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□ Fig. 25a-d. Patient Z., age 68. Diagnosis: gastric cancer. a Stomach x-ray (tight filling, vertical position, anterior projection): the stomach body is disfigured to a rigid tube with uneven contours (arrows). b Stomach X-ray (double contrast, horizontal position, anterior projection): walls of the body and the upper part are thick and rigid; the inner surface is tuberous. c Stomach X-ray (double contrast, vertical position, left oblique projection): posterior wall of the body and the upper part is thick due to infiltration extending to the cardia; the walls of the esophagus are rigid, the lumen is wide open (arrows). d X-ray of the stomach and abdominal segment of the esophagus (double contrast, vertical position, left oblique projection): relief of the cardiac rosette (cardioesophageal junction) is changed, cardia is wide open, the abdominal esophagus is a rigid tube owing to spreading of the intramural infiltration (arrows). Conclusion: infiltrative cancer of the stomach body and its upper part, with extension of the tumor onto the esophagus site distends to accumulate food masses, which are partly propelled to the stomach by esophageal contractions and partly evacuated by vomiting.

The patient rapidly loses weight and water. The skin becomes dry and flaccid, tissue turgor decreases markedly. When tested, skin folds do not straighten for a long time. This condition may develop very soon if the tumor is found in the cardia proper. As the tumor grows, it soon obstructs the entrance to the stomach to account for the typical symptoms of cancer before development of general disorders in the patient. If the tumor is at a distance from the rosette (cardioesophageal junction), then, before the tumor closes the lumen, it affects considerable areas of the gastric wall. Ulcers often develop on the tumor, which begins to disintegrate and bleed. In view of this, long before the development of cardiac im-patency, the patient develops general disorders due to chronic blood loss and intoxication with products of tumor decay and bacterial toxins. The ESR is high. The patient may experience pain owing to involvement of the nerve elements of the stomach wall or the adjacent organs.

If the tumor resides in the upper part of the stomach, the patient feels retrosternal pain or pain between the shoulder blades. Very often this is interpreted as heart pain. This pain may be the result of intensified contractions of the esophagus in patients with disordered cardiac patency. As a rule, pain develops at the moment of swallowing when the esophagus must contract. These contractions may be very painful and the patient has to drink water, to take a deep breath, assume a special position, etc. If the esophagus is strongly distended above the point of obstruction, pain may be absent immediately after small portions of food are ingested. Pain develops only after a lapse of time in connection with distension of the esophagus by the accumulated food, mucus, swallowed saliva, all of which irritate the mucosa of the esophagus, causing it to contract vigorously. In such cases the patient does not associate pain with meals but relates its development to disorders of his/her cardiovascular system.

Tumors with their primary location in the region of the fundus, on the posterior or anterior wall, or on the greater curvature may manifest for a long time only as general disorders. Gastric disorders may be either absent or so mild that the patient disregards them. The disease is often identified correctly only when the tumor attacks the stomach wall close to the entrance, which manifests as dysphagia, or when pain of specific localization develops. Hiccup is the most common clinical symptom of cancer in the zone of the fundus and the supracardiac part; it is due to involvement of the diaphragm. Among other symptoms may be pain irradiating by the diaphragmatic nerve; diaphragmatic pleurisy is not infrequent either. Left-sided pleurisy occurs in tumors not only of the stomach fundus but of its body as well, which spread onto the cardiac part. This is sometimes the first sign of the disease.

When located on the greater curvature, a tumor more often grows into the splenic portal. In patients with affections of the posterior wall, the tumor

▲ Fig. 26 a. D Fig. 26a-e. Patient S., age 59. Diagnosis: gastric cancer. a Stomach X-ray (tight filling, vertical position, anterior projection): stomach inner volume is diminished, the stomach is disfigured (rigid tube type); the contours are uneven. b Target stomach X-ray (tight filling, vertical position, anterior projection): the angular notch is straightened, the lesser curvature is depressed, the walls are rigid. c Stomach X-ray (double contrast, horizontal position, anterior projection): walls of the distal part and the body are thick and rigid due to circular infiltration. Conclusion: infiltrative cancer of the stomach. d Macrospecimen of a resected stomach: walls are thick due to intramural infiltration (arrow). e Fragments of the macro-specimen (strips): the wall is thickened due to the white tumor tissue (arrows)

▲ Fig. 26 a. D Fig. 26a-e. Patient S., age 59. Diagnosis: gastric cancer. a Stomach X-ray (tight filling, vertical position, anterior projection): stomach inner volume is diminished, the stomach is disfigured (rigid tube type); the contours are uneven. b Target stomach X-ray (tight filling, vertical position, anterior projection): the angular notch is straightened, the lesser curvature is depressed, the walls are rigid. c Stomach X-ray (double contrast, horizontal position, anterior projection): walls of the distal part and the body are thick and rigid due to circular infiltration. Conclusion: infiltrative cancer of the stomach. d Macrospecimen of a resected stomach: walls are thick due to intramural infiltration (arrow). e Fragments of the macro-specimen (strips): the wall is thickened due to the white tumor tissue (arrows)

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