The incidence and mortality rates of gastric cancer in China remain high,highlighting the urgency to explore and optimize an in-tegrated management strategy with Chinese characteristics that covers prevention,screening,diagnosis,treatment,and recovery.The integ-rative guidelines for gastric cancer were established by the Committee of Gastric Cancer under the guidance of the China Anti-Cancer Associ-ation(CACA),building on the previous edition.These guidelines enhance the core concepts of"whole person,whole body,whole journey,and whole information"and further integrate advanced diagnostic and treatment philosophies of multidisciplinary teams into holistic integ-rative medicine(MDT to HIM).They closely align with the epidemiological characteristics,genetic predispositions,original scientific research achievements,and unique prevention and control practices of the Chinese population.This revision places special emphasis on incorporat-ing the latest domestic research findings while ensuring widespread accessibility to medical services.It show cases the unique advantages of traditional Chinese medicine while incorporating China's extensive experience in cancer prevention and control,achieving a balanced integ-ration of research evidence,physician experience,and patient needs.The release of these scientific,standardized,and highly practical dia-gnostic and treatment guidelines are anticipated to provide valuable guidance for medical professionals nationwide,contributing to more precise and efficient gastric cancer prevention and treatment efforts in China,significantly improving patient outcomes,and advancing the implementation of the Healthy China Initiative.

Comprehensive treatment of gastric cancer is mainly based on the pathological staging. The T stage mainly depends on the accurate determination of the depth of the tumor invasion. The accurate T stage should be standardized pathological examination and continuous sectioning. N stage may be influenced by the number of lymph node examined. Insufficient lymph node examined may lead to stage migration. Therefore, standardizing lymph node dissection and lymph node harvest after surgery is important. M stage is mainly to improve the detection rate of peritoneal lavage cytology (CY), identify high risk factors for peritoneal metastasis, and optimize the prediction of peritoneal metastasis molecular markers, as a complementary methods of clinical examination. Currently, the quality of standardized pathological diagnosis of gastric cancer in China still needs to be improved. This article mainly elucidates the related studies and clinical experience of our center on how to do better in the optimization of gastric cancer TNM staging and pathological quality control.

As early as in the 1960s, China has begun to conduct exploratory clinical researches on gastric cancer. In the past 10 years, the research projects have increased significantly. Among them, the minimally invasive surgery represented by laparoscopy (CLASS Trial), the hot spot of the esophagogastric junction cancer (5010 Trial), the perioperative adjuvant treatment of advanced gastric cancer (CGOG1001 and RESOLVE Trials), the conversion treatment of late gastric cancer (DRAGON Trial) and high quality clinical research such as real-world research based on large database have made great progress. But there are still many deficiencies, such as few multi-center prospective research, limited research return, and the quality and innovation of scientific research data need to be further improved. However, it should also be noted that the clinical researches of gastric cancer in China have greater advantages and development space. The characteristics of large population base, rich cases and large proportion of advanced gastric cancer are conducive to real-world research. In the future, we should follow the international frontier and combine with national conditions to deepen clinical research, so that more "Chinese elements" can be introduced into the international guidelines for gastric cancer, and promote the overall level of diagnosis and treatment of gastric cancer in China.

