Staging

Postoperative management of patients requires accurate determination of the stage and grade of gastric cancer. Sometimes, early carcinoma recurs in the stump of the operated stomach, either as a second primary tumor or as a result of the operation which was performed without removal of the adjacent healthy tissue [191]. According to some authors, relapses are more common in patients with the elevated type of early carcinoma and with the exophytic form of tumor growth [139, 171].

The DNA content of tumor cells evaluated by flow cytometry has certain prognostic importance.

□ Fig. 15. Fragment of a microspecimen of gastric mucosa. Glands affected by severe dysplasia and foci of cancer in situ can be seen in the upper part of the microphotograph (A). Tunica muscularis propria of the mucous membrane (B). Marked sclerosis of the submucous membrane (C). Hematoxylin and eosin, x50

□ Fig. 15. Fragment of a microspecimen of gastric mucosa. Glands affected by severe dysplasia and foci of cancer in situ can be seen in the upper part of the microphotograph (A). Tunica muscularis propria of the mucous membrane (B). Marked sclerosis of the submucous membrane (C). Hematoxylin and eosin, x50

□ Fig. 16. Fragment of a microspecimen of gastric mucosa. Glands affected by severe dysplasia and foci of cancer in situ can be seen in the upper part of the microphotograph (A). Tunica muscularis propria of the mucous membrane (B). Marked edema of the submucous membrane (C). Hematoxylin and eosin, x50

□ Fig. 16. Fragment of a microspecimen of gastric mucosa. Glands affected by severe dysplasia and foci of cancer in situ can be seen in the upper part of the microphotograph (A). Tunica muscularis propria of the mucous membrane (B). Marked edema of the submucous membrane (C). Hematoxylin and eosin, x50

Gastric carcinoma may be diploid (68.4%), aneu-ploid (14.8%), or mixed (12.9%), or it may contain complex aneuploid cell populations (3.7%). All cancers contain polypoid populations, but early cancer normally has fewer polypoid cells compared with advanced cancer. Statistics suggest that a correlation exists between metastases and high DNA content [161].

Examination of a great number of tissue specimens of the stomach resected for early cancer shows that in 60% of cases, sclerosed submucous membrane displaces the muscular coat, or grows over it, in the area of growing carcinoma (under the tumor or in its immediate vicinity; D Fig. 15) [111]. In 15% of cases these changes occur at some distance from the tumor, where atrophy of the mucous membrane of varying degree and also dysplasia of the integumentary epithelium may develop. The structure of newly formed connective tissue is dissimilar in such cases, probably dependent on the different mechanisms and duration of its formation. Fibrous and, less fre quently, cellular connective tissues are formed. This process is usually associated with chronic inflammation or is interpreted as a response to metabolites of anaplastic cells and products of their decay [157]. But other mechanisms are also possible. It is quite probable that such tissue can be formed in the presence of persistent edema followed by hyalinosis (D Fig. 16).

In addition to the described changes in the sub-mucous membrane of the stomach, in 17% of early cancer cases, the walls of the intramural vessels (mostly in the submucous membrane) thicken at the expense of the muscular coat and sclerosed inner coat, to narrow the vessel lumen (D Fig. 17). Such changes do not depend on the stage of carcinoma, histological type, or localization of the tumor in the stomach, or on the age and gender of the patient. In addition, the intravisceral veins remain without visible pathological changes.

The described hyperplastic changes associated with early gastric carcinoma inevitably cause mac-

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