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□ Fig. 136 a, b. Patient M., age 68. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): uneven contours of the distal part and the body of the stomach; straightened angular notch (arrows). b 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 diffuse circular intramural infiltration (arrows). Conclusion: Infiltrative cancer of the distal part of the stomach with spread onto the stomach body. The patient was operated. Histologically, adenocarcinoma with the signet-ring cell component.

□ Fig. 137 a-c. Patient K., age 61. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the cavity is strongly ectatic, the fasting stomach contains much fluid and mucus; pronounced evacuation disorder. In the absence in the patient's anamnesis of gastrodu-odenal ulcer, the X-ray picture is more likely to be interpreted as a tumor affection of the pyloric part of the stomach. In order to verify etiology of the so-called stenosis of the pyloric part of the stomach, endoscopy with multiple biopsy was recommended. Endoscopy revealed severely narrowed upper part of the stomach. Histological examination of the bioptates failed to find tumor cells. The patient was examined by MRI. b MR image of the stomach (axial projection, level of the pyloric part of the stomach, T2 image): the pyloric part of the stomach is circularly narrowed due to intramural infiltration of its walls for a length of about 45 mm with the maximum wall thickness to 20 mm; the inner outline of the narrowed part is uneven and blurred, the outer sufficiently distinct. Signs of involvement of the perigastric cellular tissue are absent (arrows). c MR image of the stomach (sagittal projection, level of the pyloric part of the stomach, T2 image): more distinct is the lower border of the intramural infiltration (arrows). Conclusion: Infiltrative cancer of the pyloric part of the stomach. The patient was operated. Histologically, non-differentiated cancer. As seen from this example, MRI of the stomach proved to be the method by which it was possible to verify the nature of the so-called stenosis of the pyloric part of the stomach before operation and to confirm findings of the traditional roentgenological examination. Endoscopy failed to verify the nature of the so-called stenosis.

□ Fig. 138 a, b. Female patient Sh., age 58. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the cavity is decreased, the angular notch is straightened, the lesser curvature is shortened and depressed (arrows); b Stomach roentgenogram (double contrast, horizontal position, anterior projection): walls of the distal part and body of the stomach are thickened and rigid due to circular intramural infiltration (arrows). Conclusion: Infiltrative cancer of the distal part and the body of the stomach. The patient was operated. Histologically - signet-ring cell carcinoma.

The need for early diagnosis of gastric cancer stimulated oncologists to make a more thorough study of pyloric cancers. Simultaneously, they evaluated the potentials of X-ray methods, which were directed at the functional symptoms (disordered evacuation, residues of barium sulfate suspension within a defined lapse of time, etc.) because of the insignificant number of determinable morphological signs of organic affection. But in our studies of cancer and ulcer stenosis we arrived at the conclusion that the current semiotics of such affections, based mostly on signs of far-advanced cancers, cannot adequately lead to an early diagnosis, nor can it differentiate the two conditions (□ Fig. 137). The pyloroduodenal zone can be the site of localization of rarer diseases, such as tuberculosis, syphilis, rigid antral gastritis, or erosive gastritis. In addition, difficulties can arise in the presence of perigastric commissures and depressions in the so-called hypertrophic pyloroste-nosis, secondary changes in the gastroduodenal junction in patients with benign or malignant affection of the hepato-pancreatic-duodenal zone. Unfortunately, we must admit that at present, these conditions are identified only during surgery, because it is sometimes impossible to verify the diagnosis using available technical facilities.

The main reason for this unsatisfactory situation is that these tumors are mostly endophytic, and not adequately covered by roentgenological and endoscopic semiotics (□ Fig. 138). This is a difficult problem. Stomach deformations, which occur in

such situations, can interfere with endoscopy (which is used by most oncologists) and biopsy. The limited potentials of fibergastroscopy, which gives a rather non-specific picture as regards differential diagnosis, and insufficient knowledge of radiological diagnosis (in some cases, sheer ignorance of it), makes clinicians take unusual measures such as lap-arotomy, or frequent and futile attempts to obtain histological confirmation by examining bioptates taken during endoscopy. M.S. Levin et al. (1990) provide a good illustration of such a situation: A patient was operated on only when the diagnosis was established after the fifth attempt to obtain a positive result of endoscopic biopsy, 18 months after the patient's first visit [184].

Serious difficulties arise during a traditional X-ray examination, because so-called stenosis of the pylorus is usually accompanied by stomach ectasia owing to the presence of food residues, liquid, and mucus. Early diagnosis of tumors in such localizations is also very difficult due to the greatly diluted barium sulfate suspension and the infeasibility of it tightly filling the pyloric part (D Fig. 139).

We have formulated a basic radiology semiotics for the pathology under discussion based on signs of infiltrative growth, which can be present even in cases with insignificant affection of the stomach wall. The current traditional orientation toward the signs of diffuse tumor is the main reason for an un-

favorable prognosis, even when the diagnosis is successful. This is true for both roentgenological and endoscopic examinations [48, 55].

The recent tendency to decline radiological diagnosis leads to dramatic results. The widely used fibergastroscopy often fails to establish the true cause of the patient's deteriorated condition and only states the presence of ulceration and erosion, or even finds »intact« mucous membrane in this part of the stomach. Common biopsy proves useless in cases with submucous tumors, which do not manifest on the surface of the mucous membrane.

In such cases, X-ray findings acquire major importance in the diagnostic algorithm. But due to the small size of the tumor, the traditional techniques do not always supply sufficient information. Determination of thickness and elasticity of the walls using double-contrast radiology becomes especially important here. If the tumor is small, it is impossible to detect the presence of the well-known signs such as concentric narrowing or rigidity of walls of the antral part of the stomach, which suggest the spread of malignancy not only to the pyloric part but also to the neighboring structures. The situation becomes even more serious in the presence of concurrent peptic ulcers, which, together with erosive gastritis, mask submucous tumors and lead to an incorrect radiological and endoscopic diagnosis (D Fig. 140).

□ Fig. 139 a-f. Female patient P., age 71. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the stomach contains much fluid, mucus, and food residue; the evacuation function of the pylorus is upset. b Stomach roentgenogram (tight filling, vertical position, anterior projection) after ingestion of an additional portion of contrast medium: the pyloric part is unevenly narrowed, its walls are rigid, vigorous peristaltic activity of the intact parts of the stomach is seen. c, d Stomach roentgenograms (tight filling, vertical position, anterior projection): pyloric part is unevenly narrowed due to circular infiltration of its walls (arrow); the evacuation function of the pylorus is upset. e Stomach roentgenogram (double contrast, horizontal position, anterior projection): walls of the pyloric part are thickened and rigid due to circular intramural infiltration (arrow). Conclusion: Infiltrative cancer of the pyloric part of the stomach. f Endophotograph: pyloric part of the stomach is disfigured, greatly narrowed (resembling a sleeve), the mucous membrane in this region is grayish pink, tuberous, with a fibrin coat; the pylorus is not differentiated. Histological examination of the bioptates taken during endoscopy verified signet-ring cell carcinoma.

□ Fig. 140 a-d. Patient K., age 53. Diagnosis: gastric cancer. a, b Stomach roentgenograms (tight filling, vertical position, anterior projection): pyloric part is unevenly narrowed due to circular infiltration of its walls; the evacuation function of the pylorus is normal. c Stomach roentgenogram (double contrast, horizontal position, anterior projection): walls of the pyloric part are thickened and rigid due to circular intramural infiltration. Conclusion: Infiltrative cancer of the pyloric part of the stomach. d Endophotograph: pyloric part of the stomach is disfig-

▲ Fig. 139 b.

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