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Malignant tumors of the linitis plastica and scirrhous type are usually characterized by the absence of a pronounced clinical picture. Even more difficult is clinical diagnosis ofprimary lesions in the »dumb« zone of the greater curvature of the stomach, in its upper third, where, according to H. Fukotomi and T. Sakita (1984), infiltration of the wall may be of sig nificant thickness whereas its function may be relatively normal. At the same time, these authors indicate a high incidence of cancer of the greater curvature of the lower third of the stomach body. The number of tumors at this site exceeds that of tumors on the lesser curvature, the anterior wall, and posterior wall taken together. In our observations, this part of the stomach was affected in 57.6% of all cancer cases, the primary location of which was the greater curvature, and as a rule, additional methodological efforts were necessary for thorough study. As we have already noted, blastomatous infiltration often spreads to the higher parts, and eventually results in the classical linitis plastica type diffuse affection of the stomach. The necessity of improving the diagnosis of tumors of the greater curvature becomes even more apparent if we remember that the results of surgery for cancer of this localization are somewhat better compared with cancers of other localizations. This was true in cases of early detected infiltrative tumors, a considerable percentage of which were located primarily in the stomach body in the region of the greater curvature. In our opin-

ion, the solution here is to screen risk groups for gastric cancer (some authors call them asymptomatic subjects) [8, 57, 73].

Unfortunately, in spite of numerous publications stressing the importance of a complex use of radiological methods in combination with fibergastros-copy (with biopsy) to detect cancer of the greater curvature, many clinicians continue to depend on endoscopy alone. Meanwhile, practical experience shows that routine endoscopy with the traditional technique of taking tissue specimens, has less informative value in such cancers than in those at other locations. The mucosal relief of the greater curvature is so rich that it is very difficult to reveal minor changes in this part of the stomach, the more so if the submucous coat is involved.

The X-ray examination aimed at early diagnosis of new growths in this part of the stomach consists in a thorough study of a series of target X-rays imaging not only the mucosal relief but also the contour of the greater curvature during tighter filling of the stomach with barium sulfate suspension. The study at the phase of tight filling is mandatory. To this end, the patient has to ingest an additional portion ofbar-ium sulfate suspension (D Fig. 144) [36, 41, 54].

□ Fig. 144 a-g. Female patient V., age 48. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): on the greater curvature in the proximal portion of the antral part visualized is a small portion of an uneven contour, which is slightly depressed into the stomach cavity (arrow); peristalsis is seen over the entire length. b, c Stomach roentgenograms (tight filling, vertical position, anterior projection), dosed compression: a site of infiltration with a centrally located niche of irregular rounded shape within confinements of the stomach contours (corresponding to the revealed changes) is seen (arrows). d Stomach roentgenogram (double contrast, horizontal position, anterior projection): a portion of infiltrated wall is seen on the greater curvature of the proximal part of the antral part with folds converging towards infiltration (arrows). Conclusion: Infiltrative-ulcerous cancer of the greater curvature of the antral part of the stomach. e Endophotograph: a portion of the mucous membrane of grayish pink color, with a rough surface, slightly elevated over the surrounding tissues is seen in the sinus of the stomach on its greater curvature; folds of mucous membrane converge toward the margins of this portion; ulceration sized 0.4 x 0.3 x 0.1 cm is seen at the center of infiltration; its margins are scarlet, the floor is covered with a fibrin coat. Histological examinations of the bioptates verified non-differentiated cancer. f Macrospecimen of the resected stomach: the wall of the greater curvature is firm; a portion of the intramural infiltration with folds converging towards it is visualized (arrows). g Fragment of the macrospecimen (strip): the stomach wall is thickened due to intramural infiltration (arrows).

▲ Fig. 144 e.

□ Fig. 145 a-d. Patient A., age 61. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, right anterior quarter-oblique projection): uneven contour of the greater curvature of the sinus (arrow). b, c Stomach roentgenograms (tight filling, vertical position, left half-oblique projection), dosed compression: folds converge toward the infiltration on the greater curvature (arrows). d Stomach roentgenogram (double contrast, horizontal position, anterior projection): a portion of infiltrated wall on the greater curvature of the sinus with thickened folds converging toward this portion (arrow). Conclusion: Infiltrative cancer of the greater curvature of the stomach sinus. The patient was operated. Histologically, signet-ring cell carcinoma.

The double-contrast investigation is of special importance. It helps to assess not only the condition of the mucous membrane but also the stomach wall thickness. The method is universal, because in addition to visualizing organic changes it also helps to detect functional disorders, which are manifested by decreasing elasticity of the infiltrated stomach wall. Quantitative information obtained by this method exceeds the findings of any other modification of classical methods of examination without double contrast. Neither the presence of peristaltic activity nor the absence of deformation of the relief can today confirm the absence of endophytic gastric cancer. Diffuse cancers of the greater curvature are the main difficulty in classical roentgenology; at the same time, this is a field where the informative value ofX-ray studies is not worse than that of fibergas-troscopy (□ Fig. 145).

D Fig. 146 a-g. Female patient Ch., age 42. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, left anterior quarter-oblique projection): uneven contours of greater curvature on lower third of stomach body (arrow). b, c, d, e Stomach roentgenograms (tight filling, vertical position, left half-oblique projection), dosed compression: visualized at different degrees of compression is a depot of contrast medium with infiltration ridge and folds converging toward it (terminating at the periphery) on the greater curvature in lower third of stomach body (arrows). Conclusion: Infiltrative-ulcer-ous cancer of the greater curvature of the lower third of the stomach body. Endoscopy with subsequent histological examination of bioptates failed to reveal tumor affection. The patient was examined by MRI of the stomach. f MR image of the stomach (coronary projection in conditions of tight filling of the stomach cavity with water, T2 SSFSE): uneven contour of the greater curvature in the lower third of the stomach body (arrow). g MR image (coronary projection, tight filling of the stomach with water, FSPGR out of phase): uneven contour of the greater curvature in the lower third of the stomach body. The wall is thickened over a distance of 28 mm, heterogeneous MR signal (arrows). The serous membrane is seen at all levels, including the site of wall thickening. Conclusion: Infiltrative-ulcerous cancer of the greater curvature in the lower third of the stomach body without involvement of the serous coat of the stomach wall. The patient was operated. Histologically, non-differentiated cancer.

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