D Fig. 141 a-c. Patient V., age 58. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): uneven contour of lesser curvature of the antral part (arrow). b Stomach roentgenogram (double contrast, horizontal position, right oblique projection): wall of the lesser curvature of the antral part is thickened and rigid due to intramural infiltration (arrow). c Stomach roentgenograms (double contrast, horizontal position, right oblique projection): the walls of the prepyloric part are thickened and rigid over a length of about 2 cm due to intramural infiltration (arrows). Conclusion: Initial infiltrative cancer of the distal part of the stomach. The patient was operated. Histologically, adenocarcinoma with the signet-ring cell component.
makes it possible to differentiate between benign stenosis and malignant tumor. In patients with cancer, as distinct from cicatricial-ulcerous stenosis, the thickness of the walls in the distal part of the stomach greatly exceeds normal thickness. Concerning these signs of the blastomatous process, we must point out that one particular sign should not be considered separately from others. Clinical manifestations must also be taken into consideration in such situations.
While discussing pathologies of the pylorus, we would like to dwell on the spread of tumor in the distal direction, i.e., to the bulb and the post-bulbar part of the duodenum. The classical concept of the infiltrative process of the linitis plastica type suggests a casuistic possibility of total affection of the gastrointestinal tract: Spread of the process in the distal direction is connected largely with blastomatous lymphangitis.
To summarize what has been said about distal gastric cancer, we should like to note once again some points in radiological diagnosis of the so-called pylorostenosis. Not infrequently, while planning a stomach resection for ulcer of the pyloroduodenal zone accompanied by severe evacuation dysfunction of the pylorus, the clinician still doubts the correctness of his decision because of the serious difficulties in preoperative establishment of the pathology. Serious deformational changes occurring with stenosis of the zone in question create special conditions for the traditional X-ray and endoscopic examinations. They considerably reduce the informative value of endoscopy, which is regarded as the final preoperative method of establishing the diagnosis. In such situations, the main responsibility should be shifted to radiological diagnosis, because much experience has been gained with it in revealing diffuse cancers, the prevailing oncological pathology in this zone [45, 73].
The entire systematized radiological semiotics of infiltrative cancers of the stomach is most closely connected with a special complex ofmethodological techniques aimed at the maximum imaging of intramural tumor process. This optimism is based on the possibility ofcurrently used pneumographic and traditional components of gastroenterology to reveal thickening of the wall and its elasticity, which, in addition to evaluating the condition of the mucous membrane, effectively reveals tumor infiltration in this part of the stomach, which is the most difficult to access for an accurate diagnosis (D Fig. 141). It follows, therefore, that, considering the importance of the final interpretation ofthe evacuation dysfunction of the pylorus, one must entertain the possibility of radiological diagnosis of the so-called organic stenosis of the pyloroduodenal region .
It is time to revise the existing set of radiological signs which are still used not only by gastroen-terologists and surgeons, but also by radiological diagnosticians, who choose not to deal with the diagnosis of early gastric cancer because they lack faith in the potentials of modern radiological diagnosis. This pertains first of all to the so-called residues of barium sulfate suspension that remain in the stomach for 24 h after the start of the X-ray examination. This must not be regarded as a sign of organic stenosis of the pyloroduodenal region. We have often observed cases in which primary examination of the stomach revealed all the signs believed to suggest organic stenosis of the pyloroduodenal region: boat-shaped ectatic stomach, which is found below the pectineal line, and significant residue of contrast medium after 24 h. Three to four weeks after conservative treatment, the stomach of such patients assumed a normal shape, while contrast medium was evacuated from the stomach even earlier (D Fig. 142). There are two aspects of major importance regarding the so-called organic stenosis of the stomach. The radiologist has to understand the cause of this stenosis (to be more exact, stable evacuation dysfunction of the pyloroduodenal region), whether it be a tumor with localization in the pylorus or the prepyloric part of the stomach, or a non-tumor pathology. This question can be answered with a traditional X-ray examination based on the polyposi-tional principle, with tight filling of the stomach by a large amount of contrast medium, double contrast, and sometimes with air alone. If a small tumor is diagnosed, which causes stenosis owing to its specific location, the problem requires no further investigation. If a gastric tumor is ruled out, however, it is necessary to estimate very carefully the degree to which organic and functional components are involved. In any case, great care must be taken in interpreting the results of the examination. Of course, much depends on the clinical status of the patient. We have already expressed our negative attitude about the various pharmacological tests which are used to obtain more reliable information in these and other difficult differential-diagnosis situations. According to our data, this only adds to the difficulties of diagnosis, by masking the true picture. Our princi ple is a completely physiological X-ray examination of the stomach. Furthermore, pharmacological tests do not differentiate between functional disorder of evacuation and organic dysfunction. Only repeated X-ray examinations after one or several courses of treatment can lead to the final diagnosis. This is especially true for patients with gastroduodenal peptic ulcer, in whom stable evacuation dysfunction is due to edema and marked antral gastritis, symptoms that are relieved by prolonged adequate treatment. This position is confirmed by special studies conducted in Italy: Anti-Helicobacter therapy resulted in complete cure in 20 of 22 patients with diagnosed stenosis. In 17 patients signs of stenosis disappeared completely after 2 months and in three patients after 6 months. In other words, there was no actual organic stenosis, but rather a functional spasm of the pylorus in the presence of inflammatory changes. This confirms the important role of inflammatory and functional components of the »stenosis« picture, which is considered to be classical, and stresses the necessity of dynamic observation of such patients, including follow-up observation. With regard to evacuation dysfunction of the pyloroduodenal region, it is necessary to note that radiological diagnosis has obvious advantages over endoscopy for verifying the cause of so-called stenosis of this part of the stomach due to its specific anatomo-functional properties. In addition to data reported by the Italian researchers, our own observations of such patients confirm the need for substantial correction of the accepted set of signs characterizing so-called organic stenosis of the stomach.
