需要最新執(zhí)業(yè)醫(yī)師、執(zhí)業(yè)藥師、主治醫(yī)師、護士護師、職稱英語等考試視請加藍鷹微信號NCCNClinicalPracticeGuidelinesinOncology GastricCContinue servd. .請加藍鷹微信號GuidelinesVersion1.2016Panel

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JafferA.Ajani,MD/Chair?¤TheUniversityofTexasMDAndersonCancerThomasA.D’Amico,MD/ViceChairDukeCancerKhaldounAlmhanna,MD,MPH?MoffittCancerCenterDavidJ.Bentrem,MD,MS?RobertH.LurieComprehensiveCancerCenterofNorthwesternJosephChao,MDCityofHopeComprehensiveCancerCenterPrajnanDas,MD,MS,MPHTheUniversityofMDAndersonCancerCrystalS.Denlinger,MD?FoxChaseCancerCenterPaulFanta,MDUCSanDiegoMooresCancerFarhoodFarjah,MDFredHutchinsonCancerResearchCharlesS.Fuchs,MD,MPHCancerCenterHansGerdes,MD¤TMemorialSloanKettering

MichaelGibson,MD,PhD?CaseComprehensiveCancerCenter/UniversityHospitalsSeidmanCancerCenterandClevelandClinicTaussigCancerRobertE.Glasgow,MD?HuntsmanCancerInstituteattheUniversityofUtahJamesA.Hayman,MD,MBA§UniversityofMichiganStevenHochwald,MD?RoswellParkCancerInstituteWayneL.Hofstetter,MD?TheUniversityofTexasMDAndersonCancerDavidH.Ilson,MD,PhD?TMemorialSloanKetteringCancerCenterDawnJaroszewski,MDMayoClinicCancerCenterKimberlyL.Johung,MD,PhD§YaleCancerCenter/SmilowCancerContinueRajeshN.Keswani,MD¤TRobertH.LurieComprehensiveCancerCenterofNorthwesternContinue

LawrenceR.Kleinberg,MD§TheSidneyKimmelComprehensiveCancerCenteratJohnsHopkinsW.MichaelKorn,MD¤?UCSFHelenDillerFamilyComprehensiveCancerStephenLeong,MD?UniversityofColoradoCancerCenterCatherineLinn,MDA.CraigLockhart,MD,MHSSitemanCanceratBarnes-JewishHospitalSchoolofMedicineFred&PamelaBuffettCancerCenteratTheNebraskaMedicalRobertH.LurieComprehensiveCancerCenterofNorthwesternMarkB.Orringer,MD?UniversityofMichigan?Medical¤

KyleA.Perry,MDTheOhioStateUniversityComprehensiveCancerCenter-JamesCancerHospitalandSoloveResearchJamesA.Posey,MDUniversityofAlabamaatBirminghamComprehensiveCancerCenterGeorgeA.Poultsides,MD,MS?StanfordCancerInstituteWalterJ.Scott,MDFoxChaseCancerVivianE.Strong,MDMemorialSloanKetteringCancerMaryKayWashington,MD,PhD≠Vanderbilt-IngramCancerCenterTheUniversityofTennesseeHealthScienceCenterChristopherG.Willett,MD§DukeCancerInstituteCameronD.Wright,MD?MassachusettsGeneralHospitalCancerCenterDebraZelman,JD￥Debbie’sDreamFoundation:CuringStomachCancerCancerNicoleMcMillian,

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?Surgery/SurgicalTInternal

≠￥Patient mitteeservd. .請加藍鷹微信號

GuidelinesPrinciplesofPalliative/BestPrinciplesofPalliative/BestSupportiveCareRajeshN.Keswani,MD¤T/LeadRobertH.LurieHansGerdes,MD¤MemorialSloanKetteringCancerRobertH.Lurie

