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□ Fig. 24a-d. Patient B., age 64. Diagnosis: gastric cancer. Complained of epigastric discomfort which intensified after meals. The symptom had increased steadily during the preceding month. Nausea occurred periodically. a Stomach X-ray (double contrast, horizontal position, right oblique projection): depot of irregular shapes with converging folds on the lesser curvature. b Stomach X-ray (double contrast, horizontal position, anterior projection): after the ulcer crater is emptied of the contrast medium, thick wall of the lesser curvature with converging folds is visualized (arrow). Conclusion: infiltrative ulcerous cancer of the stomach body. c Macrospecimen of a resected stomach: firm walls, flat ulcer on the lesser curvature (arrow). d Fragments of the macrospecimen (strips): white tumor tissue underlying the ulcer crater and infiltrating the stomach wall (arrows). Histologically, an adenocarcinoma with the signet-ring cell component

ed together with all clinical symptoms of cancer of the upper part of the stomach.

Clinical symptoms of proximal gastric cancer and the time of their development depend even more on the primary (initial) site of tumor location within the limits of this anatomical part, as compared with tumors developing in other parts of the stomach. Note that, in addition to the general clinical symptoms, an important symptom such as dyspha-gia develops in some patients with cancer of the upper part of the stomach only at late stages of the disease, and in some patients not at all. The idea that dysphagia is an obligatory companion of cancer of the upper part of the stomach is therefore incorrect. A tumor originating in the immediate vicinity of the cardiac sphincter very soon spreads to the abdominal part of the esophagus to cause dysphagia. At the same time, a tumor of the upper part of the stomach located at a distance from the cardiac rosette (car-dioesophageal junction), e.g., on the posterior wall, the greater curvature, or the fundus, produces these symptoms either much later or not at all.

Dysphagia occurs in about 89.4% of cases of proximal gastric cancer. First the patient may feel only scratching, burning, or pain when swallowing food. Passage of food through a narrowed canal becomes more difficult with time. A sudden complete obstruction of the esophagus may also be the first sign, but dysphagia usually develops when the tumor size is considerable enough to affect half of the canal circumference or even greater. Marked dysphagia can also develop in the presence of very small tumors, owing to spasm of the stomach wall at the moment of food passage. However, sometimes dys-phagia does not develop in patients with extensive disease. This may happen when the involved stomach wall becomes rigid and incapable of contraction. Food drops freely through the open tube of the esophagus in such patients (D Fig. 25).

Cardiac impatency develops more often in patients with tumors infiltrating the wall of the stomach. Blastomatous infiltration spreads onto the muscular coat to involve nerve endings. First this increases the sensitivity of the muscular membrane and induces mild spasms, but later, the contractility of the muscles becomes impaired. Exophytic tumors, which rarely occur now, interfere with food passage to the stomach less frequently and at later stages of the disease. Ingested food in most cases passes freely over a mushroom-like tumor, provided the latter does not affect the rosette proper, where the mucous membrane is immobile relative to the muscular coat and the tumor can obstruct the entrance to the stomach.

Most often, dysphagia first manifests as a difficulty in swallowing solid food, and the patient has to drink water after each portion is ingested. Later it becomes difficult to swallow semi-liquid food.

As cardiac impatency gradually increases, the portion of the esophagus located above the affected

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