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▲ Fig. 61 a.

□ Fig. 60a-d. Patient I., age 58. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the distal part is disfigured, the inner cavity decreased significantly, the walls are rigid, the contour of the lesser curvature of the middle third of the stomach body is uneven (arrow). b, c Stomach roentgenograms (tight filling, vertical position, right oblique projection): a large depot of contrast medium with a surrounding ridge of infiltrated tissue (arrows). d Stomach roentgenogram (double contrast, horizontal position, anterior projection): diffuse thickening of the walls of the distal part and the body of the stomach due to circular intramural infiltration (arrows). Conclusion: Infiltrative-ulcerous cancer of the distal part of the stomach with invasion of the stomach body. The patient was operated. Histologically, a non-differentiated cancer

□ Fig. 61a-c. Female patient L., age 66. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the lesser curvature of the stomach body is short, its contour is uneven (arrows). b Stomach roentgenogram (tight filling, vertical position, anterior projection) after taking an additional portion of barium sulfate suspension: uneven contour of the lesser curvature of the stomach body (arrows). c Stomach roentgenogram (double contrast, horizontal position, left lateral projection): distinct visualization of the thickened anterior and posterior walls of the stomach body and its upper part due to circular intramural infiltration (arrows). Conclusion: Infiltrative cancer of the stomach body with invasion of the upper part. The patient was operated. Histologically, adenocarcinoma with the signet-ring cell component

It should be remembered that assessment of the stomach contours at the phase of tight filling and of its thickened wall by the double-contrast technique can be regarded as reliable only on condition that a sufficient number ofX-ray images are taken. We discussed this point in our description of the methodological aspects of radiological examination of the stomach in ► Chap. 4.

We emphasize the importance of these two signs because they can point to intramural tumor infiltration of the stomach, both at the early and at appreciably advanced stages. It must be remembered that when we speak about stomach contours, we mean the inner contours, as if viewed from inside the wall, rather than from the side of the serosa, i.e., at the site where the process of tumor infiltration occurs (D Fig. 61).

While proposing these as the two main signs of gastric cancer detectable by the traditional radiological examination (at the tight filling phase and with double contrast), we understand that the reader may disagree, because, under existing conditions, the radiologist cannot always conduct the double-contrast examination correctly. It is necessary here to point out that tight filling of the stomach with barium sulfate suspension often gives more information on the condition of its contour than adequately conducted double-contrast examination. This may happen in the presence of initial signs of infiltration of the greater curvature, the prepyloric part, and the pylorus (D Fig. 62). Therefore, if it is impossible to adequately conduct a double-contrast examination of the stomach, the sign of uneven contour of a tightly filled stomach should be accepted, because it gives sufficiently objective information on the presence of infiltration in the stomach wall. At the same time, it should be noted that in order to obtain reliable information using this sign, some other factors should be considered.

These include proper selection of the time for taking a picture, at the phase when the peristaltic wave does not pass, and observation of technical requirements for taking pictures: maximum short exposure with correspondingly increased voltage, etc. This problem can be solved partly by using the »green« film/screen system, because owing to the high sensitivity and contrast of the film, the exposure can be reduced 2-4 times. The improved qual ity of X-ray pictures combines with a decreased radiation load on the patients and the medical personnel.

D Fig. 62a, b. Patient D., age 60. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): uneven and eroded contour of the lesser curvature of the prepyloric part of the stomach (arrow). b Target stomach roentgenogram (pneumorelief, horizontal position, anterior projection): thickened wall of the lesser curvature of the prepyloric part of the stomach (arrow); peristalsis can be seen over the entire length. Conclusion: Minor cancer of the prepyloric part of the stomach. The patient was operated. Histologically, adenocarcinoma with the signet-ring cell component.

▲ Fig. 63 a.

Based on the definite prevalence of intramural growth of gastric cancer (diffuse and mixed forms), the presence of peristaltic activity as a sign excluding infiltration is not regarded today as a proof of its absence. Our experience shows that the intramural infiltration (not exceeding 3-4 cm) is often somewhat leveled owing to vigorous peristaltic activity of the neighboring parts of the stomach wall [33, 34, 58].

It is from these same standpoints that it is necessary to evaluate the various pharmacological drugs now widely used in radiological studies of the stomach to intensify or suppress peristaltic activity of the stomach walls. We conduct radiological examinations of the stomach based on a physiological approach which rules out any pharmacological drugs.

