Stomach cancer in the elderly
Introduction
Introduction to gastric cancer in the elderly Gastric cancer (gastric cancer) is the most common gastric tumor, which is derived from the epithelial malignant tumor, namely gastricadenocarcinoma. basic knowledge Sickness ratio: 0.05% Susceptible people: the elderly Mode of infection: non-infectious Complications: pyloric obstruction, abdominal pain
Cause
The cause of gastric cancer in the elderly
Nitroso compound (20%):
Nitroso compounds are a large class of chemical carcinogens, among which non-volatile nitrite amines such as N-methyl N-nitro N-nitrosoguanidine (MNNG), N-ethyl N-nitrosoguanidine (ENNG) can induce rat, dog gastric adenocarcinoma, and can observe gastric mucosal intestinal metaplasia, dysplasia and other precancerous lesions, naturally occurring nitroso compounds are extremely small, the main source is endogenous synthesis in vivo The nitroso compound can also synthesize nitroso compounds at low pH in gastric juice. When gastric mucosal lesions occur, such as gastric gland atrophy, parietal cells decrease, and gastric juice pH increases, gastric bacteria can accelerate nitrate. Reduction to a nitroso compound, it can be seen that the human gastric mucosa can be directly attacked by nitroso compounds under normal or damaged conditions.
Polycyclic aromatic hydrocarbon compounds (20%):
Carcinogens can contaminate food or form during processing. For example, Iceland is a country with high incidence of gastric cancer. Most of the residents live in fisheries and animal husbandry. They have the habit of eating smoked fish and smoked lamb. The samples of smoked fish and smoked lamb are found. There are a large number of carcinogens, including polycyclic aromatic hydrocarbons, including 3,4-benzoquinone. A large number of animal experiments have shown that experimental animals are also carcinogenic when fed to smoked foods.
Dietary factors (20%):
China's gastric cancer case matching research results show that high salt diet, pickled foods, fried foods, three meals irregularly, fast eating, eating too much, eating hot food, etc., increase the risk of gastric cancer incidence, intake High concentration of salt can damage the gastric mucosal barrier, cause mucosal cell edema, loss of gland, and high salt in the administration of carcinogenic nitroso compounds can increase the gastric cancer induction rate, and the induction time is also short, which promotes the occurrence of gastric cancer. effect.
Fresh vegetables, fresh beans, soybeans and their products, fresh fish, meat, eggs, milk can reduce the risk of gastric cancer. The consistency of epidemiological studies around the world shows that fresh vegetables and fruits have protective effects against gastric cancer, fresh vegetables. The fruit contains many nutrients needed by the human body, especially vitamins have anti-cancer effects.
These substances bind to carcinogens competitively, scavenging the formation of free radicals in the body, degrading poisons, protecting DNA, protecting macromolecules from carcinogens, stabilizing cell membranes, promoting normal cell differentiation, and other ways to achieve anticancer effects. Vitamins C has a strong ability to block nitroso compounds, and -carotene has antioxidant capacity, which can be converted into vitamin A in the small intestine to maintain cell growth and differentiation. Therefore, these two types of vitamins are likely to block carcinogenesis and Increase the ability of cell repair to reduce the incidence of gastric cancer.
Helicobacter pylori (10%):
Helicobacter pylori infection is associated with gastric cancer, based on the following reasons: Helicobacter pylori is rarely isolated in normal gastric mucosa, and the infection rate of Helicobacter pylori is increased with the increase of gastric mucosal lesions. It is currently considered that Helicobacter pylori is not a direct carcinogen of gastric cancer. However, through the injury of the gastric mucosa, the conditional factors that promote the development of the lesion increase the risk of gastric cancer. Helicobacter pylori can release a variety of cytotoxic and inflammatory factors and participate in local immunity, and the pylorus is found in the serum before measuring the disease of the gastric cancer patient. The positive rate of Helicobacter antibody was significantly higher than that of the control group, which was a risk factor for gastric cancer.
In addition, smoking, genetic, psychological factors, trace elements, chronic gastric diseases such as chronic atrophic gastritis (CAG), intestinal mucosal intestinal metaplasia (IM) and dysplasia (DYS) have been reported, and are also associated with gastric cancer.
Pathogenesis
Precursors of gastric cancer can be divided into two categories: precancerous conditions and precancerous lesions, gastric benign diseases, and the risk of developing gastric cancer, but not necessarily cancerous or the former is Refers to the ultimate fate of these diseases, the latter refers to the pathological changes of transformed cancer.
1. Precancerous status of gastric cancer (Table 1)
(1) Chronic atrophic gastritis: atrophic gastritis is a common chronic gastric disease. The rate of gastroscopy in the high-risk area of gastric cancer is as high as 80%, and the mortality rate is positively correlated with the prevalence of atrophic gastritis. The degree of atrophic gastritis is high, the detection rate of intestinal metaplasia is high, and the population of high and low gastric cancer in 8 provinces of China is surveyed. The long-term follow-up (more than 10 years) can reduce the cancer rate of atrophic gastritis by 10%. Pathological features atrophic gastritis Occurs in the antrum of the stomach, chronic inflammation of the mucosa with atrophy of the intrinsic gland, may have intestinal metaplasia or epithelial hyperplasia.