Objective:Although stage of disease is one of the main factors affecting the prognosis of gastric cancer, the prognosis of gastric cancer patients with different biological behaviors is also different, indicating that the biological behavior of gastric cancer is also of great significance. This study explores the clinicopathological characteristics of gastric cancer patients with different biological behaviors in the same TMN stage, and analyzes its impact on the prognosis, so as to provide reasonable and reliable evidences for surgical treatment.Methods:A retrospective cohort study was carried out. Clinicopathological data of patients with advanced gastric cancer undergoing radical surgery at Department of Gastrointestinal Surgery, the First Affiliated Hospital of China Medical University from January 1980 to December 2012 were collected. Case inclusion criteria: (1) advanced gastric cancer confirmed by postoperative pathology; (2) R0 resections; (3) complete follow-up data. Exclusion criteria: (1) history of previous gastric surgery, preoperative adjuvant therapy, and imaging evidence of distant metastasis before surgery; (2) age of patients <18 or > 90 years; (3) lack of clinical, pathological, or follow-up data. Cumulative survival was analyzed and plotted by the Kaplan-Meier method. Log-rank test was used for univariate analysis and Cox proportional hazard regression was used for multivariate analysis. Difference of prognosis was compared among different biological behaviors at the same TNM stage.Results:A total of 2522 patients were enrolled, including 246 cases in stage IB (T2N0M0), 422 cases in stage IIA, 474 cases in stage IIB, 681 cases in stage IIIA, 441 cases in stage IIIB, and 256 cases in stage IIIC. Their 5-year survival rates were 79.9%, 68.5%, 56.1%, 39.5%, 22.5%, and 8.1%, respectively, and the difference was statistically significant ( P<0.001). Univariate and multivariate analysis showed that for patients with stage IB gastric cancer, the macroscopic type as infiltration (HR=1.806, 95% CI:1.174-2.780, P=0.007), tissue growth mode as diffusion (HR=1.370, 95% CI:1.007-1.864, P=0.045), and positive lymphovascular cancer embolus (HR=2.073, 95% CI: 1.333-3.224, P=0.001) were independent risk factors of prognosis; for patients with stage IIA gastric cancer, the macroscopic type as infiltration (HR=1.376, 95% CI: 1.008-1.878, P=0.044), tissue growth mode as diffusion (HR=1.263, 95% CI: 1.061-1.505, P=0.009), positive lymphovascular cancer embolus (HR=2.296, 95% CI:1.753-3.008, P<0.001) were independent risk factors of prognosis; for patients with stage IIB gastric cancer, macroscopic type as infiltration (HR=1.445, 95% CI: 1.056-1.976, P=0.021), positive lymphovascular cancer embolus (HR=1.528, 95% CI: 1.194-1.955, P=0.001) were independent risk factors of prognosis; for patients with stage IIIA gastric cancer, macroscopic type as infiltration (HR=1.395, 95% CI: 1.095-1.777, P=0.007), positive lymphovascular cancer embolus (HR=1.583, 95% CI: 1.315-1.905, P<0.001) and serosal type (tendon type+colorful diffusion type) (HR=1.188, 95% CI: 1.102-1.282, P<0.001) were independent risk factors of prognosis; for patients with stage IIIB gastric cancer, macroscopic type as infiltration (HR=1.485, 95% CI: 1.063-2.076, P=0.021), positive lymphovascular cancer embolus (HR=1.315, 95% CI: 1.060-1.631, P=0.013), and serosal type (tendon type+colorful diffusion type) (HR=1.146, 95% CI: 1.052-1.248, P=0.002) were independent risk factors of prognosis; for patients with stage IIIC gastric cancer, macroscopic type as infiltration (HR=2.986, 95% CI: 1.293-6.898, P=0.010) and serosal type (tendon type+colorful diffusion type) (HR=1.135, 95% CI: 1.003-1.283, P=0.045) were independent risk factors of prognosis. Conclusion:Under the same TNM stage, different biological behaviors have very different prognosis, which indicates that the biological behavior of gastric cancer is equally as important as TNM staging for the prognosis of patients and the guidance of individualized treatment.

