Relationship Between Radiology and Endoscopy in the Diagnosis of Gastric Cancer

The relationship between X-ray and endoscopic examinations in the diagnosis of gastrointestinal pathologies have been intensively discussed ever since the invention of endoscopy and its introduction into practical medicine. During the first half of the twentieth century, the diagnosis of gastric cancer was the absolute prerogative of classical radiology, and by the 1930s, experience had accumulated in the treatment of gastric carcinoma. It then became clear that timely detection of such tumors is of primary importance. X-ray examinations became a significant aid in selecting therapeutic tactics, which was especially important in ulceration of the tumor. This stimulated surgeons to choose active strategies for treating ulcers located in the prepyloric part of the stomach. At the same time, advances in anesthesiology and surgery significantly broadened the scope of interventions, but the following soon emerged as the decisive prognostic factors include: stage of the tumor process, extent of invasion, and the presence of metastases. In that time it was difficult to detect minimally expressed metastatic processes, and physicians depended mainly on clinical symptoms.

The absence of efficient tools for the diagnosis of early gastric cancer was an obstacle to making needed changes in the traditional concept the disease. The demands of gastro-oncology for improvement of diagnostic means were realized in the modernization of X-ray equipment, making it possible to diagnose malignant tumors at their earlier stages (□ Fig. 97).

In the middle of the 1950s, a new era opened in roentenogastroenterology: Japanese researchers developed the double-contrast technique. It was now possible not only to visualize the surface of barium-impregnated mucous membrane, but also to accurately judge the elasticity of the stomach wall by inflating the stomach with air, thus revealing tumor affections with sufficiently high accuracy.

The interest of physicians in roentgenology faded, however, with the invention of fiberoptic technology in 1958. Fibergastroscopy soon became very

□ Fig. 97a-e. Female patient I., age 61. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the angular notch is straightened, a small infiltrated rigid platform is somewhat depressed into the stomach cavity with a characteristic serration (arrow). b Stomach roentgenogram (double contrast, horizontal position, anterior projection): thickened wall on the lesser curvature due to intramural infiltration prolapse into the cavity of an inflated stomach (arrow). Conclusion: Minor infiltrative cancer of the stomach cancer. c Endophotograph: a grayish site of the mucous membrane up to 1.5 cm in diameter with fine tuberosity is seen on the lesser curvature of the stomach body. Histological examination verified signet-ring cell carcinoma. d Macrospecimen of a resected stomach: a small portion of firm wall with folds of the mucous membrane converging toward it (arrowheads). e Fragment of a macrospecimen (strip): the stomach wall is thickened over a short length due to white intramural infiltration (arrows)

D Fig. 98. Patient L., age 67. Diagnosis: gastric cancer. Endopho-tograph: a grayish site of the mucous membrane, 3 cm, on the posterior wall; tuberous surface; slightly depressed relative to the surrounding tissues. Histologically, adenocarcinoma.

D Fig. 99. Female patient K., age 54. Diagnosis: gastric cancer. Endophotograph: a portion of mucous membrane in the region of the lower third of the stomach on the greater curvature; uneven surface; slightly elevated over the surrounding tissues; color contrast between the infiltrated and visually intact tissues is absent. Histologically, adenocarcinoma with the signet-ring cell component.

D Fig. 99. Female patient K., age 54. Diagnosis: gastric cancer. Endophotograph: a portion of mucous membrane in the region of the lower third of the stomach on the greater curvature; uneven surface; slightly elevated over the surrounding tissues; color contrast between the infiltrated and visually intact tissues is absent. Histologically, adenocarcinoma with the signet-ring cell component.

popular, and a new era began in gastroenterology. Upgraded endoscopes were successfully used to diagnose pathologies of the gastrointestinal tract, and of gastric cancer in particular (D Fig. 98).

Beginning in 1964, fibergastroscopes came in use. They were also used to take samples of tissues from the revealed foci of pathology. And since 1978, built-in photo and cinema cameras have been proposed for objective documentation of the endoscopic picture [201, 222, 232].