(2) Gastric ulcer: At present, most authors believe that chronic gastric ulcer will develop cancer, the incidence rate is about 0.5% to 2%. The pathological standard for judging the gastric ulcer is the complete destruction of the mucosal membrane, the adhesion of the ulcer mucosa to the muscular layer, and ulceration. The bottom muscle layer is completely destroyed by dense fibrous connective tissue and granulation tissue. The mechanism is inflammation, erosion, regeneration and repair of regenerated epithelial cells, and the differentiation is not mature enough. The cells are prone to cancer under the action of carcinogens. In addition, the cancer that occurs at the edge of the ulcer, the proportion of signet ring cell carcinoma is high and the common gastric cancer group, this feature is also an evidence to support the canceration of ulcers.
(3) Residual gastric cancer: residual stomach as a precancerous state, its relationship with gastric cancer has also been paid attention to, generally advocated, should be due to benign lesions after more than 10 years of gastric resection, cancer in the residual stomach, generalized Including patients with gastric cancer after 15 years of surgery, collectively referred to as residual gastric cancer, the incidence of residual gastric cancer is about 1% to 5.5%, biopsy pathological findings, often found in the anastomotic site with chronic atrophic gastritis Intestinal metaplasia and epithelial cell atypicality, combined with alkaline intestinal reflux, bile pancreatic juice reflux, low acid environment, gastric motility disorder, bacterial growth and nitroso compound synthesis are important factors in gastric cancer. It may become a prodromal lesion of gastric cancer. In addition, cancer that occurs after gastrojejunostomy is often associated with hyperplastic polyps. This polyp is accompanied by cystic changes in the gland.
2. Gastric cancer precancerous lesions
(1) dysplasia: also known as atypical epithelial hyperplasia (atypical epithelial hyperplasia), heterotypic epithelial hyperplasia is the gastric mucosal glandular structure and epithelial cells lose their normal state of atypical (atypical) changes, morphology and regeneration Different from simple hyperplasia, the histological boundary between benign and malignant lesions, its basic pathological features include three aspects:
1 Atypicality of cells, including an increase in the proportion of nucleoplasm, atypicality of the nucleus, and the like.
2 Abnormal differentiation, including the reduction or even disappearance of goblet cells in the metaplastic epithelium, the loss of differentiation characteristics of the gastric gland (pyloric gland or corpus callosum), and the reduction of secretion or changes in secretion traits.
3 structural disorder, including irregular gland shape, back-to-back and common wall phenomenon, gland branching, budding, papillary hyperplasia and so on.
In recent years, the research on dysplasia in China has been divided into 5 types, namely adenoma type, crypt type, regenerative type, globular type and sac-like type. The adenoma type is derived from intestinal metaplasia, starting from the shallow layer of gastric mucosa, cancerous It becomes a well-differentiated adenocarcinoma; the crypt type also occurs in the intestinal metaplasia gland, starting from the deep mucosa of the glandular crypt, the cancer becoming a highly differentiated or moderately differentiated adenocarcinoma, and the regenerative type is often regenerated after gastric mucosal defect. The glandular duct and epithelium mainly develop into poorly differentiated adenocarcinoma or undifferentiated adenocarcinoma. The globular changes occur between the pyloric gland or the intestinal metaplasia glandular epithelium, showing a large amount of mucus in the cytoplasm, and the cell body is spherical. Development of signet ring cell carcinoma, saccular gland expansion with epithelial epithelial heterotypic, only in the vicinity of cancer, the detection rate of atypical epithelial hyperplasia in high-incidence areas of gastric cancer can reach 20%, higher than the low-incidence area, the detection rate Increase with age, and more men than women, occur in the stomach antrum and stomach angle, concentrated in the side of the cancer, dysplasia can continue to 5% or so after 5 to 10 years of cancer.
(2) Gastric mucosa intestinal metaplasia: the intrinsic mucosal epithelium and fundic gland of the stomach, the cardia gland, the pyloric gland is transformed into intestinal epithelial cells, which are called intestinal metaplasia, and the metaplastic epithelial cells are composed of absorbed cells. Cup-shaped cells, Paneth cells, intestinal metaplasia with gastric cancer, 60% to 100%, the predilection site is consistent, according to the different enzyme content and activity of intestinal metaplasia, the enzyme-containing high activity is called Complete intestinal metaplasia, those with less enzymes are called incomplete intestinal metaplasia, those with complete differentiation are small intestines, and those with incomplete differentiation are large intestines, and two types of intestinal metaplasia can be The gastric mucosa exists at the same time. The small intestine is more common in benign lesions, and the large intestine is more common in cancer. It is considered that the large intestine metaplasia is a precancerous lesion of gastric cancer.