PrinciplesofSurgeryVivianPrinciplesofSurgeryVivianE.Strong,MD?/LeadMemorialSloanKetteringCancerDavidJ.Bentrem,MD,MSRobertH.LurieComprehensiveCancerCenterofNorthwesternUniversityRobertE.Glasgow,MD?attheUniversityofUtahGeorgeA.Poultsides,MD,MSStanfordCancerPrinciplesofSystemicTherapyMaryF.Mulcahy,MD?/LeadRobertH.LurieComprehensiveJafferA.Ajani,MD?¤TheUniversityofTexasMDAndersonCancerKhaldounAlmhanna,MD,MPH?MoffittCancerCenterCrystalS.Denlinger,MDFoxChaseCancerDavidH.Ilson,MD,PhD?MemorialSloanKetteringCancerA.CraigLockhart,MD,MHSSitemanCancerCenteratBarnes-JewishHospitalandWashingtonUniversitySchoolofMedicinePrinciplesofRadiationTherapyLawrenceR.Kleinberg,MD§/LeadThePrinciplesofRadiationTherapyLawrenceR.Kleinberg,MD§/LeadTheSidneyKimmelComprehensiveCancerCenteratJohnsHopkinsPrajnanDas,MD,MS,MPH§TheUniversityofTexasMDAndersonCancerJamesA.Hayman,MD,MBA§UniversityofMichiganChristopherWillett,MD§DukeCancerInstitutePrinciplesofGeneticRiskAssessmentMaryKayWashington,MD,PhD≠/Co-LeadVanderbilt-IngramCancerCenterCrystalS.Denlinger,MD?FoxChaseCancerCenterDavidH.Ilson,MD,PhD?MemorialSloanKetteringCancerMarkB.Orringer,MD?UniversityofMichiganVivianE.Strong,MDMemorialSloanKetteringCancerMaryKayWashington,MD,PhDContinue¤?Surgery/Surgical¤?Surgery/SurgicaloncologyTInternalmedicine≠PrinciplesofEndoscopicStagingandHansGerdes,MD¤MemorialSloanKetteringCancerRajeshN.Keswani,MD¤TRobertH.LurieComprehensiveCancerCenterofNorthwesternservd. .請加藍鷹微信號

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ClinicalbelievesthebestClinicalbelievesthebestmanagementforanypatientisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.TofindclinicaltrialsonlineatMemberInstitutions,clickhere: .org/clinicalCategoriesofEvidenceandConsensus:All arecategory2AunlessotherwiseSee CategoriesofEvidenceandConsensus. GastricCancer mitteeSummaryoftheGuidelinesWorkupandEvaluation(GAST-PostlaparoscopyStagingandTreatment(GAST- esForPatientsWhoHaveNotReceivedPreoperativeTherapy(GAST-3) esForPatientsWhoHaveReceivedPreoperativeTherapy(GAST-4)PostTreatmentAssessment/AdditionalManagement(GAST-5)Follow-up/Surveillance,Recurrence(GAST-6)PalliativeManagement(GAST-7)PrinciplesofEndoscopicStagingandTherapy(GAST-A)PrinciplesofPathologicReviewandHER2-neuTesting(GAST-B)PrinciplesofSurgery(GAST-C)PrinciplesofGeneticRiskAssessmentforGastricCancer(GAST-PrinciplesofMultidisciplinaryTeamApproachEsophagogastricCancers(GAST-PrinciplesofSystemicTherapy(GAST-PrinciplesofRadiationTherapy(GAST-PrinciplesofPalliativeCare/BestSupportiveCare(GAST-H)Staging(ST-1)Guidelines?areastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestoAnyclinicianseekingtoapplyorconsultthe Guidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualclinicalcircumstancestodetermineanypatient’scareortreatment.TheNationalComprehensiveCancerNetwork?( ?)makesnorepresentationsorwarrantiesofanykindregardingtheircontent,useorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanyway.TheGuidelinesarecopyrightedby prehensiveCancerNetwork?.Allrightsreserved.The bereproducedinanyformwithouttheexpresswrittenpermissionof .?2016.servd. .請加藍鷹微信號GuidelinesVersion1.2016

