A 5 6 7 8 9 10 11

remain unnoticed by the surgeon during intraoperative palpation of the stomach walls and even during visual examination of its inner surface. We have also observed similar situations, where early signs of endophytic cancer detected by X-ray examination were impalpable during surgery. If the stomach was resected at the request of an X-ray expert, the intramural infiltration was verified only after thorough morphological examination of the resected material. If resection was declined, in several months it became necessary to perform another operation following endoscopic and mainly histological confirmation of gastric cancer. This gives us the right to state that, in such situations, radiological diagnosis is of greater diagnostic importance. It must be used as substantiation of radical surgical intervention (D Fig. 67). And this requires radical revision of some standards to establish relationships between radiological diagnosis and endoscopy in gastroen-terology and gastro-oncology (D Fig. 68). ► chapter 6 deals with the objective evaluation of relationships between radiological diagnosis and endoscopy.

We have already noted that two basic X-ray signs of gastric cancer are recognized today:

1. The uneven contour of a tightly filled stomach: Sometimes this sign is revealed when a patient ingests contrast medium in a slightly greater amount than the standard recommendation.

2. A thickened stomach wall as visualized with double-contrast radiology. This is evidenced by the »ring« sign characteristic of the presence of intramural blastomatous infiltration (D Figs. 69, 70).

D Fig. 67a, b. Patient G., age 63. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): uneven contours of the lesser curvature of the antral part (arrow); peristalsis is seen over the entire length. b Stomach roentgenogram (double contrast, horizontal position, anterior projection): the wall of the lesser curvature of the antral part is thickened and rigid due to intramural infiltration (arrow). Conclusion: Minor infiltrative cancer of the lesser curvature of the antral part of the stomach. Endoscopy with subsequent histological examination of bioptates failed to reveal tumor. Traditional roentgenological examination using double contrast gave grounds for surgery in the absence of histological verification. The patient was operated. Histologically, signet-ring cell carcinoma.

□ Fig. 68a-d. Patient Z., age 54. Diagnosis: gastric cancer. The patient had no complaints. From anamnesis: familial cases of gastric cancer. The primary roentgenological examination revealed gastric cancer. Endoscopy was performed several times within 2 months. Histological examinations of bioptates did not reveal tumor cells. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the cavity of the antral part and the body of the stomach is reduced, the lesser curvature is short and depressed, uneven contours (arrows). b Stomach roentgenogram (double contrast, horizontal position, anterior projection): walls of the antral part and the body of the stomach are thickened due to intramural infiltration (arrows). Conclusion: Infiltrative cancer of the antral part and the body of the stomach. Histological examination of the bioptates taken during endoscopy failed to find tumor cells. Nevertheless, the convincing evidence of the presence of infiltrative affection of the stomach provided grounds for surgery in the absence of histological verification. c Macrospecimen: a fragment of a resected part of the stomach: the relief of the mucous membrane is leveled due to intramural infiltration (arrows). d Fragment of a macrospecimen (strip): the stomach wall is thickened due to tumor infiltration of mostly submucous and muscular coats of the stomach wall (arrows). Histologically, signet-ring cell carcinoma

▲ Fig. 68 c.

□ Fig. 69a-c. Patient K., age 65. Diagnosis: gastric cancer. a Stomach roentgenogram (vertical position, anterior projection): gas redistribution in the air bubble of the stomach; the stomach is stretched. b Stomach roentgenogram (tight filling,

vertical position, anterior projection): the lesser curvature is short and depressed, the walls of the stomach are uneven and rigid (arrows). c Stomach roentgenogram (double contrast, horizontal position, anterior projection): the wall of the lesser curvature is thickened and rigid due to intramural infiltration (arrows), a depot of contrast medium with atypically changed relief of the inner surface of the stomach. Histological examination of the bioptates taken during numerous endoscopies failed to find tumor cells. Pneumogastography was used as an additional method of examination