3. Early gastric cancer
(1) General type:
1 uplift type (type I): the prominent focus of the cancerous lesion protrudes into the stomach cavity, which is polypoid and the height exceeds 0.5cm.
2 superficial type (type II): superficial cancerous foci, no obvious uplifts and depressions, divided into 3 subtypes:
Type IIa: superficial bulge type with a height below 0.5 cm.
Type IIb: superficially flat.
Type IIc: shallow depression type, the depression does not exceed 0.5cm.
3 concave type (type III): also known as ulcer type, the depression is above 0.5cm.
4 mixed type: There are two forms of coexistence, with IIc+III, IIc+IIa as the most.
Among the 3 types, the most common type is the concave type, and the flat type is the least.
(2) Histological type: According to the morphological classification, it is divided into papillary duct adenocarcinoma, ductal gland mucinous adenocarcinoma and cordoid adenocarcinoma. According to the classification of gastric cancer research, tubular adenocarcinoma is the most common, accounting for 60%, followed by poorly differentiated gland. Cancer accounts for 15%, papillary adenocarcinoma, undifferentiated cancer is rare, and mucinous cell carcinoma accounts for about 5%.
(3) Staging: The Japanese Endoscopy Society proposed in 1962 that the depth of gastric cancer tissue infiltration was limited to the mucosa or submucosa, regardless of the size of the tumor or the presence or absence of lymph node metastasis as early gastric cancer.
In the early gastric cancer, the area with the largest diameter of 5.1 to 10 mm is called small-gastric cancer, and those below 5 mm are microgastric cancer, ultra microcarcinoma, also known as "spotted cancer" or "a little bit." "Pig point carcinoma" refers to the endoscopic biopsy confirmed the diagnosis of gastric cancer. All the serial sections of the surgically resected specimens have not found cancer. It may be that the biopsy forceps cut off the cancer and the hemorrhage and mechanical damage during biopsy, so that the residual cancer tissue remains. Shedding, 16 cases have been officially reported in China, and have been reported abroad.
(4) Metastasis of early gastric cancer: the most common is lymph node metastasis, about 5% of intramucosal cancer, about 25% of submucosal cancer, local lymph node metastasis, in addition to lymph node metastasis, there may be organ metastasis, most commonly seen in the liver. Only 0.5% of all cancers, this type of early cancer infiltration depth as much as submucosal, mostly bulging type, mostly differentiation, often with vascular tumor thrombus and lymph node metastasis.
4. Progressive gastric cancer
When the infiltration of cancerous tissue reaches the muscular layer, the serosal layer or the serosa outside is called advanced gagtric cancer, also known as advanced gastric cancer.
(1) General classification: Borrmann (1926) classified advanced gastric cancer into polyp type (type I), ulcer type (type II), infiltrating ulcer type (type III) and diffuse infiltrating type (type IV).
Type I: polypoid type, the tumor mainly grows into the gastric cavity, the bulge is obvious, it is polypoid, the basement is wide, the boundary is clear, the ulcer is rare, but there may be small erosion, which is the rarest in advanced gastric cancer. The type is about 3% to 5%.
Type II: limited ulcer type, the tumor has a large ulcer formation, the edge bulge is obvious, the boundary is clear, and the infiltration into the surrounding is not obvious, the type accounts for 30% to 40%.
Type III: infiltrating ulcer type, the tumor has large ulcer formation, the edge part is uplifted, part is infiltrated and destroyed, the boundary is unclear, and the infiltration into the surrounding area is obvious. The infiltration of the cancer tissue under the mucosa exceeds the tumor boundary seen by the naked eye. This is the most common type, accounting for about half.
Type IV: diffuse infiltration, diffuse infiltration and growth, difficult to determine the tumor boundary when touched, due to diffuse infiltration of cancer cells and fibrous tissue hyperplasia, can lead to thickening and stiffness of the stomach wall, the so-called "bag stomach", if the tumor is confined In the antrum of the stomach, an extremely narrow stenosis is formed, which accounts for about 10%.
(2) Histological classification:
Common types: papillary adenocarcinoma, cancer cells forming nipple structure, tubular adenocarcinoma, cancer cells forming different sizes of glandular ducts or glandular cavities, including highly differentiated and moderately differentiated adenocarcinomas, poorly differentiated adenocarcinomas, most of which do not form cancer cells Apparent lumen, in the form of a cord or a mass, the nucleus is biased, the cytoplasm may contain mucus, the mucinous adenocarcinoma cells produce a large amount of mucus, and the dilated glands are filled with mucus, also known as mucinous carcinoma, mucinous cell carcinoma, and It is called signet ring cell carcinoma.
Special type: This type of undifferentiated cancer is common, high malignancy, no adenoid structure, and other squamous cell carcinoma, adenomas (adenosquamous carcinoma), carcinoid, mixed cancer.
