Σταδιοποίηση σε Ca Στομάχου

Ca Στομάχου

AJCC Stages

Stages

T

N

M

0

Tis

N0

M0

IA

T1

N0

M0

IB

T2

N0

M0

T1

N1

M0

IIA

T3

N0

M0

T2

N1

M0

T1

N2

M0

IIB

T4a

N0

M0

T3

N1

M0

T2

N2

M0

T1

N3

M0

IIIA

T4a

N1

M0

T3

N2

M0

T2

N3

M0

IIIB

T4b

N0

M0

T4b

N1

M0

T4a

N2

M0

T3

N3

M0

IIIC

T4b

N2

M0

T4b

N3

M0

T4a

N3

M0

IV

Any T

Any N

M1

(T) Primary Tumor

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, muscularis mucosae, or submucosa

T1a

Tumor invades lamina propria or muscularis mucosae

T1b

Tumor invades submucosa

T2

Tumor invades muscularis propria¹

T3

Tumor penetrates subserosal connective tissue without invasion of visceral peritoneum or adjacent structures²

T4

Tumor invades serosa (visceral peritoneum) or adjacent structures²

T4a

Tumor invades serosa (visceral peritoneum)

T4b

Tumor invades adjacent structures

¹A tumor may penetrate the muscularis propria with extension into the gastrocolic or gastrohepatic ligaments, or into the greater or lesser omentum, without perforation of the visceral peritoneum covering these structures. In this case, the tumor is classified T3. If there is perforation of the visceral peritoneum covering the gastric ligaments or the omentum, the tumor should be classified T4. 
²The adjacent structures of the stomach include the spleen, transverse colon, liver, diaphragm, pancreas, abdominal wall, adrenal gland, kidney, small intestine, and retroperitoneum. Intramural extension to the duodenum or esophagus is classified by the depth of the greatest invasion in any of these sites, including the stomach.

(N) Regional Lymph Nodes

NX

Regional lymph node(s) cannot be assessed

N0

No regional lymph node metastasis³

N1

Metastasis in 1-2 regional lymph nodes

N2

Metastasis in 3-6 regional lymph nodes

N3

Metastasis in ≥ 7 regional lymph nodes

N3a

Metastasis in 7-15 regional lymph nodes

N3b

Metastasis in ≥ 16 regional lymph nodes

³A designation of pN0 should be used if all examined lymph nodes are negative, regardless of the total number removed and examined.

(M) Distant Metastasis

M0

No distant metastasis

M1

Distant metastasis

Χαρακτηριστικά Επέκτασης

Submucosal spread

• Main mechanism of transpyloric spread of tumor into duodenum
  • Brunner glands believed to prevent direct cancer invasion from gastric mucosa to duodenal mucosa

Subperitoneal spread

• Tumor may penetrate muscularis propria with extension within subperitoneal space without perforation of visceral peritoneum
  • Such tumor is classified T3
• Tumor may spread to adjacent organs between peritoneal layers forming ligaments around stomach
• Spread to left lobe of liver via gastrohepatic ligament (GHL)
  • GHL stretches from cardia and lesser curvature to insert into fissure of ligamentum venosum
  • GHL identified by presence of left and right gastric vessels
• Spread to liver via hepatoduodenal ligament (HDL)
• HDL is free edge of gastrohepatic ligament, extends from upper aspect of proximal duodenum to liver hilum
• HDL contains hepatic artery, bile duct, and portal vein
• GSL attaches posterolateral wall of fundus and greater curvature to splenic hilum
• GSL carries short gastric and leftmost parts of left gastroepiploic vessels
• GCL extends from greater curvature to transverse colon and extends anteriorly to form greater omentum, which covers colon and small intestine
• GCL contains right and most of left gastroepiploic vessels
• Spread to spleen via gastrosplenic ligament (GSL)
• Spread to transverse colon via gastrocolic ligament (GCL)
• Spread to pancreas via lesser sac

Peritoneal spread

• Tumor invading serosa can seed into peritoneal cavity
• Krukenberg tumors
  • Metastatic tumor to ovaries through peritoneal seeding
  • Usually bilateral

Nodal spread

• Perigastric lymph nodes are involved early and later drain into central nodes around celiac axis and superior mesenteric artery
  • Tumors along lesser curvature of body and esophagogastric junction (area supplied by left gastric artery) → gastrohepatic ligament nodes → left gastric nodes → suprapancreatic nodes → celiac nodes
  • Tumors along lesser curvature of antrum and pylorus (area supplied by right gastric artery) → hepatoduodenal ligament nodes → nodes along hepatic artery → celiac nodes
  • Tumors along greater curvature (area supplied by right gastroepiploic artery) → nodes accompanying right gastroepiploic vessels → nodes at gastrocolic trunk or gastroduodenal nodes → superior mesenteric or celiac nodes
  • Tumors along greater curvature of body (area supplied by left gastroepiploic artery) → nodes along left gastroepiploic vessels → splenic hilum nodes → celiac nodes
• Risk factors for lymph node metastasis include
• Lymphovascular invasion
• Depth of invasion (submucosa)
• Tumor diameter > 20 mm
• Ulcer or ulcer scar
• Mucinous adenocarcinoma histological type

Hematogenous spread

• Usually involves liver, lungs, and bones

Κατηγοριοποίηση (Ιστολογικοί Τύποι)

• Adenocarcinoma
  • Intestinal type
  • Diffuse type
• Papillary adenocarcinoma
• Tubular adenocarcinoma
• Mucinous adenocarcinoma
  • Substantial amount of extracellular mucin (> 50% of tumor) is retained within tumor

• Signet ring cell carcinoma (> 50% signet ring cells)
• Adenosquamous carcinoma
• Squamous cell carcinoma
• Small cell carcinoma
• Undifferentiated carcinoma
• Other