内科学8版胃癌.pptx

Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College讲授目的和要求讲授目的和要求1.掌握本病的掌握本病的诊断要点断要点2.熟悉本病的熟悉本病的临床表床表现 3.了解本病的病因、了解本病的病因、发病机制病机制Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College讲授主要内容讲授主要内容病因和病因和发病机制病机制病理病理临床表床表现胃胃镜检查实验室室检查X线钡餐餐诊断断并并发症症治治疗Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College概述概述胃癌系来源于胃癌系来源于胃黏膜上皮胃黏膜上皮的的恶性性肿瘤，主要是胃腺癌瘤，主要是胃腺癌2008年新年新诊断胃癌近断胃癌近100万例，病死人数万例，病死人数74万，占万，占恶性性肿瘤瘤诊断的第断的第4位和位和恶性性肿瘤病死率的第瘤病死率的第2位位2/3分布于分布于发展中国家，地理分布上以展中国家，地理分布上以日本日本和和中国中国等等东亚国国家家为高高发我国我国北方北方发病率高于病率高于南方南方，农村村高于高于城市城市，男性，男性发病率和病率和死亡率均高于女性，死亡率均高于女性，55-70岁为高高发年年龄段段全国平均死亡率全国平均死亡率约16/10万（男性万（男性21/10万，女性万，女性10/10万）万）Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因和发病机制胃癌的胃癌的发生是一个多因素、多步生是一个多因素、多步骤进行性行性发展的展的过程程不良不良环境境、饮食食及及Hp多种因素作用下，多种因素作用下，COX-2及及生生长因子因子等介等介导发生生连续性慢性炎症，由性慢性炎症，由慢性炎症慢性炎症-萎萎缩性胃炎性胃炎-萎萎缩性胃炎伴性胃炎伴肠化化-异型增生异型增生-而逐而逐渐向向胃癌胃癌演演变相关癌基因相关癌基因:ras、bcl-2、c-myc 相关抑癌基因相关抑癌基因:p53、APC、DCC、MCC 相关生相关生长因子因子:EGF、TGF-Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因和发病机制病因和发病机制-环境和饮食因素环境和饮食因素环境因素境因素美国的日本移民，胃癌美国的日本移民，胃癌发病率逐代下降病率逐代下降火山岩地火山岩地带、高泥碳土壤、水土含硝酸、高泥碳土壤、水土含硝酸盐过多、微量元素多、微量元素比例失比例失调、化学、化学污染可参与胃癌的染可参与胃癌的发生生饮食因素食因素多吃新多吃新鲜水果和蔬菜可降低胃癌的水果和蔬菜可降低胃癌的发生生经常食用霉常食用霉变食品、咸菜、腌制烟熏食品以及食品、咸菜、腌制烟熏食品以及过多的食多的食盐，增加胃癌的危增加胃癌的危险性性Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因和发病机制病因和发病机制-环境和饮食因素环境和饮食因素食物中食物中硝酸硝酸盐可以被可以被细菌菌还原成原成亚硝酸硝酸盐，与胺，与胺结合生成合生成亚硝胺硝胺胃内胃内细菌菌增加可以促增加可以促进亚硝酸硝酸盐类致癌物的致癌物的产生生 慢性胃炎慢性胃炎、胃部分切除胃部分切除、老年人老年人Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因和发病机制病因和发病机制-感染因素感染因素Hp Hp与胃癌有共同的流行病学特点与胃癌有共同的流行病学特点,胃癌高胃癌高发区区Hp感染率高感染率高;Hp抗体阳性人群抗体阳性人群发生胃癌的危生胃癌的危险性高于阴性人群性高于阴性人群 动物物实验示示:Hp可可诱发胃癌胃癌 1994年国年国际癌癌肿研究机构将研究机构将Hp定定为类致癌原致癌原Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因和发病机制病因和发病机制-感染因素感染因素Hp致胃癌的可能机制致胃癌的可能机制:1、Hp导致的慢性炎症致的慢性炎症内源性致突内源性致突变原原胃黏膜萎胃黏膜萎缩、肠化、不典型增生化、不典型增生癌癌变2、Hp还原原亚硝酸硝酸盐，N亚硝基化合物是公硝基化合物是公认的致癌物的致癌物3、Hp代代谢产物促物促进上皮上皮细胞胞变异异Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因和发病机制病因和发病机制-感染因素感染因素其他感染因素其他感染因素 