D Fig. 128 a-e. Female patient V., age 53. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): contour of the cardiac part and the fundus is uneven (black arrows), the abdominal segment of the esophagus is circularly narrowed, with a small supraste-notic dilatation (white arrow). b Stomach roentgenogram (double contrast, horizontal position, left posterior oblique projection): walls of the upper part are thickened and rigid due to intramural infiltration (arrows). Conclusion: Infiltrative cancer of the upper part of the stomach with invasion of the esophagus. In order to verify the infiltration spread, the patient was examined by MRI. c MRI (axial projection, level of upper part of the stomach, T2 image): walls of the fundus are thickened unevenly due to intramural infiltration. Infiltration spreads onto the abdominal segment of the esophagus with strongly narrowed lumen, and also onto the left crus of the diaphragm and the medial edge of the spleen (arrows). d MRI (coronary projection, level of upper part of the stomach, T2 image): uneven thickening of the fundus walls with infiltration spread to the upper two thirds of the stomach body (arrows). Conclusion: Infiltrative cancer of the body and the upper part of the stomach with invasion of the abdominal segment of the esophagus, the left crus of the diaphragm, and the medial edge of the spleen. e Fragment of a macrospecimen (strip): the wall of the stomach is thickened due to intramural infiltration of white color (arrows). Histologically, signet-ring cell carcinoma.
D Fig. 129 a-c. Patient V., age 43. Diagnosis: cancer of the lower third of the esophagus with invasion of the cardiac part of the stomach. Complaints of dysphagia, vomiting after meals, which continued for 3 months. Weight loss, 10 kg. a Roentgenograms of lower third of the esophagus (tight filling, vertical position, anterior projection) at the moment of contrast medium passage through the gastroesophageal junction: the lower third of the esophagus is unevenly circularly narrowed; uneven contours. A depot of contrast medium in the supradiaphragmatic segment (arrow). b Roentgenogram of lower third of the esophagus (tight filling, vertical position, left lateral projection) at the moment of contrast medium passage through the gastroesophageal junction: an ulcer niche with eroded contours on the anterior wall of the supradiaphragmatic segment of the esophagus (arrow), atypical relief of the cardioesophageal junction. c Roentgenogram of upper part of the stomach (double contrast, vertical position, anterior projection): thickened wall of the cardia due to tumor infiltration is seen against the background of the air bubble with the stretched folds of the proximal part of the stomach (arrow). Conclusion: Infiltrative cancer of the cardiac part of the stomach with involvement of the esophagus. Ulceration of the anterior wall of the supradiaphragmatic segment of the esophagus. The patient was operated. Histologically, squamous cell cancer. Such cases are relatively rare. As a rule, cancer occurs in the stomach with subsequent spread to the esophagus. Nevertheless, traditional X-ray examination with double contrast reveals affection of the cardiac part of the stomach. This is another confirmation of our point of view that radiological methods of examination should be used again in gas-troenterology.
Double-contrast radiology has the greatest potential in the traditional X-ray examination of the upper parts of the stomach. Only this method can demonstrate wall thickening and loss of elasticity at the initial stages of the malignant process. Thick and rough folds add to the double-contrast imaging, and this suggests malignancy. At the same time, it should be noted in this connection that it is possible to study contours of the upper part ofthe stomach using some manipulations such as changing the patient's position from vertical to tilted, or from horizontal to vertical, which helps to estimate the condition of the walls in cascade stomach.
During recent decades, there has been a distinct tendency toward an increasing occurrence of tumors in the upper part of the stomach. This is the point of particular concern to specialists, because cardio-esophageal cancer has the worst prognosis when compared with tumors of all other localizations (D Fig. 128).
