin-c FAP: fluorouracil + doxorubicin + cisplatin ECF: epirubicin + cisplatin + fluorouracil ELF: etoposide + fluorouracil + leucovorin FLAP: fluorouracil + leucovorin + doxorubicin + cisplatin PELF: cisplatin + epidoxorubicin + leucovorin + fluorouracil with glutathione and filgrastim FAMTX: fluorouracil + doxorubicin + methotrexate FUP: fluorouracil + cisplatin Endoscopic laser therapy or electrocautary may be helpful for obstructive lesions. Radiation therapy may alleviate bleeding, pain, and obstruction. 64

Side effects of conventional chemotherapy Acute Emesis Infusion-related complications Allergic reactions Short-term (reversible) Mucositis Hair and

65 Side effects of conventional chemotherapy Acute Emesis Infusion-related complications Allergic reactions Short-term (reversible) Mucositis Hair and skin Diarrhea Hepatic and renal Complicatoins of neutropenia Cumulative toxicity (sometimes irreversible) Neurotoxicty Cardiotoxicity Gonadal toxicity 65

66 PREVENTION Reduce risk factors Dietary Factors and Helicobacter pylori Infection Chemoprevention 66

67 DIETARY FACTORS AND Helicobacter pylori INFECTION Increased risk of gastric cancer excessive salt intake deficient dietary consumption of fresh fruits and vegetables infection with Helicobacter pylori Vitamin C contained in vegetables, fruits, and other foods of plant origin is associated with a reduced risk of gastric cancer Diets high in whole grain cereals, carotenoids, allium compounds, and green tea are also associated with a reduced risk of this cancer 67

68 CHEMOPREVENTION The most common type of gastric cancer is preceded by a well-characterized precancerous process involving several steps chronic gastritis glandular atrophy complete intestinal metaplasia incomplete intestinal metaplasia and dysplasia. Chemoprevention trial significant reduction of gastric cancer mortality supplementation with beta-carotene, vitamin E, and selenium There is insufficient evidence that eradication of Helicobacter pylori infection prevents either gastric cancer or precancerous lesions. 68

69 우리나라암조기검진프로그램 69

70 위암의검진권고안 ( 국립암센터, 대한위암학회 ) 검진연령 : 40 세이상 ( 남녀공통 ) 검진주기 : 매 2 년마다 ( 증상이없는경우 ) 검진방법 : 위내시경검사또는상부위장관조영술 상한연령 : 제한없음 단, 고위험군 ( 장상피화생, 위축성위염 ) 에서는담당의사의판단에따라검사간격을줄일수있습니다. 70

71 REFERENCE Pathologic Basis of Disease 7 th Cancer chemotherapy and biochemistry 71

김범수

김범수 Analysis of Outcomes after Resection of Sarcomatous Hepatocellular Carcinoma Purpose: Sarcomatous hepatocellular carcinoma (HCC) is rare. Therefore, the clinicopathologic characteristics and prognosis