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UpdatesinVersion1.2016of GuidelinesforGastricCancerfromVersion3.2015Notationsforclinical(c),surgical(yp),andpathological(p)stagingwereaddedtothetumorclassifcationasappropriatethroughouttheSeventhbulletrevised:"Endoscopicresection(ER)maycontributetoaccuratestagingofearly-stagecancers(T1aorT1b)."Twelfthbulletrevised:"Smokingcessationadvice,counseling,andpharmacotherapyasindicated."Locoregionalpathway:"Medicallyfit,unresectable"changedto"Surgically Footnote"f"revised:"SmokingcessationguidelinesareavailablefromtheU.S.PublicHealthServiceat:/professionals/ mendations/tobacco/clinicians/update/treating_tobacco_use08.pdf.See GuidelinesforSmokingFootnoteirevised:"MedicallyabletotoleratemajorabdominalFootnote"j"revised:"MedicallyunfitpatientsMedicallyunabletotoleratemajorsurgeryormedicallyfitpatientswhodeclineFootnote"k"revised:"Laparoscopywithcytologyisperformedtoevaluateforperitonealspreadwhenconsideringchemoradiationorsurgery.Laparoscopywithcytologyisnotindicatedifapalliativeresectionisplanned.LaparoscopywithcytologyisindicatedforclinicalstageT1borhigher."Underthenewcolumnheading"ConclusionsofMultidisciplinaryReview"revisedpathways,"LaparoscopicfindingsofLocoregionaldisease(cM0)"and"LaparoscopicfindingsofMetastaticdisease(cM1)."PostoperativemanagementforR0resection;pT2,N0:"ChemotherapyforpatientswhohaveundergoneprimaryD2lymphnodedissection"removedasanoption.AfterR0resection,tumorclassificationrevised:"T2,N0"changedto"Nodenegative(ypAnyT,N0)"and"T3,T4,AnyNorAnyT,N+"changedto"Nodepositive(ypAnyT,N+)."servd.

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Firstcolumnrevised:"Medicallyfit,UnresectablediseaseorupperGIendoscopy,asclinicallyGAST-APrinciplesofEndoscopyThefollowingtermsrevised:"T-stagecategory"and"M-Sectionheadingrevised:"NStagingCategorySecondbulletrevised:"Iflaparoscopywithcytologyisperformedasaseparateprocedure,peritonealwashingsshouldbeperformedaswell.Theterm"jejunostomytube"changedto"feedingGAST-F:PrinciplesofSystemicTherapy1of11Thirdbulletrevised:"FormetastaticadenocarcinomatrastuzumabcanbeaddedtochemotherapyiftumoroverexpressesHER2-neu.TrastuzumabshouldbeaddedtochemotherapyforHER2-neuoverexpressingmetastaticadenocarcinoma."Footnotereferenceswere2ofPreoperativeChemoradiation:"Irinotecanandcisplatin(category2B)"removedasanoption.ECF(epirubicin,cisplatin,andfluorouracil)changedcategory1tocategoryECFmodificationschangedfromcategory2Atocategory2Bforallmodifications.

3of11SystemicTherapyforMetastaticorLocallyCancer(wherelocaltherapyisnot"DCF(docetaxel,cisplatin,andfluorouracil)(category1)"removedasanoption.ThefollowingregimenswereremovedfromthelistofRegimens"andaddedtothelistof"OtherDCFECF(epirubicin,cisplatin,andfluorouracil)(categoryECFmodifications(category"Docetaxelandirinotecan"removedasanThe"AlternativeRegimensforConsideration"sectionwasremovedalongwiththefollowingsystemictherapyoptions:MitomycinandirinotecanMitomycinand4of11PrinciplesofSystemicTherapy—RegimensandDosingTheRegimenanddosingschedulespageswereupdatetothechangesonGAST-2of11andGAST-F3of10ofThereferencepageswereupdatedtoreflectthechangesintheGAST-G3of4PrinciplesofSupportiveCare:Thefollowingbulletremoved:"VitaminB12,iron,andcalciumlevelshouldbecloselymonitored,especiallyforpatientsreceivingpostoperativetreatment.MonthlyB12shotsmaybeneededbecauseoflossofintrinsicfactor.Ironabsorptionisreducedwithoutgastricacid.Oralsupplementation,givenwithacidsuchasorangejuice,canoftenmaintainadequatelevels.Calciumsupplementationshouldalsobeencouraged."servd.

