K

O Fig. 46a-h. Patient S., age 55. Diagnosis: gastric cancer. a Stomach roent-genogram (tight filling, vertical position, anterior projection): the distal part is tightly filled with barium sulfate suspension; uneven contours, no visible organic changes, distinct peristalsis over the entire length. b, c Stomach roentgenograms (tight filling, vertical position, anterior projection), dosed compression: uneven and eroded contour of the lesser curvature of the lower third of the stomach body; flat ulcer niche not extending beyond the contour, with folds terminating at the periphery (arrows). d, e, f Stomach roentgeno-grams (double contrast, horizontal position, anterior projection): thickened stomach wall on the lesser curvature of the lower third of the stomach body, near the angular notch, due to intramural infiltration (arrow).

Conclusion: Minor infiltrative cancer of the lower third of the stomach body. g Macrospecimen of a resected stomach; the lesser curvature of the lower third of the stomach is firm; ulceration with atypical surrounding relief (arrows). h Fragment of the macro-specimen (strip): the stomach wall is thickened due to white intramural infiltration within the confinements of the mucous and submucous coats (white arrows); invasion of the muscular coat is not detectable visually (black arrows). Histologically, signet-ring cell carcinoma

▼ Fig. 47 a.

In consideration of the great prevalence of intramu-rally growing gastric cancers, the idea of searching for early cancer as it is classically understood - according to the endoscopic classification of 1962, as affection of the mucous membrane alone - is no longer valid and also requires correction (□ Figs. 47, 48). We propose a definite symptom complex of early gastric cancer characterized by infiltrative growth, which we call intramural blastomatous infiltration. Its basic sign is uneven contours of the stomach over 1-3 cm with thickening of its wall at this level due to tumor infiltration (□ Fig. 49) [31].

We will also discuss the need to radically revise the existing list of radiological signs of gastric cancer and clinical symptoms.

□ Fig. 47a, b. Patient N., age 60. Diagnosis: gastric cancer. The patient had no complaints. Two relatives had had gastric cancer. Endoscopy revealed ulcer on the posterior wall of the stomach. Histological examination failed to detect tumor cells. a Stomach roentgenogram (tight filling, vertical position, anterior projection): uneven contour of the lesser curvature (depression); the wall is rigid (arrow). b Stomach roentgenogram (double contrast, horizontal position, left anterior oblique projection): the wall of the lesser curvature is thick and rigid due to intramural infiltration (white arrow); a depot of contrast medium on the posterior wall of the stomach body with converging folds (black arrow). Conclusion: Infiltrative-ulcerous cancer of the stomach body. Repeat endoscopy was conducted and many tissue specimens were taken. Histological studies verified non-differentiated cancer in two specimens.

D Fig. 48. The same patient, 6 months following stomach resection. X-ray of the stomach stump (tight filling, vertical position, anterior projection): the stump of irregular tapered shapes contains much fluid; evacuation is difficult due to pronounced narrowing of the gastrojejunal anastomosis affected by recurrent tumor as a result of intraoperative underestimation of the extent of intramural growth of the tumor discovered by radiological examination.

▲ Fig. 49 c.

□ Fig. 49a-c. Patient S., age 52. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the lesser curvature of the antral part of the stomach is short, its contour is uneven due to the presence of a flat ulcer niche (white arrow) and the ridge of infiltration (black arrows). b Stomach roentgenogram (double contrast, horizontal position, left oblique projection): the wall of the lesser curvature of the antral part is thickened due to intramural infiltration (arrow). Conclusion: Infiltrative-ulcerous cancer of the distal part of the stomach. c Endophotograph: ca. 1.5-cm ulcer on the lesser curvature with firm and rigid edges; the surrounding mucosa is hyperemic and infiltrated. Histological examinations of the tissue specimen verified non-differentiated cancer.