The introduction of fiberoptic endoscopes into clinical practice created the conditions for more accurate diagnosis of many diseases of the gastrointestinal tract. Adequate visualization of any part of the stomach and target biopsy have made this method especially highly effective (D Fig. 99). It was quite natural that most clinicians showed a preference for endoscopy, believing that its efficacy was much higher than that of the traditional X-ray examination. Unfortunately, this incorrect view persists today. After almost half a century of the domination of endoscopy in the diagnosis of stomach pathologies, it has become clear that this error is fatal. The problem of early diagnosis of gastric cancer has not been resolved (D Fig. 100).

Even now the importance ofX-ray examinations is underestimated in oncology of the stomach (as well as in gastroenterology as a whole). Moreover, X-ray examinations are sometimes even refused. However significant the potentials of endoscopy, it cannot radically improve the early detection of gastric cancer. This is confirmed by the results of studies by S. Sjoblom et al. (1988), R. Ridolfi et al. (1998), and K. Newbold et al. (1989), who used fibergastroscopy as the only method of examination. The proportion of early diagnosed gastric cancers was only 3-7%, which indicates the only relative value of this approach.

At first, it seemed that visualization of the surface of the gastric mucosa and the possibility of taking tissue specimens for histological examinations made endoscopy an indispensable tool for differential diagnosis of peptic ulcer and primary ulcerative cancer of the stomach. Thus, endoscopy was given preference in the diagnostic algorithm. Without trying to diminish the importance of endoscopy, we must state, however, that timely diagnosis of dys-plastic and metaplastic changes in the mucous membrane, particularly minor ulcerative cancer of the stomach, remains one of the most important problems in current gastroenterology and oncology. Despite significant progress that has been made in clinical medicine, in developing endoscopic technol-

Angular Notch Ray

□ Fig. 100a-d. Female patient G., age 66. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the angular notch is straightened, a rigid portion with a characteristic notch on the lesser curvature, slightly protruding into the cavity is seen (arrow). b Stomach roentgenogram (double contrast, horizontal position, anterior projection):wall of the antral part is thickened due to intramural infiltration (arrow). Conclusion: Minor infiltrative cancer of the antral part of the stomach. Endoscopy with subsequent histological examination of the biop-tates failed to discover tumor cells. Based on reliable signs of blastoma-tous affection detected by traditional X-ray examination (double contrast) and despite the absence of histological confirmation, the patient was operated. c Macrospecimen of the resected stomach: the firm wall is covered with apparently intact mucous membrane (arrows). d Fragment of the macrospecimen (strip): the stomach wall is thickened due to tumor infiltration (arrows). Histologically, signet-ring cell carcinoma.

ogy, and in improving methodology, the present situation with gastric cancer diagnosis remains discouraging (□ Fig. 101) [16, 28].

According to some authors, by the time indications for operative treatment »chronic ulcer« have been established, cancer is diagnosed in 35-40% patients, and about 70% of all tumors of the stomach are discovered in patients with »ulcerous disease of the stomach.« Discrepancies between intravital and posthumous diagnoses account for 18% of the total number of dead who suffered from ulcer and cancer of the stomach [60].

We studied the problem of diagnosis of peptic disease in close cooperation with endoscopists and

D Fig. 101a-f. Patient E., age 52. Diagnosis: gastric cancer. From anamnesis: complaints of epigastric discomfort and moderate pain for 2 months, rapid satiability after small meals. Endoscopy revealed an ulcer defect on the greater curvature of the stomach body. Histological examination failed to find tumor cells. After anti-ulcer therapy the patient felt subjective improvement, but repeated endoscopies did not confirm positive dynamics in the ulcer defect. X-ray examination was recommended. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the stomach body is disfigured (rigid tube), an ulcer niche on the greater curvature not extending beyond the stomach contour (arrow). b, c Stomach roentgenograms (tight filling, vertical position, left quarter-oblique projection): stomach body is disfigured (rigid tube), a stable ulcer niche on the greater curvature not extending beyond the uneven and eroded contour of the greater curvature (arrows). d Stomach roentgenogram (double contrast, horizontal position, anterior projection): walls of the stomach body are thickened and rigid due to diffuse circular infiltration (arrows). Conclusion: Infiltrative-ulcerous cancer of the stomach body. Control endoscopy with subsequent histological examination of the bioptates revealed cells of signet-ring cell carcinoma. e Macrospecimen of the resected stomach: the wall is firm, ulceration of the mucosal surface with intramural infiltration of white color (arrows). f Fragment of the macrospecimen (strip): the stomach wall is thickened due to intramural infiltration of white color, which is seen over a significant distance from the ulcer crater (arrows).

pathomorphologists for over 30 years to examine a great number of ulcer patients from the moment of primary establishment of the diagnosis to complete healing of the ulcer crater. A large number of these patients were observed from 1 to 3-5 years after cicatrization of the ulcer (□ Fig. 102). Our experience gives us grounds to speak out on the problem.