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GastricCancerTableofUpperGIendoscopyandChest/abdomen/pelvicCTwithoralandIVcontrast

Medically

PET-CTevaluationifnoevidenceofdiseasebandifclinicallyCBCandcomprehensivechemistryEndoscopicultrasound(EUS)ifevidenceofM1diseaseEndoscopicresection(ER)

Medicallyfit,e,i

contributetoaccuratestagingofearly-stagecancers(T1aorT1b)cNutritionalassessmentandBiopsyofmetastaticdiseaseHER2-neutestingifmetastaticadenocarcinomaisdocumented/AssessSiewertSmokingcessationadvice,counseling,andpharmacotherapyasindicatedfScreenforfamily

Stage

aSeePrinciplesofEndoscopicStagingandTherapy(GAST-bMaynotbeappropriateforcEMRmayalsobetherapeuticforearly-stageeSeePrinciplesofSurgery(GAST- GuidelinesforSmokinggSeePrinciplesofGeneticRiskAssessmentforGastricCancer(GAST-D).Alsosee GuidelinesforColorectalCancerScreeningand GuidelinesforGenetic/FamilialHigh-RiskAssessment:BreastandOvarian.

hSeeStaging(ST-1)fortumoriMedicallyabletotoleratemajorjMedicallyunabletotoleratemajorsurgeryormedicallyfitpatientswhodeclinesurgery.kLaparoscopywithcytologyisperformedtoevaluateforperitonealwhenconsideringchemoradiationorsurgery.Laparoscopywithcytologyisnotindicatedifapalliativeresectionisplanned.LaparoscopywithcytologyisindicatedforclinicalstageT1borhigher.Note:Note: mendationsarecategory2AunlessotherwiseClinical believesthatthebestmanagementofanycancerpatientisinaclinicaltrial.Participationinclinicaltrialsisespecially搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視Version12016,03/31/16?NationalComprehensiveCancerNetwork,Inc.2016,Allrightsreserved. Guidelinesandthisillustrationmay搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視

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GastricCancerTableof

FINAL cTisor

MedicallyfitMedicallyfit,e,i

AnyN

(category1)(category2B)

forPatientsWhoHaveNotReceivedPreoperativeTherapy(seeGAST-3) Therapy(seeGAST-4)disease

chemoradiationn,o(category1)(Definitive)

(seeGAST-5)(seeGAST-5)MetastaticdiseaseaSeePrinciplesofEndoscopicStagingandTherapy(GAST-eSeePrinciplesofSurgery(GAST-C).hSeeStaging(ST-1)fortumorclassification.iMedicallyabletotoleratemajorsurgery.).

jMedicallyunabletotoleratemajorsurgeryormedicallyfitpatientswhodeclinesurgery.mSurgeryasprimarytherapyisappropriatefor≥T1bcanceroractivelybleedingcancer,orwhenpostoperativetherapyispreferred.nSeePrinciplesofSystemicTherapy(GAST-oSeePrinciplesofRadiationTherapy(GAST-Note:Note: mendationsarecategory2AunlessotherwiseClinical believesthatthebestmanagementofanycancerpatientisinaclinicaltrial.Participationinclinicaltrialsisespecially搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視Version12016,03/31/16?NationalComprehensiveCancerNetwork,Inc.2016,Allrightsreserved. Guidelinesandthisillustrationmay搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視

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Gastric

PATHOLOGICFINDINGS

(PatientsHaveNotReceived

pTisorpT1,

R0 pT2,

5-FU±leucovorinorthenfluoropyrimidine-basedR1resectionpR2resectionpeSeePrinciplesofSurgery(GAST-hSeeStaging(ST-1)fortumorclassification.nSeePrinciplesofSystemicTherapy(GAST-F).oSeePrinciplesofRadiationTherapy(GAST-G).