The benefits of tight filling in infiltrative-ulcerous cancers of the stomach now become more apparent. The versatility of the tight-filling method helps correct the interpretation of the X-ray picture of the initial form of gastric cancer with uneven contours and protrusions in cases where double-contrast radiology fails to obtain the necessary information. Dosed compression in these situations makes it possible to examine a particular site of affection and to recognize reliable signs which may serve as criteria for a differential diagnosis of infiltrative-ulcerous cancer and peptic ulcer of the stomach. It is also possible to better visualize the specific changes in the stomach

□ Fig. 70a-c. Same patient. Pneumogastrograms: distinctly seen is the 'ring' symptom due to the ridge of infiltration around the ulcer crater (black arrow) filled with air; converging folds are thick and outstretched due to the tumor spreading onto the upper part of the stomach (white arrows). Conclusion: Infiltrative-ulcerous cancer of the stomach body with invasion of the upper part. The patient was operated. Histologically, signet-ring cell carcinoma

▲ Fig. 70 c.

contour and deformities of the relief of the mucous membrane. While we consider tight filling very valuable, we do not want to say that it is better than double-contrast radiology: In order to detect endophyt-ic forms of cancer and the early symptoms of any blastomatous process in the stomach, the greatest amount of information may be obtained using both methods.

The most important aim of research in the diagnosis of gastric cancer should be to reveal its minor forms. While the currently used definition of early gastric cancer is good from a purely practical standpoint, it should be noted that the potentials of radiological examination and endoscopy for verifying the depth of affection are limited. Deeper structures such as the muscular coat are often affected in tumor patients with typical signs of early gastric cancer. In other words, it can be considered proven that diagnosis of early cancer in its classical understanding (according to the endoscopic classification of 1962) is associated with certain difficulties of interpretation of the visible picture during preoperative determination of the depth of tumor invasion. To be more accurate, the diagnosis is not feasible. These circumstances, and the fact that surgery (the only radical way to treat the patient with subsequent pathomorphological examination) is the final method for determining the depth of invasion of the stomach wall, has led us to use the term »minor cancer« to characterize the initial manifestation [24, 25, 67, 68].

Minor cancer implies lesions of up to 1 cm. But the existing criteria of minor cancer of the stomach do not account for the specificity of the early manifestations of endophytic new growths. This is the weak point in our understanding of modern definition of gastric cancer signs, and hence in its diagnosis [25, 30].

There is, unfortunately, no consensus on the specific features of early blastomatous affection. Nor do we know what primary signs should be considered first by radiological diagnosis for early detection of cancer. The dispute is ungrounded. Again, it concerns the attempt to establish specific changes in the so-called fine relief of the mucosa, areolar zones, and the like. And again we want to declare that radiological diagnosticians should not be involved in this problem because the study of mucosal surfaces is the prerogative of endoscopists. The main objective of radiological studies, and especially of the traditional X-ray studies, should be to search for intramural blastomatous infiltration.

The characteristic radiological signs of minor cancer include uneven contours of the stomach over a short length of 1-3 cm, (which is detectable using tight filling) and thickening of the wall relevant to this part (detectable with double contrast). Rigidity of the stomach wall, which is characteristic of advanced forms of gastric cancer, is usually detectable with tumors 3-4 cm and larger. Such tumors are often affected by ulceration. In some cases, for more reliable results, it is necessary to swallow additional portions of contrast medium and to take a series of muti-projectional views. The usefulness of compression should also be noted: It facilitates the detection of converging folds, which are often found in patients with minor and mostly ulcerative cancer.

Double-contrast radiology is beneficial mainly for detection of minor cancer of the body and the upper part of the stomach. In some cases it gives detailed information on the character of changes in the distal part as well, especially in the presence of tu mor infiltration resulting in thickening of the stomach wall, which is especially characteristic of endophytic cancer [58, 183].

Our experience in screening risk groups and asymptomatic persons for gastric cancer at MONIKI confirms the fact that a complex examination of the stomach, which includes tight filling and double contrast, should be regarded as the optimal method [58, 222].

