1. Early gastric cancer
Typical symptoms: epigastric pain, nausea, loss of appetite, emaciation and so on.
With the development of the disease, the function of the stomach and the general condition of the whole body gradually change. These symptoms are usually nonspecific, sometimes hidden and may exist for a long time. Such as epigastric pain, dull pain, dull pain, nausea, loss of appetite, belching and emaciation; A few early gastric cancers with ulcer type (type ⅱ C and type ⅲ) can also have ulcer-like symptoms, such as rhythmic pain and acid regurgitation, which can be relieved by medical treatment. In some patients, gastric cancer coexists with some benign lesions or becomes cancerous on the basis of some benign lesions (such as chronic atrophic gastritis and peptic ulcer). ), and the symptoms of these benign gastric diseases persist or recur for a long time, which makes it easier for patients and doctors to relax their vigilance against gastric cancer and delay the diagnosis opportunity. Some early gastric cancer may also have symptoms such as vomiting blood, black stool or dysphagia.
① Upper abdominal discomfort:
About 80% patients have the most common first symptom of gastric cancer, similar to dyspepsia. If abdominal pain occurs, it generally starts to be slightly irregular, can not be relieved after eating, and gradually increases, which can be dull pain or dull pain. Some of them may have rhythmic pain, especially gastric antrum cancer, which can even be relieved by eating or taking medicine. Old people have dull pain and complain of abdominal distension. These symptoms are often ignored by patients and easily mistaken for gastritis or ulcer when seeking medical treatment. Therefore, middle-aged patients should be further examined if they have the following conditions, so as to avoid missed diagnosis: a. They have no history of stomach trouble in the past, but have recently developed upper abdominal discomfort or unexplained pain, which is ineffective after treatment; B. Past history of gastric ulcer, recent upper abdominal pain has regular changes, and the degree is aggravated. If the symptoms are relieved, but there is an author in the short term, we should also consider the possibility of gastric cancer and do further examination in time.
② Loss of appetite or loss of appetite:
Loss of appetite and emaciation are the second common symptoms of gastric cancer. Nearly 50% patients with gastric cancer have obvious symptoms of loss of appetite or loss of appetite, and some patients limit their food by themselves because eating too much will cause abdominal distension or abdominal pain. Unexplained anorexia and emaciation are probably the initial symptoms of early gastric cancer and need to be paid attention to. Patients with early gastric cancer generally have no obvious positive signs, and most of them only have deep tenderness in the upper abdomen except for weak general condition.
2. Advanced gastric cancer
Typical symptoms: abdominal pain, loss of appetite, nausea and vomiting, hematemesis, melena, etc.
Gastric cancer lesions from small to large, from shallow to deep, from no metastasis to metastasis is a gradual process, so there is no obvious boundary between early, late or even late. In addition, there is often a great overlap between the symptoms of each stage. Some patients have advanced lesions, but the symptoms are not obvious. Although some patients are in the early stage, their symptoms are outstanding, and some patients seek treatment with symptoms of organ metastasis or complications. According to domestic statistics, the common symptoms of advanced gastric cancer are as follows:
① Abdominal pain:
When gastric cancer develops and expands, especially through serosal infiltration, invading the pancreas or transverse mesocolon, persistent severe pain can occur and radiate to the back. A very small number of patients with perforation of cancerous ulcer may also have abdominal pain and peritoneal irritation.
② Loss of appetite and emaciation:
The absorption of cancer toxin can make patients increasingly emaciated, tired, anemia, malnutrition, often progressive aggravation, and finally cachexia.
③ Nausea and vomiting:
This is also a more common symptom, which may appear in the early stage. Gastric antrum cancer can also have symptoms of pyloric obstruction.
(4) hematemesis and melena:
When an ulcer forms on the surface of cancer, hematemesis and melena will appear. 1/3 patients with gastric cancer often have a small amount of bleeding, most of them are positive for occult blood in stool, some may have intermittent melena, but some have a lot of hematemesis.
⑤ Diarrhea:
May be related to low gastric acid, stool may be mushy, and even diarrhea. Late gastric cancer involving colon can often cause diarrhea and bloody stool.
⑥ Dysphagia:
Cancer can cause obstruction symptoms when it grows up, cardiac cancer or fundus cancer can cause dysphagia, and gastric antrum cancer can cause pyloric obstruction symptoms.
Second, the sign
1, early gastric cancer
Without warning. Or just tenderness in the upper abdomen. Most patients with advanced gastric cancer have obvious upper abdominal tenderness. 13 patients have palpable masses in the abdomen, which are hard, uneven and tender, especially the emaciated patients with gastric antrum cancer. As for metastatic lesions such as palpable mass of rectum, umbilical mass, supraclavicular lymph node enlargement and ascites, it is more evidence of advanced gastric cancer.
