revealed post-ulcer scarring at the site of the former ulcer, which appeared as a small point with folds converging towards it. This is typical of a benign ulcer (□ Fig. 105).
In expressing our view on the possible use of traditional radiology in the differential diagnosis of malignant and peptic ulcers on the stomach wall, we by no means want to belittle the benefits offered by endoscopy in verification of the nature of a stomach. We want only to present all the potentials of radiological diagnosis in gastroenterology to their full extent. While examining the stomach, the endoscopist pays special attention to the ulcer proper (its edges), whereas intramural infiltration, located mainly in the depth of the wall, is inaccessible to endoscopic visualization. (□ Fig. 106) [32, 222].
□ Fig. 105a-c. Patient D., age 52. Diagnosis: peptic ulcer in remission. Post-ulcer scar. Erosion of the mucosa. From anamnesis: peptic ulcer for many years with occasional seasonal exacerbations. Multiple X-ray and endoscopic examinations. At the present time the patient complains of intensifying epigastric pain after meals. a, b Stomach roentgenograms (double contrast): the anterior wall over a short length is slightly thickened (arrow). Small and large inclusions of barium sulfate suspension - erosions. Conclusion: Post-ulcerous scar. Erosion of the mucous membrane. c Endophotograph: sites of erosion of variable size are seen on the smooth and glassy surface of the mucous membrane. Histological examinations of bioptates taken during multiple endoscopies failed to reveal tumor cells. The patient was prescribed control X-ray and endoscopy.
□ Fig. 106a-e. Patient K., age 58. Diagnosis: gastric cancer. From anamnesis: the patient has had peptic ulcer for many years. The last exacerbation persisted for 3 months. Epigastric pain, nausea, bitter taste in the mouth. Three endoscopies revealed an ulcer defect in the middle third of the stomach body on the posterior wall with folds converging towards the defect; positive dynamics - the ulcer size diminished from 2 to 0.3 cm. Instrumental palpation: the wall around the ulcer crater is elastic. Layers of proliferating epithelium against the background of inflammatory infiltration were determined histologically in bioptates taken during endoscopy. Findings of the third histological examination revealed signs of moderately active inflammation with epithelial dysplasia in one of the eight bioptates. Focal intestinal metaplasia and single mucus-containing cells of the proper mucous membrane. Helicobacter pylori of the 2nd degree. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the stomach body is disfigured (rigid tube) with marked narrowing of the lumen. Uneven contours of the greater curvature (arrows). b Stomach roentgenogram (double contrast, horizontal position, anterior projection): pronounced deformation of the stomach body (rigid tube) with ulcerated infiltration on the posterior wall closer to greater curvature (arrows). In order to verify spread, the patient's stomach was examined by MRI. c MRI of the stomach (stomach cavity filled with water, sagittal projection, T2 image): 3 x 3 x 0.5 cm infiltration in the middle third of the stomach body on the posterior wall, closer to the greater curvature (arrow). Uneven contours. Ulcer to 0.5 cm in the central parts of the infiltration zone. d MRI of the stomach (stomach filled with water, coronary projection, T2 image): distinctly visualized infiltration of wall of the greater curvature (arrow). The inner contour of the involved wall is uneven, MR signal is heterogeneous and of moderate intensity. The outer contour is even, distinct, without signs of infiltration spreading beyond the limits of the stomach wall. Conclusion: Infiltrative-ulcerous cancer of the posterior wall of the stomach body. e Fragment of a macrospecimen (strip): submucous infiltration of white color over a short length (arrows) with minimal changes on the mucosal surface. Histologically, signet-ring cell carcinoma.
Unfortunately, an increasing number of patients with endoscopically diagnosed peptic ulcer are treated today by laser, or »red light«, the therapeutic value of which is strongly doubted for peptic ulcer, without preliminary X-ray examination. Endoscopic control detects the absence of positive dynamics. Using the double-contrast technique, it was possible in some cases to reveal signs of intramural tumors with marginal ulceration. Multiple bioptates were examined for signs of tumor; the results were negative. The low informative value of endoscopic biopsy is explained by the fact that diffuse cancer normally originates in the deep parts of the mucous membrane, whereas biopsied material usually includes elements of reactively changed columnar epithelium. The material taken from the floor of the ulcer crater also has no informative value, because it includes mostly fibrin and necrotic detritus. In other words, we are talking about infiltrative-ulcerous cancer of the stomach with atypical course, and the endoscopist who experiences difficulties in diagnosing cancer has to resort to radiological diagnosis. Unfortunately, this happens only after the course of physiotherapy has been given .
