Krukernberg is a malignant tumor of the ovary is a classic will do GIT. Althougt tract metastases to the pila can arise in other tissues such as the breast. Adenocarcinoma of the stomach, especially in the area of the pylorus, a major source of the most frequent tumor . Kreukenberg (over 80%) are found on both ovaries, consistent with the nature of these metastases.
Krukenberg tumors can be seen in all age groups, with an average age of 45 years . in united State, cancer that has metastasized to the ovary is only about 1 to 2% of cancers in Japan ovarium. but an increase in the occurrence of Krukenberg tumors is due to an increase in the prevalence of gastric cancer.
In people who have a malignancy nongynecologi, approximately 20% of adnexal masses were malignant, and 60% of them Krukenberg tumors.
In a typical microscopic picture, in the form of cells that resemble signets rings in the middle of the stroma. Majority of Krukenberg tumors are metastatic from gastric carcinoma ventrikuli.
CHAPTER II
II.I. Definition
Some definitions in this Krukenberg tumor,
Krukenberg tumor
digolongan well as Ovarian Carcinoma Metastatik.Karsinoma is usually bilateral and primary solid.Tumor derived from the corpus of the uterus, intestines, breast, and glands tiroid.Kurang over 6% of ovarian carcinomas can be found when the operation is metastatic.
Figure Krukenberg Tumors
Krukernberg is a malignant tumor of the ovary is a classic will do pencernaan.Meskipun tract metastases can also occur in other tissues such as the breast. Adenocarcinoma of the stomach, especially in the area of the pylorus, a major source of the most frequent tumor umum.Kreukenberg (over 80%) are found on both ovaries, consistent with the nature of these metastases.
II.2.EPIDEMIOLOGI
Krukenberg tumors can be seen in all age groups, with an average age of 45 tahun.Dikebayakan State, cancer that has metastasized to the ovary is only about 1 to 2% of cancers in Japan ovarium.Tetapi an increase in the occurrence of Krukenberg tumors is due to an increase in the prevalence of gastric cancer.
In people who have a malignancy nongynecologi, approximately 20% of adnexal masses were malignant, and 60% of them Krukenberg tumors.
Friedrich Ernst Krukenberg (1871-1946),
Krukenberg tumor is named by Friedrich Ernst Krukenberg (1871-1946), which he said was a new type of primary malignancy of the ovary in 1896. M enggambarkan a malignant tumor that is odd from the ovary which he gave carcinomatodes
fibrocarsinoma mucocellulare long. As the name suggests, Krukenberg considered as the primary tumor would be fibrokarsinoma the elements and structure resembles karsinoma.Ia describe as solid ovarian tumors, usually bilaterally on both ovaries and maintain the shape of the ovary (Figure 1.2), myxomatous his performance, happen, occur in young and old age, growing slowly, usually had metastasis accompanied by the occurrence of ascites recurrence and severity usually occurs due to expansion and kekambuhan.ia describe its structure with a small group or polyhydral cells that grow in a diffuse or large round with slimy contents which compresses the core into shape cincin.dia trust will be the primary tumor in ovarium.P enampilan myxomatous , occurred on the subject of old and young , growing slowly , usually ntually
fatal extansion or repetition with ascites, and the night
that happened
he described the structure as a
presentation of a small group or grow diffuse cells
polyhydral or round
with a large content of slimy
compresses the core into a form of a ring .
Figure 1.2 shows that the Krukenberg tumpor both ovaries
II.3. Microscopic
In a typical microscopic picture, in the form of cells that resemble signets rings in the middle of the stroma (Figure 1.3). Majority of Krukenberg tumors are metastatic from gastric carcinoma ventrikuli.
II.4. SYMPTOMS
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Krukenberg tumors are usually not detected early due to not show symptoms at first, but will become a cause of concern when abdominal or pelvic pain, bloating and ascites, or experiencing pain that is felt when Krukenberg seksual.Tumor intercourse can trigger a reaction that causes the ovarian stroma production of hormones, which cause vaginal bleeding, changes in menstrual habit and occurs hirsutism or virilization sometimes as the main symptom.