pT3,pT4,AnyorAnypT,

5-FU±leucovorinorthenfluoropyrimidine-basedthen5-FU±leucovorinorcapecitabinen,q(categorylymphnodedissectione,nChemoradiationn,o(fluoropyrimidine-based)

qSmalleySR,BenedettiJK,HallerDG,etal.UpdatedanalysisofSWOG-directedintergroupstudy0116:aphaseIIItrialofadjuvantradiochemotherapyversusobservationaftercurativegastriccancerresection.JClinOncol2012;30:2327-2333.SeePrinciplesofSystemicTherapy(GAST-F).rHigh-riskfeaturesincludepoorlydifferentiatedorhighergradecancer,lymphovascularinvasion,neuralinvasion,or<50yearsofageorpatientswhodidnotundergoD2lymphnodedissection.Note:Note: mendationsarecategory2AunlessotherwiseClinical believesthatthebestmanagementofanycancerpatientisinaclinicaltrial.Participationinclinicaltrialsisespecially搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視Version12016,03/31/16?NationalComprehensiveCancerNetwork,Inc.2016,Allrightsreserved. Guidelinesandthisillustrationmay搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視

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GastricCancerTableof PATHOLOGICFINDINGS(PatientsHaveReceivedPreoperativeChemotherapyor

R0R1R2

Node(ypAnyT,

ifreceivedpreoperatively(categoryifreceivedpreoperatively(categoryonlyifnotreceivedpreoperativelyonlyifnotreceivedPalliativeManagement(seeGAST-7),asclinically

hSeeStaging(ST-1)fortumorclassification.nSeePrinciplesofSystemicTherapy(GAST-F).oSeePrinciplesofRadiationTherapy(GAST-G).pR0=Nocanceratresectionmargins,R1=Microscopicresidualcancer,R2=MacroscopicresidualcancerorNote:Note: mendationsarecategory2AunlessotherwiseClinical believesthatthebestmanagementofanycancerpatientisinaclinicaltrial.Participationinclinicaltrialsisespecially搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視Version12016,03/31/16?NationalComprehensiveCancerNetwork,Inc.2016,Allrightsreserved. Guidelinesandthisillustrationmay搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視

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GastricCancerTableofPOST

Non-surgicalcandidatejfollowingprimary

Chest/abdomen/pelvicCTwithoralandIVcontrastCBCandcomprehensivechemistryPET/CTscanasclinically

MedicallyMetastatic

ifappropriateeSeePrinciplesofSurgery(GAST-jMedicallyunabletotoleratemajorsurgeryormedicallyfitpatientswhodeclineNote:Note: mendationsarecategory2AunlessotherwiseClinical believesthatthebestmanagementofanycancerpatientisinaclinicaltrial.Participationinclinicaltrialsisespecially搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視Version12016,03/31/16?NationalComprehensiveCancerNetwork,Inc.2016,Allrightsreserved. Guidelinesandthisillustrationmay搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視

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GastricCancerTableof every3–6mofor1–2every6–12mofor3–5y,thenannuallyCBCandprofileasRadiologicimagingorupperGIendoscopy,asclinicallyindicatedMonitorfornutritionaldeficiency(eg,B12andiron)insurgicallyresectedpatientsandtreatasindicated

Resectableandormedically

PalliativeManagement

SeePalliativeSeePalliativeManagementeSeePrinciplesofSurgery(GAST-sReviewifsurgeryisappropriateforpatientswithisolatedlocalrecurrences.SurgeryshouldbeconsideredasanoptionforlocoregionalrecurrenceinmedicallyfitNote:Note: mendationsarecategory2AunlessotherwiseClinical believesthatthebestmanagementofanycancerpatientisinaclinicaltrial.Participationinclinicaltrialsisespecially搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視Version12016,03/31/16?NationalComprehensiveCancerNetwork,Inc.2016,Allrightsreserved. Guidelinesandthisillustrationmay搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視

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GastricCancerTableofPERFORMANCESTATUS ECOGperformancescore