Thus, it is necessary to revise and correct the approach to the use of X-ray and endoscopic examinations in the diagnosis of gastric cancer, particularly its ulcerative forms, and in dynamic observations of patients with peptic ulcer. The diagnostic scheme is as follows:
1. Primary diagnosis - roentgenological and endoscopic (with biopsy)
2. First control examination following treatment after 3-4 weeks - X-ray alone
3. Second control examination, usually the last, 6-7 weeks after the start of treatment - roent-genological and endoscopic (with biopsy)
As can be seen from this scheme, the endoscopic examination is conducted at the stage of primary diagnosis and on healing of the ulcer crater; tissue specimens are taken for histological examinations in both cases (□ Fig. 107). Traditional radiology is involved at the stage of primary diagnosis (together with endoscopy) and in dynamic monitoring of treatment (without endoscopy). Radiology and endoscopy with histological examination of biop-tates are used only for the final evaluation. We stress again the importance of a complex approach to the diagnosis of gastrointestinal diseases. The diagnostic algorithm we propose precludes diagnostic errors that are possible in the period of clinical examination.
Confirmation of our position on the relationship between radiology and endoscopy in the diagnosis of gastric cancer can be found in some publications [60, 171, 185]. Each method separately cannot point to the diagnosis, especially in cases of infiltrative and in-filtrative-ulcerous cancer of the stomach.
Studies carried out in recent years show that there may be significant discrepancies in the results of histological examination of materials taken during biopsy and following radical surgery. In cases where cancer of the stomach cannot be verified prior to the operation these can be as great as 17-33% .
Morphological studies aimed searching for cancer cells cannot meet the current requirements either. The absence of cancer cells in bioptates does not rule out the presence of gastric cancer.
Examination of lymphoid infiltrate helps to establish the diagnosis and prognosis of tumors ofvar-ious localizations. In morphological diagnosis, valuable information is supplied by determining the quantity of intraepithelial mononuclear leukocytes, especially those with histological signs of activation, which are characteristic of adenocarcinoma. In severe dysplasia (currently regarded as neoplasia) of gastric epithelium, a content of activated intraepi-thelial leukocytes exceeding 6/1000 epitheliocytes is a bad prognostic sign. Quantitative determination of tumor markers in human blood serum at a sensitivity of 73% and specificity of 89% cannot always accurately answer whether or not blastomatous affection is present [12, 77].
Permanent comparison of radiological and en-doscopic findings during the past 30 years, with subsequent verification by histological examination of tissue specimens or by clinicoroentgenological observation of patients who did not have surgery for various reasons, leads us to conclude that there is a need for revision of the role of endoscopy in the diagnosis of not only ulcerative forms of gastric cancer, but even more of diffusely spreading carcinomas.
This is connected with the limited potentials of endoscopy in view of changes in the morphogenesis of tumor affections. Thus, despite the rapid development of endoscopy with biopsy and subsequent histological examination of the bioptates, diagnosis of early cancer (which is decisive for complete cure) remains very low at 3-7%. The low rate of radical operative interventions for gastric cancer and the low postoperative 5-year survival have remained unchanged for 40 years, and this is explained by the late diagnosis [40, 86]. The significantly high percentage of untimely diagnosis pertains to endophytic cancers. This anatomical variant of cancer, especially with predominantly submucous spread of the tumor, is the most difficult to diagnose. Researchers are therefore trying to find new ways to diagnose diffuse gastric cancer (chromatogastroscopy, loop biopsy in fibergastroscopy, improved double-contrast technologies, measuring thickness of the stomach wall using ultrasonography, computed tomography, magnetic-resonance imaging, endoscopic ultrasonography, etc.).
In cases of predominantly submucous growth, cancer infiltration can be accompanied for a long time by only insignificant changes in the mucous membrane and mild disorders in the structure of the stomach wall. Here, the importance of endoscopy decreases significantly. Atypical cells, in such cases, occur in small complexes surrounded by powerful growths of connective tissue (which are sometimes mistaken for a curable ulcerous defect of the mucous membrane). This creates significant difficulties for the morphological verification of the disease. It also explains the former, incorrect interpretation of li-nitis plastica as being the result of an inflammatory process. Today, linitis plastica is regarded as one of the most malignant forms of gastric cancer, in which tumor grows mostly in the submucous coat over a long period of time (□ Fig. 108) [28, 34, 53].
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