According to the malignant degree of gastric cancer, it is divided into 4 grades: the first stage has obvious cell differentiation, the second and third grades are moderate, the fourth grade is the worst, and the degree of malignancy is high.
(3) Transfer method:
1 direct infiltration spread: direct infiltration spread is related to the location of gastric cancer, gastric cardia cancer often invades the esophagus, liver and omentum, gastric cancer is mainly omentum, liver, pancreas, its spread mainly in the serosa The infiltrating cancer cells spread across the pyloric ring or submucosal cancer cells through the lymphatic vessels, rarely spreading directly along the mucosa, and the proximal cancer is different, which can directly extend the invasion of the lower end of the esophagus.
2 lymph node metastasis: according to the distance from the cancer, divided into the first, second, third and distant lymph nodes, the first station is the lymph nodes near the cancer such as the stomach size, the pylorus up and down, the side of the door, the spleen, the second station Spleen, total liver, left gastric artery, posterior lymph node of pancreaticoduodenal, third site of peritoneal artery, hilar, mesenteric aorta, lymph node around middle colon, distant lymph node mediastinum and left supraclavicular fossa or bilateral Upper supraclavicular lymph nodes (Virehow lymph nodes).
Lymph node metastasis: generally from near to far, through the lymphatic spread, mostly diffuse gastric cancer, cancer cells through the thoracic duct to the right supraclavicular lymph nodes, sometimes become the first symptoms and signs in the clinic, and some The reason for the phenomenon of so-called "jumping" metastasis is related to the change of lymphatic flow in gastric cancer. Tumor growth and dissemination can cause tumorous obstruction of some lymphatic vessels, while other lymphatic vessels are re-formed to compensate the stomach. Insufficient lymphatic outflow, so cancer cells can not only spread along the local lymphatics, but also spread along the lymphatic vessels that are constantly open, forming distant lymph node metastasis.
3 blood transfer: advanced patients can account for 64%, in the transfer of various organs, the most common liver accounted for 40%, lung accounted for 30%, followed by pancreas, adrenal gland, bone, kidney, spleen, brain, skin and so on.
4 planting metastasis: the cancer cells are soaked in the serosa, the planting in the peritoneum forms many metastatic nodules, producing a large amount of ascites, which can be transferred to the rectum.
Prevention
Elderly gastric cancer prevention
Third-level prevention
Try to control and eliminate known suspected carcinogenic factors and eliminate the cause to reduce its incidence, also known as Class I prevention.
Primary prevention
(1) Pay attention to food hygiene: Avoid eating more irritating diet, control drinking, regular diet, prevent overeating, to reduce the incidence of gastritis and gastric ulcer.
(2) Freezing and preserving: The method of preserving foods has been reduced from traditional salted or smoked (containing carcinogenic benzoquinones) to frozen storage.
(3) Avoid high-salt diet: Because the high-salt diet can destroy the mucus protective layer of the gastric mucosa, and the gastric mucosa is exposed to damage and contact with carcinogens, the salt intake in the diet should be reduced, so the daily salt intake Should be controlled below 10g, about 6g is appropriate.
(4) Regular consumption of fresh vegetables and fruits: It is known that nitrosamine compounds can be synthesized in the stomach under the action of low acid and bacteria, and the nitrate or nitrite which enters the stomach through food is combined with amines. Carcinogenic nitrosamines, and vitamin C can interrupt this synthesis, which helps prevent stomach cancer.
(5) Eat more milk and dairy products: In recent years, the Japan Cancer Research Society found that the incidence of gastric cancer is negatively correlated with the consumption of milk and dairy products. The reason is that milk contains vitamin A, which helps the repair of mucosal epithelium.
(6) Increasing protein intake in food: The protein content of meat, fish, and beans in food is high. Studies have shown that human protein intake is insufficient, and malnutrition is prone to gastric cancer.
(7) Smoking cessation: Japan's long-term prospective study of Pingshanxiong believes that smoking is a strong risk factor for cancer, and its risk is related to the age at which smoking begins and the amount of smoking.
Secondary prevention: through the census in the natural population, or regular follow-up examination of susceptible individuals, to achieve early detection, timely treatment, reduce the mortality rate, that is, level II prevention, identify high-risk groups of gastric cancer, when establishing high-risk individuals, should Closely related to local living habits and environmental conditions, such as whether it is a low-protein diet, whether there is a history of eating nitrosamine-rich foods or mildew foods, whether it is fried, smoked or marinated, and eating less fresh fruits and vegetables. And the quality of drinking water, etc., in addition to the family history of gastric cancer is also a factor that must be considered, especially for individuals with clinical symptoms, such as obvious symptoms or hematemesis, melena, upper abdominal mass, etc., should be regularly checked, Gastric ulcer disease with long-term unhealed or severe scar tissue, atrophic gastritis with intestinal metaplasia with severe dysplasia, and multiple polyps or single polyps larger than 2 cm in diameter should be classified as regular clinical follow-up Check the object.