SystemicClinicaltrialUnresectablelocallyadvanced,LocallyrecurrentormetastaticKarnofskyperformancescore<60%ECOGperformancescore

nSeePrinciplesofSystemicTherapy(GAST-tSeePrinciplesofPalliative/BestSupportiveCare(GAST-Note:Note: mendationsarecategory2AunlessotherwiseClinical believesthatthebestmanagementofanycancerpatientisinaclinicaltrial.Participationinclinicaltrialsisespecially搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視Version12016,03/31/16?NationalComprehensiveCancerNetwork,Inc.2016,Allrightsreserved. Guidelinesandthisillustrationmay搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視

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GastricCancerTableofPRINCIPLESOFENDOSCOPICSTAGINGANDEndoscopyhas eanimportanttoolinthediagnosis,staging,treatment,andpalliationofpatientswithgastriccancer.Althoughsomeendoscopyprocedurescanbeperformedwithoutanesthesia,mostareperformedwithconscioussedationadministeredbytheendoscopistorassistingnurseordeeperanesthesia(monitoredanesthesiacare)providedbytheendoscopistandnurse,anurseanesthetist,orananesthesiologist.Somepatientswhoareatriskforaspirationduringendoscopymayrequiregeneralanesthesia.Diagnosticandsurveillanceendoscopiesareperformedwiththegoalofdeterminingthepresenceandlocationofneoplasticdiseaseandtobiopsyanysuspiciouslesion.Thus,anadequateendoscopicexamaddressesbothofthesecomponents.Thelocationofthetumorinthestomach(cardia,fundus,body,antrum,andpylorus)andrelativetotheesophagogastricjunction(EGJ)forproximaltumorsshouldbecarefullyrecordedtoassistwithtreatmentplanningandfollow-upexaminations.Multiple(6–8)biopsiesusingstandardsizeendoscopyforcepsshouldbeperformedtoprovideadequatesizedmaterialforinterpretation,especiallyinthesettingofanulceratedlesion.1,2LargerforcepsmayimprovetheEndoscopicmucosalresection(EMR)orendoscopicsubmucosaldissection(ESD)canbeperformedintheevaluationofsmalllesions.EMRorESDoffocalnodules≤2cmcanbesafelyperformedtoprovidealargerspecimenthatcanbebetterassessedbythepathologist,providinggreaterinformationondegreeofdifferentiation,thepresenceoflymphovascularinvasion(LVI),andthedepthofinfiltration,therebyprovidingaccurateT-staging.3Suchexcisionalbiopsieshavethepotentialofbeingtherapeutic.4Cytologicbrushingsorwashingsarerarelyadequateintheinitialdiagnosis,butcanbeusefulinconfirmingthepresenceofcancerbiopsiesarenotNote:Note: mendationsarecategory2AunlessotherwiseClinical believesthatthebestmanagementofanycancerpatientisinaclinicaltrial.Participationinclinicaltrialsisespecially搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視Version12016,03/31/16?NationalComprehensiveCancerNetwork,Inc.2016,Allrightsreserved. Guidelinesandthisillustrationmay搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視