The symptoms of metastatic carcinoma generally have a relationship with the primary tumor, but sometimes a tumor that filled the pelvic cavity with ascites primernya.Karena mask the symptoms of ovarian tumors are bilateral and possibly solid metastatic malignant and may also, then there is no benefit in this case investigating the possibility other malignant tumors initially placed lainya.Karena symptoms often do not exist, people often dating terlambat.Hasil cervical cytology smears are positive, should remind us of the presence of a malignant tumor of the uterine cervix or uterine cavity can not be proven.
Diagnosis of malignant tumors are more often made after laparotomy or indication of a tumor ovarium.Agar terlamabat not the right thing to do, should be done durante operationem histological examination (frozen section or frozen). At laparotomy should also not be forgotten flushing peritonii cavity to be examined about the existing or absence of malignant cells. (exfoliative cytology ascites fluid or peritoneal fluid cavity rinses).
Whenever there is a fair amount of ascites fluid, often difficult and preoperative gynecologic examination is necessary to puncture the abdomen to remove the ascites fluid was centrifuged tersebut.Cairan, aka tone microscopically examined whether or not the discharge ganas.Dengan ascites cells in sufficient quantities, it can be examined the tools are genital.Bila ascites that can not be explained origin or why (eg due to cirrhosis of the liver), laparotomy eksploriatif should be run.
But all of these symptoms are not specific and can also arise with diseases other than cancer, and the diagnosis can only be made by of Inquiry with abdominal CT scan, or laparotomy and ovarian biopsy.
II.5. Deployment
Malignant ovarian tumors spread to lymph limfogen the aorta, mediastinal and supraclavicular, for onward spread kea far lat-tool, particularly the lungs, liver and intestine, and ureter otak.Obstruksi is a problem that often accompany malignant ovarian tumor patients.
II.6. Pathogenesis
Pathogenesis of Krukenberg tumor has been debated, namely metastasis of tumor cells of the stomach, appendix or colon to classical ovarium.Secara he thought that the spread of such tumors in the cavity due to direct seeding in limfatik.Rata perut.Tapi penyebaranya The average age of the affected Krukenberg tumor is associated with the occurrence of increased vascularity of the ovary.
tumpor shows that about two ovarian Krukenberg
At the microscopic appearance, tumor krukernberg often characterized by mucin-secreting cells in the tissue ring signets ovarium.Ketika primary tumor is found, the same ring signets usually ditemukan.Namun, other microscopic features can dominate.
Krukenberg tumor most often found in the metastasis of gastric cancer, especially adenocarcinoma, or invasive breast cancer especially lobular carcinoma payudara.Tetapi they can appear in the appendix of the colon or small intestine, rectum, gall bladder, and urinary bladder, pancreas, or cervix.
Immunohistochemistry may help in the diagnosis of Krukenberg tumors from primary ovarian neoplasia.
II.7. Determination of Malignancy Clinical Level
Internationally known until now the existence of two classification systems both commonly used, is the TNM system of the UICC (Union Internationale Contra le Cancer) and system FIGO (Federation Internationale de Gynecologie et d'Obstetrigue).
Table Klasikasi malignancies
UICC
criteria
FIGO
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T1
Limited on ovarian I
T1a
One ovary, no ascites
He
T1b
Both ovaries, no ascites Ib
T1c
One / two ovaries, no ascites
Ic
T2
Premises extension to the pelvic
II
T2a
uterus and / or tubes, without ascites
IIa
T2b
other pelvic Network, without ascites
IIb
T2C
other pelvic Network, with ascites
IIc
T3 Expansion into the small bowel / omentum in the pelvis, or the deployment of III
Intraperitoneal / gland retraperitoneal
M1
Spread to distant devices IV
|
II.8. Diagnosis
Figure tumor krukenber
Ovarian almost never see tropografi allows us to do early detection of malignant ovarian tumors by because it is very tersembunyi.Diagnosis based on 3 signs and symptoms usually appear in the course of the disease is already somewhat advanced:
1)
Symptoms insistence that be related to the growth and infiltration of primary kejaringan around,
2)
Symptoms of dissemination / dispersion caused by peritoneal implantation and manifest the presence of ascites,
3)
hormonal symptoms that manifest as defeminisasi, masculinization, or hiperestrogenisme, the intensity of the symptoms varies with tumor histological type and age of the patient.
Figure 1 . X-rays show the loop , dilatation of the colon in quadrant lower left
Gynecologic examination and abdominal palpation will get a tumor or mass in the pelvis with an assortment kosistensimulai of the cystic to solid (solid).