Tertiary prevention: Active treatment of various precancerous lesions. It is now known that patients with atrophic gastritis, gastric polyps, gastric ulcers and subtotal gastrectomy have a higher incidence of gastric cancer. Therefore, the history is longer and clear. The above-mentioned patients diagnosed were followed up regularly. After 3 months of systemic medical treatment, the symptoms were not improved. Fiber endoscopy should be performed as early as possible to confirm the pathological diagnosis. If necessary, surgical resection should be performed.
2. Risk factors and interventions
High-salt diet and Helicobacter pylori infection are the main factors leading to the initial pathological changes of gastric mucosa. Gastric cancer is a chronic disease with a long onset. Therefore, prevention work at all stages has the potential to reduce gastric cancer or delay the onset of gastric cancer, and advocate low Salt diet, anti-Helicobacter pylori infection, improve nutrient levels in the body, block the synthesis of nitroso compounds, strengthen the ability to repair gastric mucosal damage, treat precancerous lesions including chronic atrophic gastritis, gastric polyps, gastric ulcers and residual stomach It is an important measure to prevent gastric cancer. There should be planned follow-up, regular review, endoscopy every six months, and the use of fecal occult blood as one of the primary screening methods in the population census. The diagnosis of gastric cancer is a key link in prevention and treatment. Early detection is not an easy task. There is no typical manifestation of early gastric cancer. It is not easy to implement the population census extensively. How to raise vigilance for clinicians, find patients with cancer, and monitor and follow up patients with precancerous diseases are effective early diagnosis measures. Method, as soon as possible to make a pathological diagnosis, where conditions can be used to use endoscopy as an intensive means Census, endoscopy helps determine the depth and metastasis of cancer infiltration, and provides a basis for surgery. Imaging diagnosis including B-ultrasound, CT, and magnetic resonance is of great value in determining cancer metastasis. CEA, CA19-9 and CA72 in tumor markers. .4 has a certain value in the diagnosis of gastric cancer, and is more valuable in judging the recurrence of prognosis monitoring.
3. Community intervention
The community should publicize the attention to the food hygiene in various forms, avoid or reduce the intake of possible carcinogens, store the food in a frozen storage, eat more vitamin C vegetables and fruits, and have a high risk of precancerous lesions and genetic factors. The population is closely followed up and regularly examined to detect changes early and to treat them promptly.
Complication
Elderly patients with gastric cancer complications Complications pyloric obstruction abdominal pain
The main complications of bleeding, perforation, pyloric obstruction and so on.
Symptom
Symptoms of gastric cancer in the elderly Common symptoms Persistent pain, weakness, upper abdominal discomfort, weight loss, nausea, abdominal pain, cachexia, loss of appetite, black stool, anorexia
The reasonable clinical stage of gastric cancer can correctly understand the severity of the disease, determine the appropriate treatment plan, and predict the prognosis of the patient, so it has important practical value. In 1985, the Japanese Society of Gastric Cancer Research proposed a new classification method, which was approved by the UICC. The staging method is officially announced. The new TNM staging method for gastric cancer considers the clinical and pathological staging of gastric cancer to be equally important and cannot be neglected. The staging method is simple, accurate, and easy to promote in the clinic (Table 2).
1. Gastric cancer symptoms
(1) Early gastric cancer: There is no specific symptom in the early stage of gastric cancer, even without symptoms. Early gastrointestinal symptoms can account for 1/4.
The statistics of domestic gastric cancer cases show that within 3 months after the onset of symptoms, the diagnosis of gastric cancer is less than 1/3. The possibility of considering gastric cancer in the following atypical symptoms should be further examined:
1 middle-aged patients with unexplained loss of appetite, upper abdominal discomfort, weight loss and other symptoms.
2 hematemesis, black stool or fecal occult blood positive cause is unknown.
3 The original long-term chronic stomach disease history, the recent symptoms are significantly aggravated.
4 gastric ulcer, gastric polyps (emphasis are adenomatous polyps), atrophic gastritis (especially with intestinal metaplasia, abnormal epithelial hyperplasia and other precancerous lesions), patients with residual stomach.
(2) advanced gastric cancer: the patient's condition to the advanced stage, the development is accelerated, the symptoms gradually increase within a few months, the general stomach symptoms appear persistent pain in the upper abdomen, fullness, anorexia, nausea, vomiting, melena, etc. There are symptoms associated with the tumor site. Gastric sinus cancer is mostly on the side of the small curve. The upper abdominal pain appears early, and the degree is different. For example, the cancer of the cardia is not under the xiphoid or the sternum, the eating is not smooth, the pain is painful, and it gradually increases. Progressive dysphagia, vomiting, reflux mucus, such as near pyloric or pyloric duct cancer, due to pyloric obstruction due to tumor compression, individual patients develop acute gastrointestinal bleeding, gastric perforation is diagnosed, can be touched when further development Abdominal mass, ascites, jaundice, and obvious weight loss, weight loss, fatigue, edema, anemia and cachexia.