Objective:Although stage of disease is one of the main factors affecting the prognosis of gastric cancer, the prognosis of gastric cancer patients with different biological behaviors is also different, indicating that the biological behavior of gastric cancer is also of great significance. This study explores the clinicopathological characteristics of gastric cancer patients with different biological behaviors in the same TMN stage, and analyzes its impact on the prognosis, so as to provide reasonable and reliable evidences for surgical treatment.Methods:A retrospective cohort study was carried out. Clinicopathological data of patients with advanced gastric cancer undergoing radical surgery at Department of Gastrointestinal Surgery, the First Affiliated Hospital of China Medical University from January 1980 to December 2012 were collected. Case inclusion criteria: (1) advanced gastric cancer confirmed by postoperative pathology; (2) R0 resections; (3) complete follow-up data. Exclusion criteria: (1) history of previous gastric surgery, preoperative adjuvant therapy, and imaging evidence of distant metastasis before surgery; (2) age of patients <18 or > 90 years; (3) lack of clinical, pathological, or follow-up data. Cumulative survival was analyzed and plotted by the Kaplan-Meier method. Log-rank test was used for univariate analysis and Cox proportional hazard regression was used for multivariate analysis. Difference of prognosis was compared among different biological behaviors at the same TNM stage.Results:A total of 2522 patients were enrolled, including 246 cases in stage IB (T2N0M0), 422 cases in stage IIA, 474 cases in stage IIB, 681 cases in stage IIIA, 441 cases in stage IIIB, and 256 cases in stage IIIC. Their 5-year survival rates were 79.9%, 68.5%, 56.1%, 39.5%, 22.5%, and 8.1%, respectively, and the difference was statistically significant ( P<0.001). Univariate and multivariate analysis showed that for patients with stage IB gastric cancer, the macroscopic type as infiltration (HR=1.806, 95% CI:1.174-2.780, P=0.007), tissue growth mode as diffusion (HR=1.370, 95% CI:1.007-1.864, P=0.045), and positive lymphovascular cancer embolus (HR=2.073, 95% CI: 1.333-3.224, P=0.001) were independent risk factors of prognosis; for patients with stage IIA gastric cancer, the macroscopic type as infiltration (HR=1.376, 95% CI: 1.008-1.878, P=0.044), tissue growth mode as diffusion (HR=1.263, 95% CI: 1.061-1.505, P=0.009), positive lymphovascular cancer embolus (HR=2.296, 95% CI:1.753-3.008, P<0.001) were independent risk factors of prognosis; for patients with stage IIB gastric cancer, macroscopic type as infiltration (HR=1.445, 95% CI: 1.056-1.976, P=0.021), positive lymphovascular cancer embolus (HR=1.528, 95% CI: 1.194-1.955, P=0.001) were independent risk factors of prognosis; for patients with stage IIIA gastric cancer, macroscopic type as infiltration (HR=1.395, 95% CI: 1.095-1.777, P=0.007), positive lymphovascular cancer embolus (HR=1.583, 95% CI: 1.315-1.905, P<0.001) and serosal type (tendon type+colorful diffusion type) (HR=1.188, 95% CI: 1.102-1.282, P<0.001) were independent risk factors of prognosis; for patients with stage IIIB gastric cancer, macroscopic type as infiltration (HR=1.485, 95% CI: 1.063-2.076, P=0.021), positive lymphovascular cancer embolus (HR=1.315, 95% CI: 1.060-1.631, P=0.013), and serosal type (tendon type+colorful diffusion type) (HR=1.146, 95% CI: 1.052-1.248, P=0.002) were independent risk factors of prognosis; for patients with stage IIIC gastric cancer, macroscopic type as infiltration (HR=2.986, 95% CI: 1.293-6.898, P=0.010) and serosal type (tendon type+colorful diffusion type) (HR=1.135, 95% CI: 1.003-1.283, P=0.045) were independent risk factors of prognosis. Conclusion:Under the same TNM stage, different biological behaviors have very different prognosis, which indicates that the biological behavior of gastric cancer is equally as important as TNM staging for the prognosis of patients and the guidance of individualized treatment.

Patients with advanced gastric cancer have a poor prognosis, which remains the clinical concerned hot topic. The main previous treatments for advanced gastric cancer were adjuvant chemotherapy and palliative surgery, however, the application of conversion therapy has improved the survival in recent years. There are still many problems and challenges for conversion therapy because of its initial stage, such as the definition of advanced gastric cancer and conversion therapy, the selection of suitable population for conversion therapy, and the role of surgery in conversion therapy. Precision medicine will be applied to conversion therapy for advanced gastric cancer in the future, which would benefit more patients.

Patients with advanced gastric cancer have a poor prognosis, which remains the clinical concerned hot topic. The main previous treatments for advanced gastric cancer were adjuvant chemotherapy and palliative surgery, however, the application of conversion therapy has improved the survival in recent years. There are still many problems and challenges for conversion therapy because of its initial stage, such as the definition of advanced gastric cancer and conversion therapy, the selection of suitable population for conversion therapy, and the role of surgery in conversion therapy. Precision medicine will be applied to conversion therapy for advanced gastric cancer in the future, which would benefit more patients.

Patients with advanced gastric cancer have a poor prognosis, which remains the clinical concerned hot topic. The main previous treatments for advanced gastric cancer were adjuvant chemotherapy and palliative surgery, however, the application of conversion therapy has improved the survival in recent years. There are still many problems and challenges for conversion therapy because of its initial stage, such as the definition of advanced gastric cancer and conversion therapy, the selection of suitable population for conversion therapy, and the role of surgery in conversion therapy. Precision medicine will be applied to conversion therapy for advanced gastric cancer in the future, which would benefit more patients.