Using a contrast medium, and based on our experience with traditional radiological examination of the stomach, which combines the elements of tight filling and double contrast, we decided to use the double-contrast examination as the basic and the only suitable method. However, as we gained experience in combining tight filling of the stomach with double-contrast examination, we became convinced that the optimal method of radiological examination of the stomach is the one which allows visualization of the stomach contours at the phase of tight filling and estimation of stomach wall thickness using double contrast. Double contrast of the stomach

^ Fig. 63 b.
▲ Fig. 63 c. ▼ Fig. 63 d.

can sometimes give wrong information on the presence of infiltration of the wall at its relatively early stage (2-3 cm). This is most typical for the prepyloric part of the stomach and the greater curvature. Today, tight filling of the stomach must be a prerequisite element of examination by traditional radiology [28].

While using contrast media for double contrasting of the stomach, we always examine a tightly filled stomach first; to this end, the patient often has to take two portions of the medium. Then we can examine a tightly filled stomach and obtain adequate double contrast [31].

Let us name some X-ray signs of gastric cancer which were established by researchers in the first half of the twentieth century. It is known that the X-ray picture of gastric cancer is quite varied and de

▲ Fig. 63 e.

pends on the macro-morphological type of the tumor, the phase of growth, and localization of the lesion. Holzknecht and Jonas were the authors of the first book dedicated to the roentgenosemiotics of gastric cancer, published in Vienna in 1908. The filling defect, the classical sign of gastric cancer, was first described in detail in this monograph. The authors also described another specific sign of blasto-matous affection of the stomach wall - the absence of peristalsis in the involved zone - but they did not fully appreciate its diagnostic importance [147]. The third sign, the so-called atypical relief associated with cancer, was established much later, when the method of studying mucosal relief was established. In 1911, Elischer made the first attempt to obtain an X-ray picture of the tumor surface in gastric cancer patients. But it was only at the end of the 1920s and in the early 1930s that the method of examining relief was acknowledged as an obligatory component of examination of the stomach where gastric cancer is suspected [117].

Beginning with the first publications dealing with X-ray examination ofthe stomach, the so-called filling defect was believed to be the direct sign of new growth as a result ofvisualization of the tumor node against the background of the stomach cavity filled with a contrast medium according to the classical methodology. For many decades the filling defect remained the main sign of exophytic tumors as well as of the mixed forms. It was only after the appearance of publications describing early cancer that the term polypoid formation started to replace the term

□ Fig. 63a-h. Patient K., age 53. Diagnosis: gastric cancer. Complaints of epigastric discomfort after small meals, rapid satiabil-ity during the preceding 6 months. The patient lost 8 kg over a 3-month period. Roentgenological examination: a Stomach roentgenogram (tight filling, vertical position, right half-oblique projection): uneven contour of the lesser curvature of the antral part of the stomach (arrow); peristalsis over the entire length. b, c Stomach roentgenogram (double contrast, horizontal position, anterior projection): the walls are thickened due to intramural infiltration (arrow); peristalsis is visible. d Stomach roentgenogram (double contrast, vertical position, left oblique projection): the anterior wall of the stomach is thickened due to intramural infiltration (arrow). e Stomach roentgenogram (double contrast, horizontal position, left lateral projection): the anterior wall of the stomach is thickened and rigid due to intramural infiltration (arrow). Conclusion: Infiltrative gastric cancer. Despite considerable length of the lesion, peristalsis is seen on a series of X-rays. f Macrospecimen of a resected stomach: the wall is firm due to intramural tumor infiltration (arrows). g Fragment of a macrospecimen (strip): the wall is thickened due to tumor infiltration (black arrow). The muscular coat of the wall is unchanged (white arrows). h Microspecimen of a fragment of the stomach wall: non-differentiated cancer with initial invasion of the muscular coat filling defect, because of disagreement between small lesions and the traditional the filling defect concept, and also because of development ofthe double-contrast technique.

Although we regard the filling defect as one of the most important signs of gastric cancer in the diagnosis of infiltrative tumors, we must admit that its use is limited. It is decisive in determining mostly the exophytic component of the tumor, which, in the current concept of gastric cancer morphology, is of limited importance. Every tumor has an exophytic component, but the infiltrative forms, with a much higher incidence than expansive tumors, are manifested by such insignificant changes on the mucosal surface that it is practically impossible to detect them. As radiological methods of studying the stomach gradually improved, these limitations, which were characteristic of the traditional method of tight filling, were gradually removed. With introduction of the double-contrast technique, the filling defect lost its former significance. And it

▲ Fig. 63 g.

acquires a completely new meaning when the elements of the classical methods (tight filling) and double contrast are combined. Ingestion of barium suspension in a slightly greater amount for a greater contrast helps reveal an insignificant depression or unevenness of the stomach contour. This is an important addition to the other manifestations of infiltrative cancer and facilitates diagnosis to a greater degree of reliability.