II.9. Therapy
Since it is known that Krukenberg tumors known to have come from a secondary tumor from a metastasis, treatment in treating cancer is the primary treatment of choice.
Actual conditions dri tumors rarely enforced only by clinical examination. The use of ultrasound (ultrasonography) and CT scan (Computerised axial tomography scanning) can be about providing valuable information on tumor size and perluasanya before pembedeahan.Laparotomi eksploriatif with frozen section biopsy (frozen section) still remains the most useful diagnostic procedure to get a true idea of tumors and perluasanya menentuka strategies and further handling.
. 
Ct-Scan images of the abdomen on Krukenberg tumor
For malignant ovarian tumor surgery is an option utama.Pada early stage, TAH + BSO procedure is + OM + APP (optional). Extensive surgical procedure is determined by the incidence of frequent deployment to the other side (bilateral) and a tendency to invade the uterine body (corpus uterus). Though surgery is not solely for the treatment, determination of accurate levels of clinical disease when pembedahandan histopathology results are very important for the future conduct adequate treatment.
Biopsy in some places, such as the omentum, lymph nodes and the pre-aortal and sub-diaphragmatic area, it is very penting.Pembedahan also very important as a primary action with extensive disease patients is to lift as much as possible of the tumor tissue, if at all possible though not all the tumor tissue can be removed completely (debulking). With debulking (bulk reductive sugery) allows chemo or radiotherapy more effective.
If in the future a more effective combination ditemukian, this would justify the basic principles of thinking bulk reductive surgery / debulking of malignant ovarian tumors are diatas.Tindakan conservative (only the ovarian tumors, oophorektomi or oophoro cystectomy) can still be justified if the level of clinical T1a disease, young women, not to have children, low histological grade tumors such as dysgerminomas, granulosa cell tumor, and arrhenoblastoma or low malignancy potential = borderline malignancy, it is, compassion accountable, although some experts believe such action remains a gamble.
Strict supervision of a postoperative pemderita conditiosine quo non (mandatory). Dilakukanya with chemotherapy and radiotherapy can also petrified, but sometimes useful.
II.10. . Radiotherapy
As a follow-up treatment is commonly used in the clinic level T1 and T2 (FIGO: Level I and II), which is given to the pelvis alone or the whole cavity perut.Juga radiotherapy can be given to the disease tingkatanya bit further, but this much last-last chemotherapy given concurrently , either before or after as an adjuvant, a radio-sensitizer and radio-enhancer.
In many flashlights, radiotherapi no longer considered to have a malignant tumor treatment tempatdalam ovarium.Pada clinical levels of T3 and T4 (FIGO: level III and IV) conducted de-bulking followed by kemoterapi.Radiasi to kill tumor cells remaining, only effective on the type of tumors that are sensitive to light (radiosensitive) as dysgerminomas and granulosa cell tumors.
II.11 Chemotherapy
Now have gained a recognized place in the treatment of malignant tumors ovarium.Sejumlah sitostatica drugs have been used, including alkylating agents (such as cyclophosphamide, chlorambusil), antibiotics (such as adriamycin) and other agents (such as Cis-Platinum). Various combinations of agents have been used that it can show the potential meaning.
The presence of ascites may be controlled with chemotherapy intraperitoneal.Isotop radioactive sekarng rarely used in the treatment of these tumors, ascites fluid was shunting techniques into the jugular vein through a plastic tube ovarian hormone preparations often use progestativa.
II.12. Complication
Merupaka bowel obstruction complications that often occur in cases of advanced levels which are managed by resection of the bowel once or several times to several times to create a by-pass when the condition of the patient permits.
Second look laparotomy
To ensure the success of treatment with radiotherapy or chemotherapy, a second laparotomy prevalent, even terkadsdang until the third (third look laparotomy). This allows us to make an accurate assessment can establish premises penyakitnya.Hingga process selanjutnya.Bisa treatment strategies need to be stopped or continued with alternative other treatments.
II.13. Prognosis
Depending on the age and especially malignant process in addition to extensive histological types of cases tumornya.PAda clinic level T1 and T2, AKH-5 years of about 60-70%. In cases with more advanced level (T2 and T3) with adequate palliation can be achieved AKH- 5 years between 30% - 60%, while T4 5-year life expectancy for practically nothing (0%).