OBJECTIVETo investigate the prognostic factors of patients with lymph node-negative metastasis gastric cancer (pN0).

METHODSClinicopathological data of patients with pN0 gastric cancer who underwent radical operation at the Department of Surgical Oncology, The First Hospital of China Medical University from May 1980 to August 2012 were collected and analyzed retrospectively.

INCLUSION CRITERIA(1) Patients were diagnosed as gastric adenocarcinoma; (2) Postoperative pathology confirmed T1a to 4bN0M0 gastric cancer; (3) Total number of harvested lymph node was more than 15. The patients, who died within 1 month after the operation, died of other diseases, had remnant gastric cancer, or had incomplete follow-up data, were excluded. Univariate analysis was used to analyze the clinical factors that may influence the prognosis of patients with stage pN0 gastric cancer, then, those significant variables were entered into the Cox's proportional hazards regression model for multivariate analysis to obtain the independent prognostic factors for patients with pN0 gastric cancer finally. Furthermore, the prognosis of patients with pN0 advanced gastric cancer (invasive depth ≥ T2) were analyzed using the same method.

RESULTSA total of 610 patients with pN0 gastric cancer were enrolled in the study, including 441 males and 169 females with age ranging from 19 to 83 (mean 56.4±11.0) years, D1 lymph node dissection in 45 cases, D2 lymph node dissection in 543 cases, D3 lymph node dissection in 22 cases, and 384 cases of advanced gastric cancer. The overall followed-up was 1 to 372 (median 32) months. Ninety cases (14.8%) were dead during the follow-up. The median survival was 277.7(95%CI: 257.6 to 297.8) months, and the 1-, 3-, 5-year survival rates were 96.5%, 87%, 83.2%. Univariate analysis showed that tumor diameter, depth of invasion, gross type, lymph node dissection and lymph vessel cancer embolus were related to the prognosis (all P<0.05). The 5-year survival rate of patients with tumor diameter >4 cm was significantly lower than those with tumor diameter ≤4 cm (75.6% vs. 87.8%, P=0.000). The 5-year survival rates of T1a, T1b, T2, T3 and T4 were 98.4%, 92.8%, 84.2%, 61.0% and 31.4% respectively, and the difference was statistically significant (P=0.000). In gross type, 5-year survival rate of early gastric cancer was 96.0%, and of Borrmann I( to IIII( type gastric cancer was 100%, 83.4%, 73.7% and 68.9% respectively, whose difference was statistically significant(P=0.000). The 5-year survival rates in patients undergoing lymph node dissection D1, D2 and D3 were 100%, 83.3% and 58.7%, and the difference was significant (P=0.005). The 5-year survival rate of patients with positive lymphatic cancer embolus was lower than those with negative ones (69.4% vs. 86.9%, P=0.000). Multivariate analysis showed that the gross type [Borrmann II(/early gastric cancer: HR(95% CI)=15.129(3.284 to 69.699), Borrmann III(/early gastric cancer: HR(95% CI)=14.613 (3.292 to 64.875), Borrmann IIII(/early gastric cancer: HR (95% CI)=15.430 (2.778 to 85.718),Borrmann IIIII(/early gastric cancer: HR(95%CI)=12.604 (1.055 to 150.642), P=0.025] and the positive lymphatic cancer embolus [HR(95% CI)=3.241 (2.056 to 5.108), P=0.000] were the independent prognostic factors of patients with pN0 gastric cancer. For pN0 patients with advanced gastric cancer, multivariate analysis showed that the depth of invasion [stage T3/stage T2: HR(95%CI)=1.520 (0.888 to 2.601), stage T4/stage T2: HR(95%CI)=2.235(1.227 to 4.070); P=0.031] and the positive lymphatic cancer embolus [HR(95%CI)=3.065 (1.930 to 4.868); P=0.000] were the independent risk factors influencing the prognosis.

CONCLUSIONSPositive lymphatic cancer embolus and worse gross pattern indicate poorer prognosis of patients with pN0 gastric cancer, which may be used as effective markers in evaluating the prognosis. As for pN0 advanced gastric cancer, invasion depth and positive lymphatic cancer embolus can play a more important role in the prediction.