Traditional Radiological Signs

In order to enable the reader to objectively assess the need for changes in the currently used set of traditional radiological signs of gastric cancer, we wish to give a concise history of the problem. There are a lot of signs that we think are connected only with far-advanced symptoms of cancer: The so-called filling defect corresponds mainly to far-advanced symptoms of intestinal and mixed forms of cancer. It is a sign of exophytic growth which is seen against the background of an air bubble during X-ray examination and it is typical of cancer of the upper part of the stomach. Other signs are peristaltic activity of the stomach walls, indicating that there is no tumor infiltration of the stomach, and the so-called floating splinter on the stomach contour. Much later (in

▲ Fig. 49 a.

the 1960s) the sign of an uneven stomach contour was described, and this remains important today. Unfortunately, it is given the least consideration in the general symptom complex of gastric cancer.

Of special importance are the various manifestations of gastric mucosal relief, which are indispensable for the diagnosis of the initial signs of gastric cancer [144, 145]. This also concerns those signs which were proposed by Japanese radiologists for the study of the so-called fine relief with double contrast. Unfortunately, there are publications which propose examination of the so-called pleated relief and areolar pattern of the tunica mucosa. However, it is not necessary to study the relief of the stomach mucosa with double contrast to detect the so-called bald sites of microrelief, finest irregularities, depressions, and only slightly noticeable elevations. If the mucosa is well impregnated with highly concentrated barium sulfate suspension, the image of the relief on the opposite side will always blur the image obtained for study, no matter how distinct it is. Hence, the image will be inadequately interpreted. A very good method exists for studying the relief of the inner surface of the stomach. This is endoscopy. Moreover, endoscopy is also used to take tissue specimens for histological studies, which makes this method especially valuable in the diagnosis of tumors which manifest themselves on the mucous membrane. Study of the relief of the gastric mucosa may be useful only in an

▲ Fig. 50 a.

examination of the cardiac rosette (cardioesopha-geal junction), where the condition of the relief is of primary diagnostic importance owing to its anatomical properties, in particular, the absence of the submucous coat (D Figs. 50, 51).

D Fig. 50a-d. Versions of normal structure of the cardiac rosette (cardioesophageal junction) relief. A series of X-rays of the upper part of the stomach (double contrast, horizontal position, left oblique projection): folds of the cardiac mucosa are continuation of the esophageal mucosal folds, symmetrically radiating from the medial wall of the upper part and uniformly unfolding as they reach the submucous coat (visually detectable asymmetry is due to projection distortions); very distinct impregnated interfold spaces.

□ Fig. 51a-e. Female patient I., age 70. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): uneven contour in the cardiac projection (arrow). b Stomach roentgenogram (double contrast, vertical position, left oblique projection): changed relief of the cardiac rosette (cardioesophageal junction); the specific radial pattern is absent (arrows), uneven esophageal walls. Conclusion: Infiltrating cancer of the upper part of the stomach. To rule out infiltration spreading onto the esophagus, the patient was examined by computed tomography. c, d Computed tomograms of the stomach (the stomach is inflated with air, the patient is positioned on her right side; the level of the abdominal segment of the esophagus): the walls of the abdominal segment of the esophagus are thickened to 13 mm (arrow) due to intramural infiltration. e Computed tomogram of the stomach (position on the right side, the stomach is inflated with air, the level of the cardia): distinct visualization of the thickened wall of the stomach in the region of the cardiac rosette due to intramural infiltration (arrow), which spreads onto the abdominal segment of the esophagus. Conclusion: Infiltrative cancer of the upper part of the stomach with invasion of the abdominal segment of the esophagus.

▲ Fig. 51 d. ▼ Fig. 52 a.

Current roentgenosemiotics of gastric cancer include the »old« sign - retention of residual barium sulfate suspension in the stomach 24 h after its intake, which occurs in cancer of the prepyloric part and the pylorus proper. Unfortunately, the so-called filling defect remains the main X-ray sign in the symptom complex of gastric cancer in its different versions (cup-shaped cancer, etc.).