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GastricCancerTableofPRINCIPLESOFENDOSCOPICSTAGINGANDEndoscopicultrasound(EUS)performedpriortoanytreatmentisimportantintheinitialclinicalstagingofgastriccancer.5Carefulattentiontoultrasoundimagesprovidesevidenceofdepthoftumorinvasion(T-category),presenceofabnormalorenlargedlymphnodeslikelytoharborcancer(N-assessment),andoccasionallysignsofdistantspread,suchaslesionsinsurroundingorgans(M-category)orthepresenceofascites.6Thisisespeciallyimportantinpatientswhoarebeingconsideredforendoscopicresection(EMRorESD).7Hypoechoic(dark)expansionofthegastricwalllayersidentifiesthelocationoftumor,withgraduallossofthelayeredpatternofthenormalstomachwallcorrespondingwithgreaterdepthsoftumorpenetration,correlatingwithhigherT-categories.Adarkexpansionoflayers1–3correspondwithinfiltrationofthesuperficialanddeepmucosaplusthesubmucosal,T1disease.Adarkexpansionoflayers1–4correlateswithpenetrationintothemuscularispropria,T2disease,andexpansionbeyondthemuscularispropriaresultinginanirregularouterborderthatcorrelateswithinvasionofthesubserosa,T3disease.LossofthebrightlinerecognizedastheserosaisnowstagedaspT4a,andextensionofthemassintosurroundingorganssuchastheliver,pancreas,andspleenisstagedaspT4bdisease.PerigastriclymphnodesarereadilyseenbyEUS,andtheidentificationofenlarged,hypoechoic(dark),homogeneous,wellcircumscribed,roundedstructuresaroundthestomachcorrelateswiththepresenceofmalignantorinflammatorylymphnodes.Theaccuracyofthisdiagnosisissignificantlyincreasedwiththecombinationoffeatures,butalsomaybeconfirmedwiththeuseoffine-needleaspiration(FNA)biopsyforcytologyassessment.8FNAofsuspiciouslymphnodesshouldbeperformedifitcanbeachievedwithouttraversinganareaofprimarytumorormajorbloodvessels,andifitwillimpactontreatmentdecisions.Furthermore,anattemptshouldbemadetoidentifythepresenceofascitesandFNAconsideredtoruleoutperitonealspreadofNote:Note: mendationsarecategory2AunlessotherwiseClinical believesthatthebestmanagementofanycancerpatientisinaclinicaltrial.Participationinclinicaltrialsisespecially搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視Version12016,03/31/16?NationalComprehensiveCancerNetwork,Inc.2016,Allrightsreserved. Guidelinesandthisillustrationmay搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視

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GastricCancerTableofPRINCIPLESOFENDOSCOPICSTAGINGANDEMRorESDofearly-stagegastriccancercanbeconsideredadequatetherapywhenthelesionis≤2cmindiameter,isshownonhistopathologytobewellormoderatelywelldifferentiated,doesnotpenetratebeyondthesuperficialsubmucosa,doesnotexhibitLVI,andhasclearlateralanddeepmargins.En-blocexcisionofsmallgastriclesionsbyESDhasbeenshowntobemoreeffectivethanEMRincuringsmallearly-stagegastriccancer,butrequiresgreaterskillsandinstrumentationtoperformandhasasignificantriskofcomplicationsincludingperforation.9JapaneseGastricCancer mendthatEMRorESDshouldbeconsideredforearly-stagegastriccancerlesions≤2cmdiameterwithoutassociatedulcerEMRorESDofgastriccancersthatarepoorlydifferentiatedharborevidenceofLVI,invadeintothedeepsubmucosa,havepositivelateralordeepmarginsorlymphnodemetastases,andshouldbeconsideredtobe plete.Additionaltherapybygastrectomywithlymphadenectomyshouldbeconsidered.10EUSperformedafterchemotherapyorradiationtherapyhaveareducedabilitytoaccuratelydeterminethepost-treatmentstageofSimilarly,biopsiesperformedafterchemotherapyorradiationtherapymaynotaccuratelydiagnosethepresenceofresidualdiseasebutstillprovideusefulinformation.12Endoscopictumorablationcanbeperformedfortheshort-termcontrolofbleeding.Endoscopicinsertionofexpandablemetalstentsiseffectiveinlong-termreliefoftumorobstructionattheEGJorthegastricoutlet,thoughsurgicalgastrojejunostomymaybemoreefficaciousforthosewithlonger-termsurvival(seePrinciplesofPalliativeCare/BestSupportiveCare[GAST-H]).13,14Long-termpalliationofanorexia,dysphagia,ormalnutritionmaybeachievedwithendoscopic-orradiographic-assistedplacementoffeedinggastrostomy(PEG)incarefullyselectedcaseswherethedistalstomachisuninvolvedbytumor,ortheplacementofafeedingjejunostomy(PEJ).15Endoscopicsurveillancefollowingdefinitivetreatmentofgastriccancerrequirescarefulattentiontodetailformucosalsurfacechanges,andmultiple(4–6)biopsiesofanyvisualizedabnormalities.Stricturesshouldbebiopsiedtorule-outneoplasticcause.EUSperformedinconjunctionwithendoscopyexamshasahighsensitivityforrecurrentdisease.16EUS-guidedFNAshouldbeperformedifsuspiciouslymphnodesorareasofwallthickeningareseen.Note:Note: mendationsarecategory2AunlessotherwiseClinical believesthatthebestmanagementofanycancerpatientisinaclinicaltrial.Participationinclinicaltrialsisespecially搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視Version12016,03/31/16?NationalComprehensiveCancerNetwork,Inc.2016,Allrightsreserved. Guidelinesandthisillustrationmay搜索公眾號：藍鷹執(zhí) 關注后即可免費獲取各類考試視

