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□ Fig. 3. Macrospecimen of a resected stomach. Ulcerated 9x4.5-cm endophytic tumor (dissected in two parts) in the vicinity of the esophagus (arrows). Histologically, a poorly differentiated adenocarcinoma with the signet-ring cell component and invasion of the muscular coat

□ Fig. 1. Macrospecimen of a resected stomach. A 9x9-cm ulcer is seen in the pyloric part on the lesser curvature with a ridge of infiltration (arrows); the ulcer spreads over onto the anterior and posterior walls (distal cancer). Histologically, a moderately differentiated adenocarcinoma of the stomach with invasion of the serosa

□ Fig. 2. Macrospecimen of a resected stomach. A 5x3-cm infiltrative-ulcerous cancer (arrows) on the lesser curvature, 5 cm from the distal and proximal edges of resection. Histologically, a signet-ring cell carcinoma of the stomach with invasion of the muscular coat es cancer develops in the cardiac part, the upper third of the body, and the fundus - so-called proximal cancer (□ Fig. 3) [196, 271 ]. The greater curvature is attacked by the tumor in 8-9% of cases. Tumor activity on the anterior wall of the stomach is relatively rare (□ Fig. 4).

However, screening data suggest that tumors in the greater curvature and the anterior wall occur far more frequently than might be expected [33, 58, 129, 224]. In most cases, the newly revealed cancers ex-

□ Fig. 4. Macrospecimen of a resected stomach. Infiltrative-ulcerous cancer (1 cm diameter) with eroded edges (arrows). Histologically, a moderately differentiated adenocarcinoma of the stomach tend over a significant length, and at the time of discovery the tumor cannot be regarded as located at the site of its origination.

During the past 30 years, the incidence of distal cancer has decreased, whereas the number of cases of proximal carcinoma has increased [86, 271], which agrees with the results of studies conducted at MONIKI (► see Diagram 4). Diagnosis of proximal gastric cancer is a difficult problem. Such tumors are normally accompanied by invasion of the esoph-ageal wall, which makes endoscopic diagnosis much more difficult and sometimes even infeasible (O Fig. 5). Moreover, the tumor often metastasizes into the para-esophageal lymph nodes. This worsens the prognosis and makes it difficult to treat the patient surgically. »Displacement« of the traditional site of cancer from the distal part of the stomach to its proximal part must stimulate a revision of the current approach to diagnosis.

O Fig. 5. Macrospecimen of a resected stomach. Large tumor in the area of the gastroesophageal junction invading the eso phageal wall. Histologically, a moderately differentiated adenocarcinoma invading the serosa and the esophageal wall

According to some authors, the prognosis of the disease depends on the localization of the tumor, but in our opinion, such a dependence is quite disputable. As a rule, the prognosis would be best with tumors in the pyloric part and on the lesser curvature, and worst with total involvement of the stomach. It is evident that the prognosis would normally depend on the tumor's histological type and its stage. Intestinal carcinomas would have a better prognosis (they are easier to diagnose), while with diffuse carcinomas the latent course is longer and hence the prognosis is worse.

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