2. Signs
There is no positive sign in the early abdominal cancer examination, so the examination does not help the early diagnosis. When entering the advanced stage (intermediate and advanced stage), there may be tenderness in the upper abdomen, fullness or blockage in the stomach area, hard and fixed, and the surface is uneven and nodular When the pyloric cancer is obstructed, the dilated stomach type can be seen, there is a water sound, the upper abdomen is full, and it invades the pancreas, especially the pancreatic head invasion and the duodenal ligament, and the pancreaticoduodenal lymph node metastasis Common bile duct, obstructive jaundice, with intrahepatic metastasis, hepatic surface nodules, hard, can also be accompanied by jaundice, peritoneal implantation can produce ascites, mostly bloody, small intestine, colon and mesenteric metastasis can occur intestine Obstruction, intestinal type, peristaltic wave, female patient transferred to the ovary, is Krukenberg tumor, distant lymph node metastasis can appear on the left supraclavicular or bilateral supraclavicular lymph nodes, these signs indicate that they have entered the middle and late stage, more than Lose the opportunity to cure the disease.
Examine
Examination of gastric cancer in the elderly
Laboratory inspection
Routine examinations in the laboratory are not important for early diagnosis and diagnosis. As a way to understand the condition and determine the treatment plan, observe the toxicity of chemotherapy, regularly check the total number of white blood cells in the routine, hemoglobin and platelet count, urine routine and fecal occult blood. It is necessary to find abnormalities in liver and kidney function.
2. Serum enzymology
It can be used in early diagnosis, curative effect observation and prognosis monitoring. It has auxiliary value. Pepsinogen (PG) is a digestive enzyme precursor secreted by gastric mucosa. It can be divided into two subtypes, PCI and PGII. PGI/PGII is normal. The gastric mucosa is 1, and the atrophic gastritis is decreased. When the PGI is significantly decreased, the risk of intestinal type gastric cancer is increased. The alkaline phosphatase (ALP) activity is increased in gastric cancer patients, and is divided into five isoenzymes. AIP2 is from the liver. If the increase indicates that there may be liver metastasis.
In recent years, the relationship between the level of serum pepsin (PG) and the occurrence of gastric cancer has been paid more and more attention. The content of serum pepsin can often reflect gastric mucosal lesions. PGI is mainly secreted by the main cells of the fundus gland, except for PGII. The above glands also have gastric antrum and pyloric gland secretion. When the gastric gland is atrophied, the main cells are reduced, and the serum PGI content tends to decrease. When atrophic gastritis is accompanied by intestinal metaplasia, the gastric antrum gland extends to the corpus, and the PGII content is also With the increase of the gastric fundus and gastric antrum mucosal lesions, the PGI/II ratio is the highest. When the lesions are widely distributed, the PCII content increases and the PGI/II value decreases significantly due to the decrease of PGI content. The PGI/II value can be used as an indicator to identify susceptible subjects of gastric cancer.
1. Imaging examination
(1) X-ray inspection:
1 stomach sputum meal angiography: the use of barium sulfate and stomach wall to produce shadows for diagnosis, gastric sputum angiography X-ray signs of gastric cancer mainly have shadows, filling defects, mucosal fold changes, peristaltic abnormalities and obstructive changes, etc. The traditional stomach examination has been gradually replaced by double contrast angiography of the stomach.
2 Gastric double contrast method: Gastric double contrast agent is a kind of examination method in which the contrast agent with low consistency and high concentration of barium sulfate and gas (air or CO2) is simultaneously injected into the stomach for fluoroscopy.
1 X-ray findings of early gastric cancer:
Type I (bumping type): filling defects in the stomach, the height of the bulge is greater than 5 mm, and the diameter is more than 2 cm.
Type IIa (shallow bulge type): The height of the bulge does not exceed 5 mm, and the local gastric cavity disappears or merges and destroys.
Type IIb (superficial flat type): The lesion is flat and superficial, the stomach cavity disappears, merges or destroys, and changes irregularly.
Type IIc (shallow depression type): Filling spots with superficial depressions not exceeding 5 mm, irregular edges.
Type III (recessed type): A shadow with a depth of more than 5 mm is formed, and the surrounding mucosa is interrupted.
Although early gastric cancer has the above characteristics, it is sometimes indistinguishable from small peptic ulcers, gastric erosion, atypical hyperplasia, etc., so further examination of the gastroscope is still needed.
2 X-ray findings of advanced gastric cancer: divided into 4 types.
Borrmann type I ( umbrella type): limited filling defect, the diameter is more than 3cm, the shape is not uniform, the surface is uneven, the base is wide, and the boundary of the normal stomach wall is clear.