EB病毒病毒Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因和发病机制病因和发病机制-遗传因素遗传因素胃癌有明胃癌有明显的的家族聚集家族聚集倾向向，家族，家族发病率高于人群病率高于人群2-3倍倍据据历史史记载，拿破，拿破仑一家三代人中大多死于胃癌：一家三代人中大多死于胃癌：祖父祖父死于胃癌；父死于胃癌；父亲死于胃癌；死于胃癌；三个妹妹三个妹妹也均患胃癌；他也均患胃癌；他本本人人也于也于1821年死于胃癌年死于胃癌少数胃癌属少数胃癌属遗传性胃癌易感性胃癌易感综合征，合征，浸浸润性胃癌性胃癌有更高的有更高的家族家族发病病倾向向Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因和发病机制病因和发病机制-癌前状态癌前状态癌前疾病癌前疾病-指与胃癌相关的胃良性疾病，有指与胃癌相关的胃良性疾病，有发生胃癌的危生胃癌的危险癌前病癌前病变指易指易转变成癌成癌组织的病理的病理组织学学变化，主要指化，主要指异型增生异型增生肠型化生：分小型化生：分小肠型和大型和大肠型型 异型增生：异型增生：胃黏膜腺管胃黏膜腺管结构及上皮构及上皮细胞失去正常的状胞失去正常的状态出出现异型性改异型性改变，组织学上介于良学上介于良恶性之性之间Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因和发病机制病因和发病机制-癌前状态癌前状态肠上皮化生、萎上皮化生、萎缩性胃炎及异型增生性胃炎及异型增生胃息肉胃息肉炎性息肉：多炎性息肉：多222cm的的广基息肉广基息肉胃胃溃疡发生率生率约0.5%2%，多因，多因溃疡边缘的炎症、糜的炎症、糜烂、再、再生及异型增生所致生及异型增生所致残胃炎残胃炎毕式胃大部切除式胃大部切除术后后1015年年发生，残胃癌生，残胃癌发生率生率约0.6%2.5%Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病理病理好好发部位部位胃胃窦(58%)(58%)、贲门(20%)(20%)、胃体、胃体(15%)(15%)、全胃或大部、全胃或大部分胃分胃(7%)(7%)早期胃癌早期胃癌病灶病灶局限且深度不超局限且深度不超过黏膜下黏膜下层的胃癌，而不的胃癌，而不论有无淋有无淋巴巴结转移移进展期胃癌展期胃癌胃癌深度超胃癌深度超过黏膜下黏膜下层，侵及肌，侵及肌层者称中期胃癌者称中期胃癌；侵及侵及浆膜或膜或浆膜外膜外者称晚期胃癌者称晚期胃癌Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病理病理Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病理病理-组织病理学组织病理学按腺体的形成及粘液分泌能力又可分按腺体的形成及粘液分泌能力又可分为乳乳头状腺癌、管状腺癌、粘液腺癌、印戒状腺癌、管状腺癌、粘液腺癌、印戒细胞癌、混合胞癌、混合性腺癌、腺性腺癌、腺鳞癌、髓癌、髓样癌、肝癌、肝样腺癌、腺癌、鳞状状细胞癌和未胞癌和未分化癌分化癌按分化程度按分化程度分化良好、分化中等、分化差分化良好、分化中等、分化差Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病理病理-侵袭与转移侵袭与转移直接蔓延直接蔓延直接侵入直接侵入邻近器官，近器官，胃底胃底贲门癌癌常侵犯食管、肝及大网常侵犯食管、肝及大网膜，膜，胃体癌胃体癌则侵犯大网膜、肝及胰腺侵犯大网膜、肝及胰腺淋巴淋巴转移移 先局部淋巴先局部淋巴结，再到，再到远处淋巴淋巴结，最常，最常见，Virchow淋淋巴巴结血行播散血行播散 以累及肝以累及肝脏多多见，其次肺、腹膜、，其次肺、腹膜、肾上腺、上腺、肾、脑、骨髓、骨髓腹腔内种植腹腔内种植癌癌细胞脱落入腹腔种植于胞脱落入腹腔种植于肠壁和盆腔，壁和盆腔，如如种植于卵巢称种植于卵巢称Krukenberg瘤瘤Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College临床表现临床表现-症状症状早期胃癌早期胃癌多无症状，部分患者可有消化不良症状多无症状，部分患者可有消化不良症状进展期胃癌展期胃癌上腹痛（餐后加重）、上腹痛（餐后加重）、纳差、差、厌食、乏力、体重减食、乏力、体重减轻并并发症或症或转移症状移症状累及食管下段累及食管下段-咽下困咽下困难、幽幽门梗阻梗阻-恶心、呕吐心、呕吐上消化道出血上消化道出血-呕血或黑呕血或黑粪胃癌胃癌肝肝转移移-右上腹痛、黄疸或右上腹痛、黄疸或发热胃癌胃癌肺肺转移移-咳嗽、呃逆、咯血咳嗽、呃逆、咯血胃癌胃癌胸膜胸膜转移移胸腔胸腔积液、呼吸困液、呼吸困难胃癌胃癌胰腺胰腺转移移背部反射性疼痛背部反射性疼痛Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College临床表现临床表现-体征体征早期胃癌早期胃癌 无明无明显体征体征晚期胃癌晚期胃癌上腹部包上腹部包块，上腹，上腹压痛痛胃癌胃癌肝肝转移移 肝大、黄疸、腹水肝大、黄疸、腹水胃癌胃癌腹膜腹膜转移移 腹水、移腹水、移动性性浊音音侵犯侵犯门静脉或脾静脉静脉或脾静脉脾脾脏增大增大远处淋巴淋巴结转移移Virchow淋巴淋巴结Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜检查胃镜检查胃胃镜结合黏膜活合黏膜活检是是诊断胃癌最可靠的手段。