▲ Fig. 71 a.

For diagnosis of the early forms of infiltrative cancer, the accepted algorithm of examination must be directed not at endoscopic detection of disfiguring changes in the surface of the mucous membrane but at the search for an intramural blastomatous process, which is better detectable by X-ray examination. It has long been recognized that the complexity of forming a differential diagnosis only by the signs of pathological changes on the surface of the gastric mucosa makes it impossible in most cases to detect sufficiently specific differentiation criteria (O Fig. 71).

Based on what has been said, we are now absolutely sure that the sign of intramural blastomatous infiltration (characterized by thickening of the stomach wall over a length up to 3 cm), which we proposed in 1993, should be considered the initial manifestation of gastric cancer [31].

O Fig. 71a-e. Female patient V., age 68. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): uneven contours of the lesser curvature of the upper third of the stomach body (arrow). b, c Stomach roentgenograms (tight filling, vertical position, anterior projection) after ingestion of an additional portion of barium sulfate suspension: more distinctly visualized are uneven and eroded contours of the lesser curvature of the upper third of the stomach body (arrow). d Stomach roentgenogram (double contrast, vertical position, anterior projection): the wall of the lesser curvature is rigid, the contour is slightly depressed into the stomach cavity (arrow). e Stomach roentgenogram (double contrast, horizontal position, left lateral projection): in the optimal projection, visualized is the thickened anterior wall due to intramural infiltration (arrow). Conclusion: minor infiltrative cancer of the anterior wall of the upper third of the stomach body. Histologically, adenocarcinoma with the signet-ring cell component.

Ultrasonographic Signs

In 1976, Lutz and Petzolt were the first to describe target ultrasonographic symptoms in a patient with gastric tumor: increased echogenicity of the central part of the stomach and decreasing echo toward the periphery [185]. The potentials of ultrasonographic studies in pathologies of the stomach were also studied by Russian researchers. Lemeshko proposed »the symptom of affection of a hollow organ« to designate the acoustic picture of changes in the gastrointestinal tract, in the stomach in particular [17]. However, sonographic signs (badge-cockade, target, affection of a hollow organ, etc) are characteristic of advanced forms of cancer and mostly of the intestinal type. Few publications of this period discussed the condition of the stomach wall in more detail. But despite the proven possibility of visualization of the stomach wall coat, appropriate significance was not attached to the new signs because the approach to sono-graphic diagnosis of gastric cancer was oriented to endoscopy, which was then dominant. It was only 10-15 years later, when morphological studies were started (in which diffuse cancer, characterized mostly by intramural growth, was given special importance) that publications appeared which evaluated the potentials of sonography under this new aspect. These publications radically changed the general attitude toward known signs of gastric cancer. Their authors tried to estimate the potential of sonography for characterizing the walls of an intact and affected stomach; and they proved that it was possible to visualize all coats of the stomach wall using ultrasound (D Fig. 72) [31, 42, 49].

The known ultrasonographic signs of intramural tumor infiltration are based on the sonographic picture of an intact liquid-filled stomach which

▲ Fig. 72 a.

appears as a five-layered structure with even contours and a thickness of 6-7 mm in the pyloric part and of 4-7 mm in the stomach body and its upper part [28, 38, 50, 53].

The main ultrasonographic symptoms of intramural blastomatous infiltration include thickened walls of the stomach in the involved region and a sig

nificantly changed five-layered structure at this level (D Fig. 73). During ultrasound examination, wall thickness remains constant (absence of pseudo-thickening due to passage of a peristaltic wave). Thickness of the wall in the region of infiltration can be even or uneven. If the wall is to 8-10 mm thick it is normally uniform with even and distinct contours,