It has become commonplace that when discussing new growths in this localization we usually mean advanced cases. The main reason for oncological neglect is that the patients present late for medical attention, i.e., they do not visit the doctor until the dysphagia dominates the clinical picture, indicating the spread of the process onto the esophagus. The difficulty of diagnosing proximal cancer is due (in addition to the late clinical manifestations) to the fact that the prevalence of endophytic forms over exophytic forms is not taken into consideration. The radiological semiotics of cancer of the upper part of the stomach continues to be based on the old signs of exophytic new growth (additional shadow, splashing of barium sulfate suspension, etc.).
Another problem has become the subject of special concern for gastroenterologists in recent years. This is the so-called specialized columnar epithelium, or Barrett's esophagus (Barrett epithelium; the lower part of the esophagus is lined with cylindrical epithelium; gastrointestinal metaplasia). Barrett's esophagus is an acquired disease in which squamous epithelium of the esophagus is replaced by cylindrical epithelium, owing to the prolonged attack on the mucous membrane by gastric contents; it is regarded as a complication of gastro-esophageal reflux alongside with ulcers and peptic strictures of the esophagus. The British surgeon
N. Barrett was the first to describe the syndrome in 1950; it includes hernia of the esophageal hilus of the diaphragm, peptic ulcer of the esophagus, and focal changes in the mucous membrane of its distal part . During recent years, the interest of gastroenterologists in Barrett's esophagus has increased significantly. This is explained by the epidemic spread of this pathology worldwide (beginning in the 1980s) and by the considerably increasing occurrence of proximal cancer of the stomach. Gastrointestinal metaplasia is regarded by the gastroenterological community as a precancerous condition, because the incidence of adenocarcinoma in such patients is 30 times higher than in the population as a whole.
Histological examination of columnar epithelium, which results from metaplasia and replaces multi-layered squamous epithelium, differentiates between the following three types of cells in accordance with Barrett's classification:
2. Cardiac or transitional
Columnar epithelium of the stomach is practically identical to epithelium of the fundus and the cardia, whereas the specialized cylindrical epithelium has the properties of gastric and intestinal epithelium: The cells have cilia on their surfaces and crypts containing mucus-forming goblet-shaped, and entero-endocrine cells. Combinations of various forms of metaplasia of the esophageal epithelium are also possible, but the absorbing capacity of these cells is insufficient, as distinct from true enterocytes. Therefore, intestinal-type metaplasia is regarded as incomplete. Esophageal metaplasia may extend to a distance of 3-15 cm from the line of transition of the gastric epithelium to the esophageal epithelium.
Endoscopically, the following two types of Barrett's esophagus are distinguished:
1. A short segment of the Barrett esophagus -metaplasia extends for less than 3 cm
2. A long segment of the Barrett esophagus -metaplasia extends for more than 3 cm
There are some factors predisposing to development of Barrett's esophagus. Thus, hernia of the esophageal hiatus of the diaphragm occurs in 75-80% cases, and dysfunction of the lower esophageal sphincter develops in 19-20% patients. There are no pathognomonic symptoms of Barrett's esophagus, and its clinical symptoms do not differ from those of the gastroesophageal reflux, but it should be noted that about 95% of patients experience heartburn.
At the present time, endoscopy with biopsy of the mucous membrane is commonly used for diagnostic purposes, but the endoscopic signs are sometimes meager and therefore, between four and 15 bi-optates should be taken from various parts of the esophagus spaced at 1-2 cm. On esophagoscopy, the portion of cylindrical metaplasia appears hyperemic and contrasts with the pale pink epithelium of the esophagus.
Since patients with Barrett's esophagus are highly predisposed to adenocarcinoma, it is necessary to note again that roentgenology should be returned to the field of gastroenterology as soon as possible. The lower segments of the esophagus of patients with X-ray signs of reflux esophagitis will then be examined by the endoscopist more thoroughly. The necessary number of tissue specimens will be taken to facilitate the diagnosis of blastomatous processes at the earlier stages (D Fig. 129).
Thus, from the current standpoints of epidemiology and morphology of gastric cancer, tumors of the upper part of the stomach have become the pressing problem of gastro-oncology in the twenty-first century.
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