确断胃癌最可靠的手段。确诊率达率达959999%以上以上早期胃癌早期胃癌好好发部位：部位：胃胃窦及胃体及胃体胃胃镜下表下表现：息肉息肉样隆起或凹陷、平坦但黏膜粗糙、触隆起或凹陷、平坦但黏膜粗糙、触 之易出血，斑片状充血及糜之易出血，斑片状充血及糜烂染色胃染色胃镜、放大胃放大胃镜、窄窄带光成像光成像和和激光共聚焦激光共聚焦胃胃镜可以提高可以提高诊断率断率Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜检查胃镜检查早期胃癌内早期胃癌内镜分分类法：法：型（息肉型（息肉样型）：广基无蒂，常型）：广基无蒂，常2cm 型（浅表型）：本型最常型（浅表型）：本型最常见，又分三个，又分三个亚型型 a型（浅表隆起型）：病型（浅表隆起型）：病变稍高出黏膜，稍高出黏膜，0.50.5cm b型（浅表平坦型）：病型（浅表平坦型）：病变表面粗糙呈表面粗糙呈颗粒状粒状c型（浅表凹陷型）：凹陷型（浅表凹陷型）：凹陷0.50.5cm，底面粗糙，底面粗糙 型（型（溃疡型）：黏膜糜型）：黏膜糜烂比比c型深，但不超型深，但不超过黏膜下黏膜下层Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜检查胃镜检查Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜检查胃镜检查早期胃癌（早期胃癌（型）：胃角上息肉样隆起，表面充血、糜烂、型）：胃角上息肉样隆起，表面充血、糜烂、伴有少许出血，活检示低分化腺癌，手术证实为黏膜内癌伴有少许出血，活检示低分化腺癌，手术证实为黏膜内癌Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜检查胃镜检查早期胃癌（早期胃癌（aa型）：胃窦后壁丘样隆起，型）：胃窦后壁丘样隆起，类圆形、表面少许糜烂，活检示印戒细胞癌类圆形、表面少许糜烂，活检示印戒细胞癌Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜检查胃镜检查 早期胃癌（早期胃癌（型）：胃窦前壁溃疡，形不规则、边不整型）：胃窦前壁溃疡，形不规则、边不整基底覆以黄白苔，活检示黏膜内黏液细胞癌基底覆以黄白苔，活检示黏膜内黏液细胞癌Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜检查胃镜检查进展期胃癌展期胃癌胃胃镜下表下表现：肿瘤表面凹凸不平，糜瘤表面凹凸不平，糜烂，有，有污秽苔苔深大深大溃疡、底部覆有、底部覆有污秽苔，苔，溃疡边缘呈呈结节样隆起、隆起、无聚合无聚合皱襞，病襞，病变处无蠕无蠕动流出道狭窄流出道狭窄皮革胃皮革胃Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜检查胃镜检查 Bormann分型法：分型法：型：息肉型，型：息肉型，肿瘤向胃腔内生瘤向胃腔内生长隆起隆起型：型：溃疡型，型，单个或多个个或多个溃疡，边缘隆起，与黏膜分隆起，与黏膜分界清楚界清楚型：又称型：又称溃疡浸浸润型，隆起而有型，隆起而有结节状的状的边缘向四周向四周浸浸润，与正常黏膜分界不清，最常，与正常黏膜分界不清，最常见型：又称弥漫浸型：又称弥漫浸润型，癌型，癌发生于黏膜表生于黏膜表层之下，向四之下，向四周浸周浸润扩散，伴散，伴纤维组织增生，少增生，少见。如累及全胃，。