Cancer of the Antral and Pyloric Parts

Blastomatous affection of the distal part of the stomach occurs quite frequently. Although its incidence tends to decrease, it is necessary to note that this concerns only exophytic tumors and in a small number of countries, where to human health has a high priority. The most prevalent cancers are infiltrative tumors, the occurrence of which remains at about the same level (D Fig. 130).

Pyloric cancers are a special problem in the detection of distal tumors. They occur less frequently

□ Fig. 130 a-c. Female patient U., age 62. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): cavity of the distal part is decreased, the distal part is disfigured (rigid tube), its contours are uneven, the walls are rigid. b, c Stomach roentgenograms (double contrast, horizontal position, anterior projection): circular infiltration of the distal part of the stomach, markedly rigid walls, thickened wall of the lesser and the greater curvatures of the stomach body due to infiltration spreading in the proximal direction (arrows). Conclusion: Infiltrative cancer of the distal part of the stomach with invasion of the stomach body. The patient was operated. Histologically, signet-ring cell carcinoma.

▲ Fig. 130 c.

□ Fig. 131 a, b. Patient I., age 57. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the pyloric part is narrowed, the lesser curvature of the distal part is very short, the sinus sags, the evacuating function of the pylorus is upset. b Stomach roentgenogram (double contrast, horizontal position, anterior projection): marked convergence of the folds in the direction of the thickened portion of the wall of the lesser curvature in the pyloric part (arrow). Conclusion: Infiltrative cancer of the pyloric part of the stomach. The patient was operated. Histologically, signetring cell carcinoma.

□ Fig. 132 a-e. Female patient G., age 63. Diagnosis: gastric cancer. a Stomach roentgenogram - (tight filling, vertical position, anterior projection): cavity of the distal part and the lower third of the stomach body is decreased, the lesser curvature is short and depressed, its contours and contours of the greater curvature are uneven (arrows). b, c Stomach roentgenograms (tight filling, vertical position, anterior projection): the cavity is diminished, evacuation is accelerated. Uneven contours, rigid walls, the angular notch straightened (arrow). d Stomach roentgenogram (double contrast, horizontal position, anterior projection): the walls of the distal part and the body of the stomach are thickened and rigid due to circular intramural infiltration. Conclusion: Infiltrative cancer of the distal part of the stomach with invasion of the stomach body. e Endophotograph: the stomach lumen is disfigured, narrowed, the mucous membrane is grayish pink, dull, with uneven surface, readily injured on contact, the folds in this region are completely smoothed down. Histological examination of the bioptates verified signet-ring cell carcinoma of the stomach.

▲ Fig. 131 c.
▲ Fig. 132 e.

than antral cancers. According to some authors, they account for 4-16% of all gastric carcinomas. Nevertheless, it would be reasonable to discuss them as one group because of their common clinical manifestations [185, 223]. Because of their location in the pylorus, even relatively small tumors manifest by obstructive symptoms at the early stages of their growth (D Fig. 131). As distinct from stenosis, the pylorus may develop incompetence due to infiltration, and the patients experience constant hunger while losing weight (D Fig. 132). Practical experience shows that early clinical symptoms induce the patient to seek medical aid, but X-ray and endoscopic examinations sometimes prove ineffective for timely detection of the tumor in this zone; the anatomy of the pylorus is the most difficult for radiological examination and endoscopy. In addition, distal cancers must be differentiated from stenoses of the pyloro-duodenal region. The diagnosis of ulcerous stenosis with obliterated or indistinct clinical signs is often established in patients with this localization of cancer (D Fig. 133). As the infiltrative forms of tumor growth predominate in this part, the diagnosis is even more difficult due to the specific anatomical and functional properties of this part of the stomach and the absence of marked symptoms of organic affection, interpreted in most situations to be the result of the inflammatory process. But patients often go to the doctor when their tumor is already easily palpable (D Fig. 134) [42]. Conspicuous manifes tations of pyloroduodenal pathologies resulted in rapid accumulation of clinical data, the importance of which is difficult to overestimate even today. As knowledge of the nature of obstruction of the pylor-ic part grew, two aspects emerged. First, the necessity of selecting the proper degree of operative intervention implies preoperative establishment of the cause and the spread of the pathological process (D Fig. 135) [66]. Second, research into the role of cancers of the linitis plastica type influenced the present situation as regards identification of the nature of pyloric stenosis (D Fig. 136). The basic concepts of this research remain unchanged today. In current publications we meet the same point of view on the onset of the primary focus of infiltration in the pre-pyloric part and on tumor spreading in the proximal direction. As regards ulcers of the pyloric part, most researchers agree that they are usually malignant [10].

Stomach Over FilledStomach Ulcer Pathological Examination

□ Fig. 133 a-e. Patient L., age 65. Diagnosis: gastric cancer. Complaints of occasional vomiting, usually in the second half of the day. The feeling of overfilled stomach after meals. Anamnestic data: endoscopy conducted about 2 months earlier revealed a small ulcer in the pyloric part of the stomach. Histological examination of bioptates failed to find tumor cells. Control endoscopies did not reveal positive dynamics. X-ray examination of the stomach was recommended. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the pyloric part is disfigured, narrowed, the walls are rigid (arrows). b Stomach roentgenogram (tight filling, horizontal position, left posterior oblique projection): the pyloric part is disfigured (rigid tube) (arrow). c, d Stomach roentgenograms (double contrast, horizontal position, anterior projection): the pyloric part is disfigured, the walls are rigid, the lesser curvature has the shapes of a rigid platform with a depot of contrast medium (arrow). e, f Stomach roentgenograms (double contrast, horizontal position, anterior projection) after additional ingestion of a gas-producing mixture and practically complete evacuation of the barium sulfate suspension: the walls of the pyloric part of the stomach are thickened and rigid due to circular intramural infiltration (arrows). Conclusion: Infiltrative-ulcerous cancer of the pyloric part of the stomach. The patient was operated. Histologically, signet-ring cell carcinoma.

□ Fig. 134 a-c. Patient K, age 46. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the pyloric part and the distal half of the antral part are narrow, evacuation function of the pylorus is upset, the

▲ Fig. 134 b.

walls are rigid. b Stomach roentgenogram (double contrast, horizontal position, anterior projection): the pyloric part and the distal half of the antral part are narrowed, the walls are thickened and rigid due to circular intramural infiltration (arrows). Conclusion: Infiltrative cancer of the pyloric part of the stomach with invasion of the antral part of the stomach. c Endophoto-graph: the pyloric part of the stomach is very narrow and disfigured, the mucous membrane is spotted: grayish pink spots against the background of hyperemia; the surface is smooth and glassy. Histological examination of the bioptates verified signet-ring cell carcinoma.

□ Fig. 135 a-c. Patient S., age 59. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): antral part of the stomach is disfigured (hourglass), the angular notch is straightened, contours are uneven (arrows). b Stomach roentgenogram (double contrast, horizontal position, anterior projection): walls of the antral part, the sinus, and the stomach body are thickened and rigid due to diffuse circular intramural infiltration (arrows). Conclusion: Infiltrative cancer of the antral part of the stomach with involvement of the stomach body. c Endophotograph: the antral part of the stomach is strongly disfigured and narrowed. The mucous membrane is scarlet, infiltrated, with uneven surface. Ulceration with tuberous firm margins and flat uneven floor covered with necrotic mass is seen on the greater curvature. Histological examination of bioptates verified signet-ring cell carcinoma.

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