D Fig. 72a-e. Ultrasonogram of a normal stomach. a Transverse echotomogram of the stomach (without filling with water, section at the level of the antral part): visualized are intact walls of the antral part of the stomach, to 6 mm thick (arrow). b Transverse echotomogram of the stomach (without filling with water, section at the level of the stomach body): intact wall of the stomach body, to 5 mm thick; the signal from the wall is hypoechogenic and homogeneous (arrow). c Transverse echotomogram of the stomach (the stomach cavity is filled with water, section at the level of the antral part): distinctly visualized in a five-layered structure of the stomach wall (arrows). d Transverse echotomogram of the stomach (the cavity of the stomach is filled with water, section at the level of the stomach body): distinctly visualized are all the five coats of the intact stomach wall (arrows). e Transverse echotomogram of the stomach (the stomach cavity is filled with water, section at the level of the upper part of the stomach, an additional projection): the five-layered structure of the stomach wall is intact (arrows)

D Fig. 73. Patient N., age 62. Diagnosis: gastric cancer. Echotomogram of the stomach (the stomach cavity is filled with water, longitudinal section relative the stomach axis): the posterior wall is thickened to 9-12 mm over a length of 5 cm; the five-layered structure is absent (arrow)

D Fig. 74. Patient R., age 68. Diagnosis: gastric cancer. Echotomogram of the stomach (the stomach cavity is filled with water, oblique section at the level of stomach body): local thickening of the stomach wall to 7-8 mm with disordered echo structure due to intramural infiltration over a length of 3 cm (arrows) ▼ Fig 74

which is characteristic of a relatively early gastric cancer (D Fig. 74). If the tumor spreads over a large area, the wall thickens to 15-20 mm; its inner contour is uneven and tuberous. Some patients, in addition to thick walls and changes in the five-layer structure, may also have a distinct exophytic component of the tumor protruding into the lumen of the stomach. If the tumor is located in the antral part of the stomach with involvement of all its walls, the ultrasonographic picture of the walls corresponds to the picture of the cancer canal (D Fig. 75).

An important advantage of ultrasonography is that it can detect relatively early signs of gastric cancer extending over about 3 cm. Initial affection of the stomach wall attended by moderately pronounced but stable thickening and destruction of the layered structure is thus revealed (D Fig. 76) [43, 50, 98]. While we value the potentials of ultrasonography in the diagnosis of gastric cancer, we nevertheless think that its staging potentials are limited; determination of stages I and II is best accomplished by morphological study of material from the resected stomach.

Our research showed that ultrasound reliably and distinctly recognized ulcers in the infiltrated wall of the stomach in patients in whom ulceration was discovered by X-ray and endoscopic examinations of the stomach (D Fig. 77). In the presence of an ulcer crater greater than 10 mm, accumulated air can be determined in its central parts (D Fig. 78).

□ Fig. 75a-e. Patient L., age 73. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, right quarter-oblique projection): the distal part unevenly narrowed, uneven contours due to a circular intramural infiltration, invading the stomach body by the lesser curvature (arrows). b Stomach roentgenogram (double contrast, horizontal position, anterior projection): walls of the distal part are thickened and rigid due to circular intramural infiltration (arrows). Conclusion: Infiltrative cancer of the distal part of the stomach. c Endophotograph: the mucous membrane of the greater curvature of the stomach sinus is strongly disfigured and tuberous, protrudes into the stomach lumen to narrow its lumen.

▲ Fig. 75 e.

Histological examination verified adenocarcinoma with the signetring cell component. d Echotomogram of the stomach (the stomach cavity is filled with water, the sagittal section at the level of the antral part of the stomach): the walls are thickened circularly and unevenly, the five-layered structure is disordered at this level (arrow). e Echotomogram of the stomach (the stomach cavity is filled with water, transverse section at the level of the pyloric part of the stomach): the lumen of the pyloric part is narrowed with formation of a cancer canal to 6 cm long, the walls are thickened to 7-5 mm (arrows)

D Fig. 76. Female patient U., age 71. Diagnosis: infiltrative cancer of the stomach. Echotomogram of the stomach (longitudinal section relative to the stomach axis): the anterior wall is thickened to 11 cm with corresponding disorder in the layered structure at this level. Border between the intact and the involved wall of the stomach is distinctly visualized (arrows)