CHAPTER III
Gastric carcinoma
III.1 Introduction
Gastric carcinoma is an epithelial tumor that is malignant gastric mucosa with differentiation kelenjar.Secara anatomy, gastric gland has two components, namely: foveola (crypt, pit) and secretory component (adenomere). Foveola part of this is an area that is important for growth gastric carcinoma, especially generative cell layer that lies on the basal.Perbedaan advance of the types of gastric carcinoma depends on the proportion of the foveola and secretory.
According to the Japanese Society of Gastroenterological Endoscopy in 1962, early carcinoma of the stomach is adenocarsinoma limited to the mucosa or sub-mucosa (muscularis externa did not achieve) notwithstanding the absence of involvement of lymp nodes initidak regional.Karsinomna same as carcinoma in situ or dysplasia, gastric, because on the state of the tumor has not passed the basal membrane and does not cause metastase.Tetapi early gastric carcinoma, in some cases can be found on lymp node metastases and the liver.
III.2. ANATOMY gastric
Figure. Anatomy of gastric
Based faalnya, stomach is divided into two parts. Three-quarters comprising proximal fundus and corpus, serves as a container for swallowed food and gastric acid production sites and pepsin, while a quarter of the distal antrum work or mix food and push it into the duodenum and produce gastrin. Fundus thin walls, while the walls of the corpus, antrum moreover, thick and strong LAPI san muscles (Wim de Jong, 2004)
Characteristic is quite prominent on the anatomy of the stomach is a very rich blood circulation and derived from the four majors with a large artery on the side of the greater curvature and minor as well as the stomach wall. Behind and medial edge of the duodenum, also found large arteries (a.gastroduodenalis). Bleeding can occur due to erosion of the arterial wall in peptic ulcer of the stomach at au duodenum (Wim de Jong, 2004)
Veins of the stomach and duodenum empties into the portal vein. Circulation is very rich vein with collateral relationship to the embryonic organ in connection with the stomach and duodenum. Gastric lymph channels is quite complicated, everything will end up in the gland and preaorta paraaorta in embryonic root of the mesentery. Between the hull and the base of the embryonic lymph nodes are in the greater curvature, lesser curvature, the hilum of the spleen, hepatoduodenal ligament, the upper edge of the pancreas and various other places in retr operitoneal (Wim de Jong, 2004)
Sympathetic innervation of the stomach as usual through the nerve fibers that accompany the arteries. Pain impulses delivered via efferent sympathetic nerve fibers. Parasympathetic fibers derived from n.vagus and take care of parietal cells in the fundus and corpus of the stomach. These cells function to produce stomach acid. Anterior vagus (sinister) gives a branch to the gall bladder, liver, and antrum as Laterjet anterior, posterior while n.vagus (dextra) gives branches to the visceral ganglion seliakus to another in the stomach and into the antrum as Laterjet posterior nerve (Wim de Jong, 2004)
III.3. Epidemiology
Gastric carcinoma is the second most carcinoma in the world in 1990, an estimated 800,000 new cases and 650,000 klematian numbers pertahun.Sekitar 60% darei terdsapat cases of the disease in the State berkembang.Insiden found 20 times on the Japanese State, when compared from United States Serikat.Pada areas with high risk of gastric carcinoma is more common with intestinal type.
Intestinal-type gastric carcinoma more frequently in the age above 30 years with more men than women ssering.
III.4.Faktor Risk of Gastric Carcinoma In Occurrence
Some experts observed that gastric carcinoma is an ongoing process that starts from chronic gastritis, chronic atrophic gastritis, intestinal metaplasia, dysplasia and finally gastric carcinoma.
Opinion of other experts say ;
Gastric atrophy may be accompanied by loss of parietal cells that can result in reduced acid production labung (hipochlorhidria or achlorhidria), the decreased levels of vitamin C and compensated with increased serum gastrin.Keadaan can cause potential induction of gastric epithelial cell proliferation.
Factors that contribute to the incidence of gastric carcinoma :
1. Infection with Helicobacter pylori
Gastric carcinoma has a strong relationship with Helicobacter infection pylori.Pada study showed that H. pylori induce phenotypic changes can lead to carcinoma, among others: atrophy of the gastric mucosa, intestinal metaplasia and dysplasia.