In other words, the entire set of former X-ray signs was, and still is, based on the intestinal forms of gastric cancer. Its main anatomical signs were the results of prevailing changes mostly on the gastric mucosal surface [14, 65]. The outdated roentgenose-miotics of gastric cancer is based on the concept that the most common initial localization of the tumor is in certain parts of the stomach, viz., posterior wall, lesser curvature, the antral part (O Fig. 52). The greater curvature and the anterior wall were regarded as the sites where primary cancer tumors were unlikely to occur (O Fig. 53).

As a matter of fact, the same principle underlay the whole structure of the methodological approach to radiological examination of the stomach. The relief of the gastric mucosa was visualized with the

first gulps of the barium meal with dosed compression; next, as the stomach gradually filled with barium suspension, peristalsis of the gastric walls was studied, while less weight was given to characteristics of the stomach contours.

D Fig. 52a-e. Patient R., age 57. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the lesser curvature is depressed, its contour is uneven (arrows). b Stomach roentgenogram (pneumo-relief, horizontal position, anterior projection): the relief of the lesser curvature of the stomach body presents as a single thickened fold (arrows); mucosal folds terminate near the last fold of the lesser curvature. c Stomach roentgenogram (double contrast, horizontal position, anterior projection): infiltration of the wall of the lesser curvature is seen more distinctly; the wall is thickened and rigid (white arrow); a depot of barium sulfate is seen on the anterior wall as a fissure (black arrow). Conclusion: Infil-trative-ulcerous cancer of the lesser curvature of the stomach body. d Macrospecimen of a resected stomach: the stomach wall is dense; ulcers on the mucosal surface (arrow) with the surrounding relief changed due to tumor infiltration. e Fragment of a macrospecimen (strip): the stomach wall is thickened due to white intramural tumor infiltration (arrows)

▲ Fig. 52 d.

O Fig. 53a-j. Patient M., age 61. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the abdominal segment of the esophagus is disfigured, its walls are uneven, the rectilinear character of its mucosal folds is absent due to intramural infiltration (arrow). b Anterior projection (tight filling, vertical position, left lateral projection) at the moment of contrast medium passage through the gastroesophageal junction: marked deformation of the abdominal segment of the esophagus; uneven narrowing of the lumen due to intramural infiltration (arrows). c Stomach roentgenograms (double contrast, vertical position, left anterior oblique and left lateral projections) at the moment of contrast medium passage through the gastroesophageal junction: uneven narrowing of the abdominal segment of the esophagus (white arrows), changed relief of the cardiac rosette (black arrows). d Stomach roentgenogram (double contrast, horizontal position, left posterior oblique projection): atypical relief of the cardiac rosette is more distinct (arrow). Conclusion: Infiltrative cancer of the upper part of the stomach with invasion of the esophagus. In view of infeasibility of conducting adequate endoscopy because of the pronounced narrowing of the abdominal segment of the esophagus, the patient was examined by computed tomography. e, f Computed tomograms (native-state study, supine patient, level of the lower third of the esophagus): marked thickening of the esophageal walls over a significant distance due to intramural infiltration (arrows). g Computed tomogram (tight filling with E-Z-CAT DRY, supine patient, level of the cardia): the cardiac wall is thickened due to intramural infiltration invading the abdominal segment of the esophagus (arrows). h Computed tomogram (tight filling with E-Z-CAT DRY, supine patient, level of the supra-diaphragmatic segment of the esophagus): the esophageal walls are thickened due to intramural infiltration spreading in the proximal direction. i Macrospecimen of a resected stomach: the wall of the cardia is firm; atypical relief of the cardiac rosette due to intramural infiltration (arrows). j Fragment of a macrospecimen (strip): the stomach wall is thickened due to white intramural infiltration (arrows). Histologically, signetring cell carcinoma

Was this article helpful?

0 0

Post a comment