D Fig. 142 a-d. Female patient Ya., age 54. Functional spasm of the pylorus. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the antral part and the sinus of the stomach are ectatic, the stomach walls are even, evacuation function of the pylorus is disordered. b Stomach roentgenogram (tight filling, vertical position, anterior projection) in 24 h: residue of barium sulfate suspension is seen in the stomach cavity. Repeated endoscopy with biopsies failed to detect tumor cells. In the absence of signs of blastomatous affection, as evidenced by the main two instrumental methods, the patient was given conservative treatment. The same patient observed 3 weeks later. c Stomach roentgenogram (tight filling, vertical position, anterior projection): organic changes are not detectable, stomach contours are even, timely evacuation. d Stomach roentgenogram (tight filling, vertical position, anterior projection) in 24 h: the stomach is free of barium sulfate suspension, which is evenly distributed in the large intestine.
Cancer of the Greater Curvature
Until recently, the greater curvature was believed to be a rare localization of gastric cancer. For this reason, the literature contains only few reports on studies of tumors of the greater curvature. According to some authors, primary blastomatous affection of the greater curvature occurs in 1-3%, and they did not regard this pathology as an independent localization form. Other authors indicate a higher incidence of cancer of this localization (7.3-8.9%), but the results of screening demonstrate a much higher percentage of primary affection of the greater curvature.
Our experience in radiological diagnosis of gastric cancer shows that its primary localization on the greater curvature is much more frequent than reported by the authors who estimated it as 12.9% [41, 46, 99]. For several reasons - the main one being the absence of endoscopic confirmation - we observed patients with primary affection of the greater curvature for a year and longer. We found that the final stage of these tumors was endophytic fibrous carcinoma type infiltration of all walls of the stomach. This led us to conclude that a considerable portion of diffuse intramural cancers originate on the greater curvature. Thus, we think it necessary to discuss the diagnosis of tumors located on the greater curvature in more detail (D Fig. 143) [31, 34].
Owing to the specific anatomo-functional properties of the greater curvature, additional approaches to detecting the early signs of tumor are necessary. These approaches are not included in the existing standard methodology for reasons discussed in previous chapters. The standard methodology regards affections of the greater curvature in general, and tumors in particular, as a rarity. Most cancers originating on the greater curvature are not detected for the following two reasons: (a) the presence of pronounced mucosal folds, extending in a dorsal-ventral direction on the greater curvature, which respond to inflammatory disease and often do not stretch during X-ray and endoscopic examinations; (b) the absence of special additional techniques of examination .
The clinical picture of blastomatous affection of the greater curvature is not specific either. In most cases, cancer of this localization is characterized by an asymptomatic course, although some patients may complain of dull pain unassociated with meals and continuing for the greater part of the day. Other clinical symptoms, including loss of body weight, do not develop in all patients, and if they do, it is at later stages of the disease.
D Fig. 143 a-e. Patient I., age 55. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): uneven contour of the greater curvature (arrow). b Stomach roentgenogram (tight filling, vertical position, anterior projection), dosed compression: more distinctly visualized is the eroded contour of the greater curvature of the stomach body (arrows). c Stomach roentgenogram (tight filling, vertical position, anterior projection), dosed compression: intensified compression reveals a depot of contrast medium (arrow). d Stomach roentgenogram (double contrast, horizontal position, anterior projection): the wall of the greater curvature is thickened due to intramural infiltration; visualized at the center is a small rounded light image corresponding to an ulcer crater (arrow). Conclusion: Infiltrative-ulcerous cancer of the greater curvature of the stomach body. e Endophotograph: visualized in the region of the stomach sinus is a portion of mucous membrane, to 3 cm in diameter, which is slightly elevated over the surrounding tissues; the surface is rough, of grayish pink color, with flat linear ulceration at the center. Histological examination of the bioptates verified non-differentiated cancer.
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