如累及全胃，则胃胃变成一固定而不能成一固定而不能扩张的小胃，称的小胃，称为皮革胃皮革胃(linitis plastica)Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜检查胃镜检查Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜检查胃镜检查进展期胃癌（进展期胃癌（型）：胃体后壁球型）：胃体后壁球形隆起，表面糜烂不平、伴出血形隆起，表面糜烂不平、伴出血Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜检查胃镜检查进展期胃癌（进展期胃癌（型）：胃角巨大癌性溃疡，型）：胃角巨大癌性溃疡，基底不平、厚苔，周边环堤样隆起基底不平、厚苔，周边环堤样隆起Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜检查胃镜检查进展期胃癌（进展期胃癌（型）：胃角类圆形溃疡，型）：胃角类圆形溃疡，基底不平结节状，病变向周边浸润基底不平结节状，病变向周边浸润Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜检查胃镜检查超声内超声内镜 可可较准确判断准确判断肿瘤侵犯的深度，有助于早期和瘤侵犯的深度，有助于早期和进展期癌的展期癌的区分区分 可以了解有无局部淋巴可以了解有无局部淋巴结转移，作移，作为CT的的补充充Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜检查胃镜检查胃镜下胃镜下2.5cm隆起性包块，隆起性包块，EUS示局限于黏膜下层内的示局限于黏膜下层内的低回声，病理示腺癌低回声，病理示腺癌Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College实验室检查贫血血大便大便隐血阳性血阳性Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical CollegeX X线钡餐线钡餐表表现龛影或充盈缺影或充盈缺损，难以区分良以区分良恶性性黏膜黏膜皱襞破坏、消失或中断，襞破坏、消失或中断，临近胃黏膜僵直，蠕近胃黏膜僵直，蠕动消失，消失，胃癌可能性大胃癌可能性大Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College诊断诊断胃癌的胃癌的诊断主要依据胃断主要依据胃镜检查加活加活检对中上腹痛中上腹痛、消化不良消化不良、呕血呕血或或黑黑粪者及者及时行胃行胃镜检查对下列情况下列情况应定期胃定期胃镜检查：慢性萎慢性萎缩性胃炎伴性胃炎伴肠化生或异型增生者化生或异型增生者 胃胃溃疡经正正规治治疗2月无效月无效 胃大部切除胃大部切除术后后10年以上者年以上者Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College并发症出血出血多呈呕血或黑多呈呕血或黑粪、5%可可发生生难治性大出血治性大出血贲门或幽或幽门梗阻梗阻进食困食困难、呕吐、腹、呕吐、腹胀及及营养不良养不良穿孔穿孔 多多见于幽于幽门前区的前区的溃疡型癌型癌Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College治疗治疗早期胃癌早期胃癌没有淋巴没有淋巴结转移移时，可采取，可采取内内镜治治疗进展期胃癌展期胃癌没有全身没有全身转移移时，行，行手手术治治疗肿瘤切除后，瘤切除后，应尽可能清除残胃的尽可能清除残胃的Hp感染感染Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College治疗-内镜治疗内内镜下黏膜切除下黏膜切除术EMR（endoscopic mucosal resection)内内镜下黏膜剥离下黏膜剥离术ESD（endoscopic submucosal dissection)适用于高或中分化、无适用于高或中分化、无溃疡、直径小于、直径小于2cm且无淋巴且无淋巴结转移者移者切除切除组织送病理送病理检查，发现癌癌组织侵侵袭黏膜下黏膜下层，需追加，需追加手手术治治疗Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College治疗-内镜治疗Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College治疗-手术治疗早期胃癌可采取胃部分切除早期胃癌可采取胃部分切除术进展期胃癌如无展期胃癌如无远处转移，尽可能根治性切除移，尽可能根治性切除伴有伴有远处转移或伴有梗阻者，可行姑息手移或伴有梗阻者，可行姑息手术Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College治疗-化学治疗早期胃癌不伴有任何早期胃癌不伴有任何转移，移，术后一般不需要化后一般不需要化疗术前新前新辅助化助化疗可使可使肿瘤瘤缩小、增加手小、增加手术根治及治愈机会根治及治愈机会术后后辅助化助化疗 静脉化静脉化疗、腹腔内化、腹腔内化疗、持、持续性腹腔温性腹腔温热灌注、淋巴靶向化灌注、淋巴靶向化疗化化疗药物物5-氟尿氟尿嘧啶、替加氟、替加氟、丝裂霉素、阿霉素、裂霉素、阿霉素、顺铂、卡、卡铂、亚硝硝脲类、足叶乙足叶乙甙