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GastricCancerTableofPRINCIPLESOFENDOSCOPICSTAGINGAND1HatfieldAR,SlavinG,SegalAW,LeviAJ.Importanceofthesiteofendoscopicgastricbiopsyinulceratinglesionsofthestomach.Gut.1975;16:884-886.DYSchwartzJT,CainGD,GyorkeyF.Prospectiveevaluationofbiopsynumberinthediagnosisofesophagealandgastriccarcinoma.Gastroenterology4AkiyamaM,OtaM,NakajimaH,YamagataK,MunakataA.Endoscopicmucosalresectionofgastricneoplasmsusingaligatingdevice.GastrointestEndosc.5BotetJF,LightdaleCJ,ZauberAG,etal.Endoscopicultrasoundinthepre-operativestagingofgastriccancer:AcomparativestudywithdynamicCT.6BentremD,GerdesH,TangL,BrennanM,CoitD.Clinicalcorrelationofendoscopicultrasonographywithpathologicstageand einpatientsundergoingcurativeresectionforgastriccancer.AnnSurgOncol.2007;14:1853-1859.7OkadaK,FujisakiJ,KasugaA,etal.Endoscopicultrasonographyisvaluableforidentifyingearlygastriccancersmeetingexpanded-indicationcriteriafor8KeswaniRN,EarlyDS,EdmundowiczSA,etal.RoutinepositronemissiontomographydoesnotalternodalstaginginpatientsundergoingEUS-guidedFNA9YahagiN,FujishiroM,KakushimaN,etal.Endoscopicsubmucosaldissectionforearlygastriccancerusingthetipofanelectrosurgicalsnare(thintype).DigEndosc esafterendoscopicresectionforearlygastriccancer:1370casesofabsoluteandextended11ParkSR,LeeJS,KimCG,etal.Endoscopicultrasoundandcomputedtomographyinrestagingandpredictingprognosisafterneoadjuvantchemotherapyinpatientswithlocallyadvancedgastriccancer.Cancer2008;112:2368-2376.12SarkariaIS,RizkNP,BainsMS,etal.Post-treatmentendoscopicbiopsyisapoor-predictorofpathologicresponseinpatientsundergoingchemoradiationtherapyforesophagealcancer.AnnSurg2009;249:764-767.13SchmidtC,GerdesH,HawkinsW,etal.Aprospectiveobservationalstudyexaminingqualityoflifeinpatientswithmalignantgastricoutletobstruction.AmJ14VakilN,MorrisAI,MarconN,etal.Aprospective,randomized,controlledtrialofcoveredexpandablemetalstentsinthepalliationofmalignantesophagealobstructionatthegastroesophagealjunction.AmJGastroenterol2001;96:1791-1796.15ShikeM,LatkanyL,GerdesH,BlochAS.Directpercutaneousendoscopicjejunostomiesforenteralfeeding.GastrointestEndosc1996;44:536-540.16LightdaleCJ,BotetJF,KelsenDP,TurnbullAD,BrennanMF.Diagnosisofrecurrentuppergastrointestinalcanceratthesurgicalanastomosisbyendoscopicultrasound.GastrointestEndosc1989;35:407-412.Note: mendationsarecategory2AunlessotherwiseClinical believesthatthebestmanagementofanycancerpatientisinaclinicaltrial.Participationinclinicaltrialsisespecially搜索公眾Note: mendationsarecategory2Aunlessoth