2. Diet
In the epidemiological study of the relationship between diet with gastric carcinoma, especially type intestinal.Diet with a dab of fresh fruit ad vegetables can lower the risk of Strong gastric carcinoma, therefore Danya antioksidan.Intake effects of salt, alcohol, smoke rook and nitrosamine exposure may increase the risk gastric carcinoma and precursor lesions may cause.
3. Bile Reflux
III.5. Classification
Classification of early gastric carcinoma based on macroscopic lesion overview of the results of endoscopic examination (Japanese Gastroenterological Endoscopic Society), namely:
Type I : protruding lesions on mucosal surfaces (polypoid, nodular or villous)
Type IIa : elevaasi lesions on mucosal surfaces
Type IIb : Lesions in the form of flat / flat with the mucosal surface
Type IIc : depressed lesions of the mucosal surface
Type III ; Lesions were excavated from the surface of the mucosa.
Classification by other RTA Borrman:
1. fungating
2. fungating with Krater
3. fungating with ulcer
4. Diffuse infiltrating carcinoma (linitis plastic)
Classification based on histopathologic picture:
Classification based histropatologi picture being used several State is lauren.Klasifikasi classification is associated with environmental factors, the tendency of the incident and the presence of precursors.
·
Type intestinal
In this type appears the glandular structures with good or moderate differentiation. Sometimes it can also be accompanied by tumor cells buruk.Gambaran differentiation is usually derived from intestinal epithelial metaplasia.
Intended for the intestinal type possessed a similar picture with adsenokarsinoma colon, containing an array of nodes with solid areas or papillary.Sel-cells with columnar or cuboidal bentruk the core lies in the basal part. Sometimes the lumen containing mucin.
·
Type of diffuse
This type memperrlihatkan fragile cohesion between cells and penetrate cells in diffuse gastric wall with little or no description of glandular structures,. Encountered In the absence of this type of mucus secretion, when the mucus is in the tumor cells can be pushed to the edge of the cell nucleus so called ring signets sel.Biasanya these tumors are often referred to linitis plastic.
·
Type Mixed
In this type memperlihyatkan between intestinal-type and diffuse-type in nearly equal amounts.
In early gastric carcinoma, intestinal type histologically appear in most cases, but the diffuse type and mixed type premises can also be found lower frequencies.
Other histopathological classification according to the WHO, based on the dominant histopathologic picture:
·
Tubular Adenocarcinoma
In this situation looks picture tubular dilatation and bercabag-branches of different sizes, can be found aciner.Sel-cell structure can be formed columnar, cuboidal or intraluminal flat.Pada can be seen mucin.Clear cell can also be found.
·
Papillary adenocarcinoma
This type of carcinoma is well differentiated exophytic carcinoma who terbentuk.Finger like the piston or lining epithelium and stroma kuboidal composed of fibrovascular cores.
·
Mucinous adenocarcinoma
This carcinoma has two main features, namely:
-
glands were lined by mucus-secreting columnar epithelium and interstitial mucin,
-
Signet ring cell carcinoma
·
rinf Signet cell carcinoma
When the tumor is composed of over 50% of malignant cells with intracytoplasmic mucin.
III.6. Clinical Symptoms
Early carcinoma of the stomach often does not cause symptoms, although 50% of patients who do not feel the typical complaints in the abdominal area, such as dyspepsia, burning sensation in the stomach (heart burn) and loss of appetite.
III.7. Radiological examination
Radiological examinations are often performed for this disease is a type of endoscopy, an examination of the most sensitive and specific ntuk gaster.Endoscopi diagnose carcinomas with high resolution can detect minor changes in the color, architectural reliefs of gastric mucosal surface which leads to early gastric carcinoma.
Radiological examination using a barium enema was used in Jepan as a protocol for screening, if later found further abnormalities examined by endoscopy.
III.8. Examination Cytology
Gastric cytology cytology brushing.Pada done through normal circumstances, it appears classify superficial epithelial cells are regularly set up a picture like honey comb.Sel these cells have a round nucleus with evenly dispersed chromatin core.
In the state of gastritis, cell cytoplasm appears more kuboidal derngan little bit and core membesar.Pada carcinoma cells, the cells became more spread out in groups or slightly irregular, enlarged cell nuclei and hiperromatin and have children of multiple nuclei or giant nucleoli.
Cytology brushing if done correctly, has a value accurate to 85%, but when these checks can keakuratanya increased to 96%.