Bormann type II (non-invasive ulcer type): the ortho position is irregular shape shadow, surrounded by a relatively complete ring embankment, the outer edge is erected, and the boundary of the normal stomach wall is clear, the local peristalsis disappears, and the lateral margin is a typical half-month sign. (meniscus sign).
Borrmann type III (infiltrating ulcer type): large ulcer, irregular shape, narrow and irregular ring levee, ridge-like bulge on the outer edge, unclear boundary, adjacent stomach wall stiffness, part of the ring dyke disappeared.
Borrmann type IV (diffuse invasive type): the gastric cavity is limited or the whole stomach is reduced and deformed, the stomach wall is stiff, can not expand, the pathological boundary is unclear, there is no obvious uplift or depression in the stomach cavity, there is a small ulcer on the mucosal surface, and the nodules and mucosal folds are flat. Or thicken and harden the deformation.
3 X-ray diagnosis of other gastric malignancies:
A. The general range of malignant lymphoma is large, the gastric mucosa is obviously thick and irregular, and sometimes there is a shadow, and the edge mucosa of the shadow is interrupted and destroyed.
B. Leiomyosarcoma leiomyosarcoma is a submucosal tumor with a smooth filling defect in the stomach. The mucosal bridge is often passed above, and the local gastric compartment is still visible. When the lesion progresses to the gastric mucosa, there is a local shadow.
(2) CT examination: When the thickness of early gastric cancer is more than 5mm, it can be clearly found that when it exceeds 1cm, CT can observe the three-layer structure of the stomach wall, which is quite mucosal, submucosa and muscle serosal layer. Most scholars use Moss. CT staging; stage I intraluminal mass, gastric wall thickening <1cm, no metastasis, stage II gastric wall thickening >1cm, no extraluminal invasion, stage I, II estimated surgical resection, stage III gastric wall thickening with extraluminal Infringement, no distant transfer, stage IV has a distant transfer.
(3) Ultrasound examination of gastric cancer: mucosal layer rupture (first layer) can be seen in the early stage of gastric cancer, and the hypoechoic area of the mucosal muscle layer (second layer) is thickened. When the submucosa is invaded, the third layer is intermittent. Type I, type I gastric cancer shows better, type II, III is poor, advanced gastric cancer mass protrudes into the cavity, showing nodular or polypoid hypoechoic area, thicker basal part, limited range and normal gastric wall boundary, ulcer formation In the thickened stomach wall, the concave area can be seen, the edge is uneven, and the echo is strong, the thickening of the stomach wall is low echo, the whole infiltrator has a low echogenic thickening of the stomach wall, irregular, stiff, narrow gastric cavity, creep disappearing, lymph node of gastric cancer At the time of metastasis, the lymph nodes around the stomach and the abdomen are swollen, mostly with low echo, and the boundary is clear. It is single or multiple fusion. The size of 0.7cm or more can be detected. The larger lymph nodes can be irregular. See strong and uneven echoes are mostly degeneration of metastatic lymph nodes, necrotic manifestations, advanced gastric cancer with organ metastasis such as liver, pancreas can detect low echo occupancy, typical sonogram of liver metastasis is "bull eye sign" or" The structure of the heart circle is multi-round or round-like, with clear boundaries and a wide halo around. Ultrasound can diagnose liver metastases with a diameter of 1 cm. The diagnostic rate of liver metastases is up to 90%. The rate of output is higher than CT and other imaging studies.
(4) Gastroscopic examination: In the mid-1980s, the electronic gastroscope was successfully researched. The imaging system was directly displayed on the screen using a miniature camera system. It can record and print, take photos, look directly at the gastric mucosal lesions and adopt a living tissue. The final pathological diagnosis is irreplaceable in any examination of gastric cancer.
1 early gastric cancer: uplift type, mainly manifested as local mucosal uplift, protruding to the gastric cavity, pedicle or broad-based, rough surface, some appear papillary or nodular, surface may have erosion, superficial type as boundary Neat, inconspicuous local mucosal roughness, slightly uplifted or sunken, surface color faded or reddish, may have erosion, such lesions are most likely to be missed, recessed type has more obvious ulcers, depression more than mucous layer, above Each type can be combined to form a mixed early gastric cancer.
2 middle and advanced gastric cancer: often has typical manifestations of gastric cancer, endoscopic diagnosis is not difficult, the uplift type lesions are larger in diameter, irregular in shape, cauliflower or chrysanthemum-like, the surface is rough and uneven, often with ulcers, hemorrhage, depression Often the central ulcer of the mass, irregular shape, blurred edges, rough base, exudation or necrosis, irregular nodules around the lesion, sometimes redness around the mucous membrane, edema, erosion, wrinkles interrupted or sputum, The top can be worm-like.