The existing view of the absolute priority of endoscopy in the diagnosis of peptic ulcer and »primary ulcerous« cancer requires serious revision [32, 44, 51]. Some definitions that are often used in the medical literature should also be corrected.

First of all, the term »chronic ulcer«, which is often used in the literature, should be removed from the nomenclature. Only peptic ulcer may be »chronic«. Peptic ulcer is the manifestation of ulcerous disease. Ulceration of the stomach wall due to medication with non-steroid anti-inflammatory preparations has nothing to do with ulcerous disease. This is quite another nosological entity. The same holds for ulceration associated with cancer (□ Fig. 103).

□ Fig. 102. Patient O., age 40. Diagnosis: peptic ulcer in remission. Endophotograph: greater curvature of the antral part of the stomach is moderately disfigured due to transverse folds of the mucous membrane converging toward the funnel-shaped depression of the post-ulcer scar. The mucous membrane of the antral part is pale pink, smooth, and glassy.

□ Fig. 102. Patient O., age 40. Diagnosis: peptic ulcer in remission. Endophotograph: greater curvature of the antral part of the stomach is moderately disfigured due to transverse folds of the mucous membrane converging toward the funnel-shaped depression of the post-ulcer scar. The mucous membrane of the antral part is pale pink, smooth, and glassy.

□ Fig. 103. Female patient A., age 50. Diagnosis: infiltrative cancer of the stomach body. Endophotograph: a flat ulcer of polygonal configuration, sized 0.7 x 0.3 cm, on the greater curvature of the upper third of the stomach body; even, sloping edges of pale-pink color, even floor lined with fibrin. Periulcerous mucous membrane is pale pink, smooth, and glassy. Histologically, adenocarcinoma with the signetring cell component.

Thus, ulcer can be only a symptom occurring in various pathologies, rather than a disease.

The results of our dynamic X-ray and endoscop-ic examinations of peptic ulcer patients show that the optimal time of ulcer niche healing is 1.52 months. In 85% of cases, the final form of ulcer healing is a post-ulcer scar giving a specific X-ray picture. In 3-5% of cases, the cured ulcer is not detectable with X-ray. In 8-10%, peptic ulcer can be exacerbated or complicated due to inadequate treatment. It should therefore be remembered that an ulcer proper cannot recur. The scar cannot have primary ulceration. Seasonal exacerbations of peptic ulcer are manifested by a peptic ulcer of new localization. It may develop in the immediate vicinity of the scar, but never on the scar proper.

Complications of peptic ulcer include only perforation, penetration, and bleeding. The concept of ulcer malignization is still a matter of dispute. Some insist that the absolute majority of ulcers are potentially malignant. Others reject the very idea of possible malignization. Most surgeons support the the ory of malignization by the fact that 10-19% peptic ulcers become malignant. Based on our vast experience, and supported by current morphology concepts, we declare that this is impossible. We have not observed a single case of malignization of peptic ulcer. Reported cases of malignant transformation of peptic ulcer involved those in which ulcerous cancer was not diagnosed in due time. The frequency of such cases is 13.5-15% of all ulcers of the mucous membrane of the stomach. The literature data on ulcer malignization are nothing but a lame excuse for diagnostic error [28, 37, 51].

Such errors are directly connected with an excessive confidence in endoscopy and an underestimation of the potentials of current gastroroentgen-ology. The idea of ulcer malignization only discredits endoscopy, this valuable tool of examination, which, however, is unable to give full information in all cases, despite its indisputable role in the differential diagnosis of ulceration of gastric mucosa (□ Fig. 104) [28].

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  • Hugo
    What are the basic projection for a barium meal examination?
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