Let us point out once again that the absence of peristalsis is a threatening sign, suggesting a considerable (as regards depth and area) affection of the stomach wall with involvement of the muscular coat. Minor endophytic cancer, located mostly in the sub mucous coat, does not invade the muscular coat and therefore does not affect peristalsis. For this reason, the presence of peristalsis does not rule out endo-phytic cancer (O Fig. 63).

The main relief element characteristic of gastric cancer is the so-called relief defect. But this term should not be likened to the filling defect. As stated above, the requisite condition for visualizing the filling defect is tight filling of the stomach with a contrast medium. What is necessary for a relief defect is adequate impregnation of the mucous membrane with a thin layer of contrast medium. In some cases, a relief defect is devoid of any pattern; in others it has its own pathological pattern, which in most cases is connected with impregnation of the ulcer crater. Each defect is a limited elevation on the inner surface of the stomach wall due to protrusion of the tumor into the stomach lumen. In essence, this is a tumor which is more or less elevated over the surface of the mucous membrane (exophytic or mixed tumor).

When the inner surface of the stomach is examined using a thin layer of contrast medium, the ordinary pattern of folds and furrows is absent. Instead, multiple indistinct defects appear on the relief; they are of various shapes and not isolated but, on the contrary, fuse (merge) to a lesser or greater extent. They are not fully separated, and there may be narrow or broad stripes of barium sulfate suspen-

□ Fig. 64a-e. Patient R., age 67. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): markedly disfigured pyloric part of the stomach; uneven and eroded contours, the angular notch straightened (arrows); b Stomach roentgenogram (double contrast, horizontal position, anterior projection): the walls of the distal part and thickened due to intramural infiltration (white arrows). Ulceration on the greater curvature of the antral part (black arrow). Conclusion: Infil-trative-ulcerous cancer of the distal part of the stomach. Histological examination of bioptates taken from the edges of the ulcer crater did not reveal the presence of tumor cells. The patient was examined by MRI. c MRI of the stomach (coronary projection, T1 image): the »ring« sign in the antral part, heterogeneous MR signal from the infiltration ridge (arrow). d MRI of the stomach (coronary projection, T2 image): hyperintensive signal from water in the ulcer crater (arrow). e MRI of the stomach (sagittal projection, T2 image): circular thickening of the antral part wall to 14 mm; heterogeneous MR signal from the wall (arrow). The patient was operated. Histologically, a non-differentiated cancer

sion which sort of trim the defects on the relief, to show their irregular contours (D Fig. 64). Uneven in width and intensity, these stripes sometimes terminate, then appear again, before they finally disappear. They can narrow or widen to form stable shapeless spots of contrast medium resembling deep lacunas of sophisticated configuration. Regardless of the specificity of the pattern or the prevalence of this or that detail, the pathological relief is characterized by stability.

It is necessary to note again that this briefly described X-ray picture of the relief of the inner stomach surface is characteristic above all of the exophytic forms of cancer, the proportion of which is quite insignificant today, and also of its mixed forms. Unfortunately, in most cases it characterizes advanced forms of cancer, in which the tumor protrudes into the stomach lumen and has an irregular tuberous form, which interferes with studies at the pneumo-relief phase. From the current standpoint of epidemiology and morphogenesis of gastric cancer, the study of the surface relief alone during X-ray examination does not meet the modern requirements of gastroenterology and must be regarded by radiologists only as an additional source of information supplementing the two basic radiological signs, namely, uneven contours with tight filling and thickening of the stomach walls with the double-contrast technique (D Fig. 65).

Nevertheless, practical radiological diagnosis still often tends to be based upon the known triad of signs, count today, unfortunately, as the so-called general roentgenosemiotics of gastric cancer. The triad includes the filling defect, due to sufficiently large exophytic tumor; the absence of peristaltic activity of the stomach walls in the region ofblastoma-tous infiltration; and, finally, atypical mucosal relief. The practitioners examine the patient for the presence of these three signs without considering the morphological form or stage of the cancer.

We think that the three main signs mentioned above provide no valuable diagnostic information. In the overwhelming majority of cases, these signs indicate only the presence ofa tumor in the advanced stage. Moreover, they are sometimes not detectable even in patients with advanced disease. For example, circular affection of the antral part of the stomach completely rules out the symptom of atypical relief, and affection of the posterior wall is often accompanied by almost complete absence of an aperistaltic zone.