2. Nuclide check
CEA, CA19-9 and CA72.4 specificity can reach 95% in gastric cancer, carcinoembryonic antigen (CEA) in tumor-associated antigen is high in gastric cancer tissue, high in serum and gastric juice, and can also be used in precancerous diseases. Elevated, CA19-9 is elevated in a variety of digestive system cancers, the positive rate of gastric cancer is 30% to 40%, the increase can predict metastasis, recurrence, lowering when the treatment is effective, and the serum CA-125 level is often increased. Membrane or peritoneal invasion, and elevated serum AFP often have liver metastasis, such as high preoperative CA19-9 and CA-125 levels, often means poor prognosis, CEA> 50g / L or CA19-9 > 200g / ml Patients, regardless of whether or not they had surgery, had no difference in survival. The positive rate of tumor-associated glycoprotein (TAG-72) was 49%, more positive than CEA, and the sensitivity and specificity of gastric cancer monoclonal antibody MG7 for gastric cancer diagnosis. Higher sex, it is generally believed that these tumor markers only help to distinguish the prognosis of the tumor and the efficacy of chemotherapy, but not help the diagnosis of gastric cancer.
Diagnosis
Diagnosis and diagnosis of gastric cancer in the elderly
Diagnostic criteria
If you pay attention to the common morbidity factors and clinical features of the elderly, early diagnosis can be obtained for most cases. For the following cases, patients should be further examined. If necessary, they should be observed regularly and repeatedly.
1. Anyone over the age of 60, has a history of chronic gastritis and has been confirmed as atrophic gastritis or has obvious intestinal metaplasia, confirmed chronic gastric ulcer, gastric adenomatous polyps, or had a subtotal resection of the stomach has been 5 ~ For more than 10 years, all should be the key monitoring targets, regular barium meal examination, cytological examination, or gastric fiber endoscopy.
2. There are general gastrointestinal symptoms, even if the symptoms are mild, such as continuous or intermittent episodes for 3 to 6 months or more.
3. Have a history of ulcers, such as regular changes in symptoms, or frequent episodes.
4. Unexplained weight loss, or long-term fecal occult blood test positive.
Differential diagnosis
1. Identification with benign diseases
(1) gastric ulcer: due to the absence of specific symptoms and signs of gastric cancer, the clinical manifestations are similar to ulcer disease. In particular, young people with gastric cancer are often misdiagnosed as gastric ulcer or chronic gastritis. Progressive ulcer-type gastric cancer has a large shadow and is located in the cavity. There are finger marks and fissure signs, gastric mucosal folds, local stomach wall stiffness, poor gastric dilatation, etc., but spastic ulcers, due to the proliferation of basal fibrous tissue, so that the shadow is partially trapped in the gastric cavity, easy to be confused with ulcerative gastric cancer, Need to be further identified by gastroscope.
(2) gastric polyps: gastric polyps can occur at any age, 60 to 70 years old is more common, small polyps can be without any symptoms, larger can cause similar gastric cancer performance, need to differentiate with elevated gastric cancer, gastric polyps X The line is filled with defects, about 1cm in diameter, complete round, pedicled, movable, and the diameter of the raised gastric cancer is often >2cm, the base is wide, the mobility is poor, and the surface is not smooth. The gastroscopic biopsy should be confirmed.
(3) stomach, leiomyomas: gastric leiomyomas can occur at any age, more common in 50 years old, mostly single, 2 ~ 4cm size, occurs in the antrum and stomach, X-ray is round or oval Shape filling defects, about 2% can be malignant, can be differentiated from gastric cancer by gastroscopy biopsy.
2. Identification with other malignant tumors
(1) Primary malignant lymphoma of the stomach: Primary malignant lymphoma of the stomach accounts for 0.5% to 8% of gastric malignant tumors. It is more common in young adults and has a good gastric antrum. The clinical manifestations are similar to those of gastric cancer, about 30% to 50%. % of patients with Hodgkin's disease have persistent or intermittent fever. The detection rate of X-ray barium meal examination can reach 93%-100%, but it can be diagnosed as gastric malignant lymphoma only 10%. X-ray sign is diffuse gastric mucosal fold. Irregular thickening, irregular pattern of multiple ulcers, large folds of ulcerated mucosa, single or multiple round filling defects, "goose-like" changes, gastroscope seeing huge gastric mucosal folds, single or Multiple polypoid nodules, surface ulcers or erosion should be considered as gastric lymphoma first.
(2) gastric leiomyosarcoma: gastric leiomyosarcoma accounts for 0.25% to 3% of gastric malignant tumors, accounting for 20% of gastric sarcoma, more common in the elderly, good stomach and stomach, tumors often >10cm, spherical or hemispherical, Can cause large ulcers due to ischemia, according to the location can be divided into:
1 intragastric type (submucosal type), the tumor protrudes into the stomach cavity.
2 gastric type (subserosal type), the tumor grows outside the stomach.
3 stomach wall type (dumbbell type), the tumor grows to the inside and outside of the stomach at the same time.