Adenocarcinoma ; classification ; diagnosis ; mortality ; Adult ; Aged ; Aged, 80 and over ; China ; Female ; Humans ; Lymph Node Excision ; statistics & numerical data ; Lymph Nodes ; pathology ; surgery ; Lymphatic Metastasis ; physiopathology ; Lymphatic Vessels ; pathology ; Male ; Middle Aged ; Multivariate Analysis ; Neoplasm Invasiveness ; pathology ; physiopathology ; Neoplasm Staging ; statistics & numerical data ; Prognosis ; Proportional Hazards Models ; Retrospective Studies ; Risk Factors ; Stomach Neoplasms ; classification ; diagnosis ; mortality ; Survival Rate

OBJECTIVETo elucidate the current diagnosis and treatment status of gastric cancer in the Chinese population based on three high volume databases.

METHODSClinical and pathological data of patients who underwent gastric cancer resection with complete follow-up information between January 2000 and December 2012 from Sun Yat-sen University Cancer Center, The First Affiliated Hospital of China Medical University and Tianjin Medical University Cancer Hospital were retrospectively analyzed. The overall survival rate was calculated by Kaplan-Meier method. The prognostic risk factors were analyzed by using Cox proportional hazards model.

RESULTSA total of 8 338 cases were enrolled into the study, including 2 977 cases (35.7%) from Sun Yat-sen University Cancer Center, 3 043 cases (36.5%) from The First Affiliated Hospital of China Medical University and 2 318 cases (27.8%) from Tianjin Medical University Cancer Hospital. There were 5 852 male cases and 2 486 female cases with a ratio of 2.4 to 1.0. The age of patients was from 15 to 89 years old (median 59 years old). The ratio of early gastric cancer (T1NanyM0) was 11.5% (956/8 338). There were 2 226 gastric cancer cases (26.7%) originating from the fundus and cardiac region, 1 637 cases (19.6%) from the body, 3739 (44.9%) cases from the antrum, and 736 cases (8.8%) from the whole stomach. The median maximal tumor diameter was (4.5 ± 2.8) cm. Based on the Lauren classification, 3 448 cases (41.4%) were intestinal type and 4 890 cases (58.6%) diffuse type. A total of 1 975 cases (23.7%) and 6 363 cases (76.3%) underwent complete and subtotal gastrectomy respectively. The majority of patients (7 707 cases, 92.4%) underwent radical gastric resection, while 631 cases (7.6%) palliative resection. According to AJCC/UICC seventh edition of gastric cancer TNM staging system, 802 patients (9.6%) were stage I(A, 735 patients (8.8%) stage I(B, 695 patients (8.3%) stage II(A, 1 507 patients (18.1%) stage II(B, 1 247 patients (15.0%) stage III(A, 1 342 patients (16.1%) stage III(B, 1 583 patients (19.0%) stage III (C and 427 patients (5.1%) stage IIII(. The average number of retrieved lymph node was 21.0 ± 13.1, in which 5 761 patients (69.1%) had more than 15 retrieved lymph nodes. The overall 1-, 3-, 5- and 10-year survival rates were 83.0%, 56.8%, 49.1% and 43.0% respectively. For patients receiving radical resection, the 1-, 3-, 5- and 10-year survival rates were 84.9%, 59.5%, 51.7% and 45.3% respectively. The overall 5-year survival rates for different stages were as follows: stage I(A 93.8%, stage I(B 80.8%, stage II(A 70.8%, stage II(B 59.6%, stage III(A 44.4%, stage III(B 32.9%, stage III(C 18.9% and stage IIII( 10.2%. Cox regression model showed that age, tumor site, tumor size, Lauren type, T staging, N staging, M staging and number of retrieved lymph nodes were independent factors affecting the prognosis of gastric cancer patients (P=0.000).

CONCLUSIONRetrospective study on these domestic three high volume databases demonstrates the clinical and pathological characteristics of gastric cancer based on Chinese population, which is expected to stand as a ground of basic data for future clinical research.

Adolescent ; Adult ; Aged ; Aged, 80 and over ; China ; Databases, Factual ; Female ; Gastrectomy ; Humans ; Lymphatic Metastasis ; Male ; Middle Aged ; Neoplasm Staging ; Prognosis ; Proportional Hazards Models ; Retrospective Studies ; Risk Factors ; Stomach Neoplasms ; diagnosis ; surgery ; Survival Rate ; Young Adult