2. Upper abdominal mass
Prerectal recess tumor, umbilical mass, left supraclavicular lymph node enlargement, left axillary lymph node enlargement, ascites, etc. Usually indicates distant metastasis. Due to different metastatic sites, corresponding signs often appear, which makes the clinical manifestations very complicated. For example, liver metastasis can lead to hepatomegaly and jaundice, ovarian metastasis can lead to ovarian enlargement and a lot of ascites, and lung metastasis can lead to dyspnea.
3. Others
Gastric cancer with cancer syndrome can also become an important sign, such as thrombophlebitis and dermatomyositis. Advanced patients may have fever and cachexia.
Three. Clinicopathological staging
This staging standard is divided according to the depth of tumor invasion (T), lymph node involvement (N) and distant metastasis (M), also known as TNM staging method.
The tumor is confined to the epithelial layer and does not invade the muscularis mucosa.
T 1 invades mucosa and submucosa.
T2 invades the muscularis or subserous layer.
T3 tumor has penetrated serosa.
T4 tumor invades adjacent organ structures or cavities and extends to esophagus or duodenum.
No, no lymph node metastasis.
N 1 lymph node metastasis is within 5cm from the tumor edge.
N2 lymph node metastasis is 5cm away from the tumor edge, including lymph node metastasis around the left gastric artery, common hepatic artery, splenic artery and celiac artery.
M0 has no distant metastasis.
M 1 has distant metastasis, including metastasis near common bile duct, posterior pancreaticoduodenal metastasis, mesenteric root metastasis and aortic metastasis.
Based on the international TNM staging method of gastric cancer, the following clinicopathological staging criteria for gastric cancer were established:
T the depth of tumor infiltration.
T 1 regardless of the size of the tumor, the lesion is only confined to mucosa or submucosa.
T2 infiltrates into the muscularis or serosa.
T3 penetrates the serosa.
T4 invades adjacent structures or cavities and extends to esophagus and duodenum.
Lymph node metastasis.
N0 has no lymph node metastasis.
N 1 lymph node metastasis is within 5cm from the tumor edge.
N2 Perigastric lymph node metastasis is 5 cm away from the tumor edge, including lymph node metastasis around the left stomach, liver, spleen and celiac artery.
M remote transfer status.
M0 has no distant metastasis.
M 1 has distant metastasis, including lymph node metastasis in groups 12, 13, 14 and 16.
According to the above definition, the division of each period is shown in Figure 8.
With the understanding of the biological characteristics of gastric cancer cells and the analysis of the prognosis of patients with gastric cancer, the above-mentioned stages of gastric cancer still can't reflect the characteristics of gastric cancer well, so Japanese scholar 1998 formulated the 13 version of gastric cancer plan, as shown in Figure 9.
The stomach is divided into upper (U), middle (M) and lower (L) regions by drawing three equal points on the whole length of the big bend and the small bend. The upper 1/3 region includes the cardia and the fundus of the stomach, the middle 1/3 region is the majority of the stomach, and the lower 65438+.
If multiple areas are involved, all the affected areas should be described according to the degree of involvement, and the part where the tumor is located, such as LM or UML, should be listed first. Tumors invading esophagus or duodenum were recorded as E or D respectively.
T 1 Tumor invades mucosa and/or mucosal muscle (M) or submucosa (SM).
SM 1 means that the cancer passes through the muscularis mucosa less than 0.5 mm.
SM2 means that the cancer has passed through the muscularis mucosa for more than 0.5 mm. ..
T2 tumor invaded muscularis or subserosa.
T3: The tumor penetrated serosa (SE).
T4: Tumor invades adjacent structures.
Tx: The invasion depth is not clear.
Tumors that penetrate the muscular layer can spread to the omentum (or even to the gastrocolon and hepatogastric ligament) without penetrating the dirty peritoneum covering these structures. In this case, the tumor is called T2. If a dirty peritoneum penetrates, it is designated as T3. Invasion of omentum, esophagus and duodenum does not mean T4 stage lesions, and the grading of submucosal tumors extending to esophagus or duodenum depends on the maximum infiltration depth of these positions.
According to the location of primary tumor, regional lymph nodes can be divided into three stations. Occasionally, a tumor in a certain part has metastasis of specific lymph nodes, which can be used as a sign of distant metastasis (denoted by m); When the tumor invades the esophagus, adjust the substation numbered 19 ~ 1 12 accordingly.
A. Liver metastasis (h):
H0: No liver metastasis; H 1: liver metastasis; Hx: I don't know.
B. peritoneal metastasis (p):
P0: No peritoneal metastasis; P 1: peritoneal metastasis; Px: I don't know.
C. peritoneal exfoliative cytology (cy):
CY0: Benign/uncertain cells; CY 1: cancer cells; CYx: No cytological examination.
Note: Cytological diagnosis? Suspected malignant? It should be CY0.
⑤ Other long-distance transmission (m):
M0: No other metastasis (even if there is metastasis of peritoneum, liver or exfoliated cells).
M 1: distant metastasis except peritoneum, liver or exfoliated cytology.
Mx: It can't be transmitted clearly.