Generally speaking, the signs which were described later, such as termination of folds at the tumor border or the »hoop« symptom, described by Knothe, are characteristic only of exophytic forms of gastric cancer, which occur far less frequently. If we want to be more objective, we should point out that purely exophytic forms do not exist today. The

X-ray picture of diffuse (endophytic) cancer, especially of its early manifestations, has little in common with the »classical triad« of signs; to be more exact, it has nothing in common [31, 37].

Only some of the earlier established symptoms of gastric cancer remain significant today. They have been described in the literature sufficiently well, and therefore we mention some only to remind the reader of their existence. These include microgastria, various deformities of the stomach (hourglass, rigid tube, rigid cascade, cancer canal, etc.), limited displacement of the stomach, depressed and short lesser curvature, increased or decreased angle of the gastric notch, increased stomach-spinal column and stomach-diaphragm distances, disordered (accelerated or slowed down) evacuation, rigidity of the stomach walls, stronger contour contrast, ulcer niche in a »dry« stomach, bald or leveled mucosal relief, rigid relief, floating splinter, resilient »corset bone«.

It has long been known that only radical operative treatment can help the patient, and this concept is not disputed. For this reason, roentgenooncology in the second halfof the twentieth century developed in the direction of revealing minor forms of gastric cancer.

Tight filling of the stomach has become an indispensable component of any modern X-ray examination of the stomach. Supplemented by the double-contrast technique, it markedly increases the chance of obtaining the necessary diagnostic information and significantly aid in forming the diagnosis. We are convinced that with a tightly filled stomach, one can reveal the specific signs of gastric tumor, including its initial forms. This becomes especially important in patients with endophytic cancer, but it requires complete rejection of the principles aimed exclusively at searching for intestinal forms of cancer. Under certain conditions of X-ray examination, malignant infiltrations, which disfigure the contour

D Fig. 65a, b. Patient B., age 62. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the wall of the greater curvature of the distal part of the stomach is straightened and rigid (black arrow), peristalsis is seen over the lesser curvature of the distal part, the symptom of a floating splinter (white arrow). b Stomach roentgenogram (double contrast, horizontal position, anterior projection): diffuse thickening and rigidity of the walls in the distal part due to circular intramural infiltration (arrows). Conclusion: Infiltrative cancer of the distal part of the stomach and its body of the stomach, can characterize spread of the new growth and its properties - the exophytic component, ulceration, the nature of infiltration (circular or a rigid spot, etc). In diffuse (mostly submucous) cancer, the relief pattern of the mucosa is normal, or nearly normal, depending on individual properties. Blastomatous infiltration spreads mostly intramu-rally, and until a given moment does not involve surface layers of the mucous membrane proper. In this case, the mucosal relief which is visualized by an

m^i
▲ Fig. 66 a.

endoscopist is formed at the expense of the mucous membrane proper, which overlies the tumor. The mucous membrane itself in such cases shows signs of dystrophy. As the tumor progresses, the mucosal cover thins, the dystrophic process increases, and all coats of the mucous membrane are eventually replaced by the tumor tissue. The relief pattern persisting on the inner surface of the stomach is characteristic of the early stages of infiltrative cancer. For a long time, these stages of infiltrative cancer were unknown to many roentgenologists, despite attempts to establish standard roentgenosemiotics (D Fig. 66).

We fully agree with R. Gutmann, who wrote in his monograph »Sur les cancers gastriques imisci-bles a l'operation« (1960) that, contrary to common opinion, early X-ray diagnosis of gastric cancer is feasible in most cases [132]. He stresses that in some cases, early affection of the gastric mucosa can

D Fig. 66a-d. Patient A., age 67. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): uneven contours of the lesser curvature, depression in the form of a platform of about 2 cm with characteristic serration by the margins showing the borders of intramural infiltration (arrow). b Stomach roentgenogram (double contrast, horizontal position, anterior projection): wall of the stomach body is thickened over a length of about 3 cm, rigid due to intramural infiltration (arrow). Conclusion: Minor infiltrative cancer of the angular notch. c Macrospecimen of a resected stomach: stomach wall is thickened, a small navel-like depression with visually unaltered converging folds of the stomach mucosa (arrows). d Fragment of a macrospecimen (strip): the stomach wall is thickened over a distance of about 3 cm due to intramural infiltration of the submucous coat (arrows). Histologically, adenocarcinoma with the signet-ring cell component.

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