O Fig. 77a-f. Patient T., age 64. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): uneven and eroded contours of the greater curvature of the stomach sinus is depressed into the stomach cavity (arrow). b Stomach roentgenogram (double contrast, horizontal position, anterior projection): the wall of the greater curvature of the stomach sinus is thickened due to intramural infiltration (black arrows); in the center a rounded depot of contrast medium is visualized, corresponding to reflection of the ulcer crater (white arrow). c, d Ultrasonogram of the stomach: a series of echotomograms shows local thickening of the wall of the greater curvature of the sinus over a length of 5 cm due to intramural infiltration with the corresponding disorder in the five-layered echo-structure at this level (black arrows). Ulcer crater in the depth of the infiltrated wall (white arrow). Conclusion: Infiltrative-ulcerous cancer of the stomach sinus. e Macrospecimen of a resected stomach: a crater-like depression with an overhanging ridge of infiltrated tissue (arrows); the wall is thickened; white tissue infiltrating the stomach wall is seen. f Fragments of a macrospecimen (strips): stomach wall is thickened due to white ulcerated tumor infiltration (arrows). Histologically; adenocarcinoma with the signet-ring cell component O Fig. 78. Patient E., age 61. Diagnosis: infiltrative-ulcerous cancer of the stomach. Echotomogram of the stomach (longitudinal section at the level of the upper third of the stomach body): the walls are unevenly thickened from 7 to 25 mm over a length of 12-13 cm: the absence of differentiation of the layers. A large ulcerous defect sizing 2x1 cm in the center of the thickening; air is present (arrow). Histologically; a non-differentiated cancer.

The set of ultrasonographic signs currently used to diagnose gastric cancer can also be used to establish accurately the boundaries of the tumor, which is very important for diagnosis of the infiltrative forms. Margins of infiltration are determined more accurately in patients with endophytic cancer of the stomach. More commonly, it is possible to visualize only one border in patients with diffuse cancer (D Fig. 79).

Most therapeutic and prophylactic institutions today have ultrasonographic equipment. Therefore, when X-ray and endoscopic examinations (with subsequent histological studies) fail to verify gastric cancer, ultrasonography should be used as an additional method at the pre-hospital stage.

While we value the potentials of sonography in the diagnosis of gastric cancer highly, we still adhere to the opinion that it is only an additional diagnostic method. The primary and basic instrumental methods of revealing gastric cancer are the traditional X-ray and endoscopic examinations.

D Fig. 79a-e. Patient N., age 68. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the lesser curvature of the stomach body is short and depressed; ulcer niche on the greater curvature of the stomach body (arrow). b Stomach roentgenogram (double contrast, horizontal position, left lateral projection): the stomach walls are thickened due to intramural infiltration (black arrows) with a depot of contrast medium (white arrow). Conclusion: Infiltra-tive-ulcerous cancer of the stomach body. c Endophotograph: ulcer with a flat irregular floor and tuberous and eroded edges, and also periulcerous ridge are seen in the lower third of the stomach body on the posterior wall with invasion of the greater curvature; some mucosal folds converge toward the ridge periphery. Histologically; signet-ring cell carcinoma. d, e Ultrasonograms of the stomach distinctly visualize the border between the intact and involved stomach wall (arrow)

▲ Fig. 79 b. ▼ Fig. 79 c.
▲ Fig. 79 d.

elaboration of methodological instructions for the use of CT in diagnosing diseases of the stomach, particularly tumors. Signs of gastric cancer detected by computed tomography were then established (□ Fig. 80) [33, 35, 81, 235, 251].

As experience with CT accumulated, its disadvantages became apparent. The main one was its limited potential for revealing intramural infiltration of the stomach. Some authors spoke of possible hyperdiagnosis due to the so-called pseudo-thickening of the stomach wall. Hence, the opinion was expressed that computed tomography might be used only as the source of additional information on the extent of affection and the spread of the process onto the adjacent anatomical structures.

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