III.9. Macroscopic examination
Grossly, the size of early carcinoma of the stomach is divided into two classes, namely denhgan tumor size <5mm, called by the minute and with a size of 6-10 mm tumors, called small.
The location of tumors in the gastric carcinoma is the pylorus and antgrum (50-60%). Curvutura minor (40%), cardia (25%), Curvutura major (12%). Least a lot going on in the area of gastric carcinoma kurvutura antropyloric minor part.
III.10. Therapy
Standard therapy in gastric carcinoma is usually a subtotal gastrektomy.Operasi, radical subtotal gastrectomy, depending on the spread of the tumor and mucosa common type of surgery subtotal terkena.Secara gastrectomylebih preferred, because morbidity rendah.Karsinoma gastric minimal response to radiation therapy and relative do not respond to chemotherapy.
Operating standards of cancer gastric radical subtotal gastrectomy was
III.11. Prognosis
Early gastric carcinoma is a tumor with good prognosis by karna metastse to lymph nodes and rarely terjadi.tumor angioinvasi with surgery baik.Tumor gives results which are limited to intramukosa, with gastrektomy, resulted in 93% cure rate when lymph node metastases t6anpa regional.Bila cancer cells reach the submucosa without lymph node metastases to the regional, the cure rate after gastrektomy about 89%, but when it happens metastases, regional lymph to, the success rate reaches 80%. Survaival life year after gastric resection five years is 80 -95%. incidence of local recuren on this very rendah.Bila carcinoma in patients with early gastric carcinoma gastrectomy is not done then it will progress to advanced carcinoma.
Patients with diffuse-type carcinomas have a worse prognosis when compared with intestinal type, poor prognosis can also occur when the patient age were children or young adults.
In general, the prognosis in carcinoma is associated with miraculous factors, among others:
·
Age Patients
Patients with age Musda have a worse prognosis, especially in diffuse type.
·
Location Tumors
When tumor lesions found on distral area, the better prognosis when compared with lesions in this area.
·
Tumor Size
Smaller tumors have a better prognosis.
·
The involvement of regional lymph node
If there has been no lymph node metastases in the regional, the prognosis becomes more baik.Bila regional lymph nodes have been invaded by malignant cells, the prognosis be reduced by about 10%.
·
Inflammatory Reaction
Cellular infiltration between the tumor with normal tissue often associated with degenerative changes in the tumor, the prognosis is good merupaka.
·
Type of Microscopic description
Intestinal-type gastric carcinoma has a better prognosis than diffuse-type premises.
III.12. Metastases
Tumor metastasis in early gastric carcinoma terutrama through limfogen but can also through local invasion of malignant cells as well as some cases may occur hematogen.Pada nodules on sentinel supraclavicular (Virchow) as a clinical anifestai pertama.Sel-tumor cells can also metastasizes to regional periumbilikal and nodul.Invasi local subcutaneous form occurs
in the area of the duodenum, pancreas and retroperitoneum organs and ovaries (Krukenberg tumor) the tumor metastases to the liver can also usually through hematogenous pathways.
CHAPTER IV
CONCLUSION
Krukenberg tumor
digolongan well as Ovarian Carcinoma Metastatik.Karsinoma is usually bilateral and primary solid.Tumor derived from the corpus of the uterus, intestines, breast, and glands tiroid.Kurang over 6% of ovarian carcinomas can be found when the operation is metastatic.
Krukenberg tumors can be seen in all age groups, with an average age of 45 tahun.Dikebayakan State, cancer that has metastasized to the ovary is only about 1 to 2% of cancers in Japan ovarium.Tetapi an increase in the occurrence of Krukenberg tumors is due to an increase in the prevalence of gastric cancer.
Krukenberg tumors are usually not detected early due to not show symptoms at first, but will become a cause of concern when abdominal or pelvic pain, bloating and ascites, or experiencing pain that is felt when Krukenberg seksual.Tumor intercourse can trigger a reaction that causes the ovarian stroma production of hormones, which cause vaginal bleeding, changes in menstrual habit and occurs hirsutism or virilization sometimes as the main symptom.
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Pathology and genetics of tumors of the digestive system, the World Health
Organization Classification of tumors.IARC Press, Lyon. 2000: p 38-49
3. DA.The Stomach Owen, inclusive; alimentatry Canal and Associated Organs.In: Mills SE editor, Stenberg's Diagnostic Surgical Pathology. 4 th Ed.Vol 2.Lippincott
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