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▲ Fig. 93 a.

D Fig. 93a-d. Patient S., age 60. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): contour of the lesser curvature is uneven, the angular notch is straightened (arrows). b Stomach roentgenogram (double contrast, horizontal position, right half-oblique projection): the wall of the lesser curvature of the antral part and the body of the stomach is thickened and rigid due to intramural infiltration with marked convergence of the folds (white arrows) and a depot of contrast medium (black arrow). Conclusion: Infiltrative-ulcerous cancer of the antral part and the body of the stomach. Endoscopy revealed a 4x3-cm ulcer defect with rigid walls in the lower third of the stomach body on the lesser curvature. Histological examination of the bioptates taken from the floor of the granulating ulcer: sites of columnar epithelium; from the edges of the ulcer defect: small accumulation of proliferating epithelium against the background of inflammatory infiltration. Elements of yeast-like fungus. Tumor cells are not found. The patient was examined by MRI. c MRI of the stomach (stomach filled with water, axial projection, the level of the antral part and the body of the stomach, T2 image): anterior and posterior walls of the antral part are unevenly thickened, MR signal is heterogeneous, mostly hypointense due to intramural infiltration (arrows). d MRI of the stomach (stomach filled with water, sagittal projection, T2 image): infiltration spreads along the posterior wall to the angular notch, along the anterior wall to the middle third of the stomach body. The affection extends over 6.5 cm (arrows). Distal part of the thickened walls has eroded contours, the lumen of the pyloric part at this level is narrowed unevenly. Thickening of walls is uneven, maximum thickness to 12-15 mm. The inner contour of the affected wall is uneven, the outer contour is distinct and even. MR signal from infiltrated wall is mostly hypointense and heterogeneous. No signs of invasion of the adjacent cellular tissue. Enlarged lymph nodes are not detected. Conclusion: Infiltrative-ulcerous cancer of the antral part and the body of the stomach. Repeat endoscopy with subsequent histological examination of the bioptates revealed signet-ring cell carcinoma. This example is more evidence that one may not depend on the results of endoscopic examination alone.

D Fig. 94a-g. Patient A., age 64. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the angular notch is straightened, markedly uneven contour of the lesser curvature of the stomach body (arrows). b Stomach roentgenogram (double contrast, horizontal position, anterior projection): a depot of contrast medium (white arrow) is distinctly visualized on the posterior wall of the lower third of the stomach body surrounded with marked infiltration (black arrows). c Stomach roentgenogram (double contrast, vertical position, left lateral projection): uneven contours of the posterior wall due to intramural infiltration with an ulcer niche (arrows). Conclusion: Infiltrative-ulcerous cancer of the stomach. d Endophotograph: a ridge of infiltrated tissue of about 3 cm with ulceration in the center is seen on the posterior wall of the lower third of the stomach body. Histological studies of bioptates did not reveal tumor cells. The patient was examined by MRI. e, f MR images of the stomach (coronary and axial projections, T2 SSFSE), the lumen is narrowed in the distal part due to tumor infiltration of the lesser curvature and the adjacent anterior and (more markedly) posterior walls (arrows). g MR image of the stomach (axial projection, T2 SSFSE), ulceration in the depth of tumor infiltration on the posterior wall; hyperintense MR signal from water (arrow). Conclusion: Infiltrative-ulcerous cancer of the stomach. Histological study of numerous bioptates taken during repeated endoscopies verified non-differentiated gastric cancer

The inner contours of the wall at the level of the affection are usually uneven and tuberous. The ulcerative form of gastric cancer is characterized by the niche or depot signs - a bright hyperintensive signal visualized in the depth of the affected wall of the stomach on the T2 image and a low-intensity signal on the T1 image are characteristic of water. Ulcers usually have irregular shapes and uneven contours (□ Fig. 94).

Tumor infiltration extending beyond the limits of the stomach wall to the peri-gastric cellular tissue is characterized by indistinct outer borders of the tumor and by a reticular and band-like pattern of the perigastric cellular tissue with a heterogeneous MR signal, which is more pronounced on the T1 image. The absence of a visualized hypointensive stripe (showing the serous membrane) in tumor affection of the pyloric part may suggest infiltration of the serous membrane (□ Fig. 95) [164, 216, 243].

As the tumor spreads to the adjacent organs and structures, the border between the affected stomach wall and the organ to which infiltration spreads is absent. The intensity of the signal from tumor invasion in the involved organ corresponds to the that of the infiltrated stomach wall (□ Fig. 96).

□ Fig. 95a-i. Female patient B., age 58. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): stomach cavity strongly decreased, the stomach is disfigured (rigid tube):, its contours are uneven over the entire length (arrows). b Stomach roentgenogram (tight filling, horizontal position, left posterior oblique projection): the stomach cavity markedly decreased, the stomach is disfigured (rigid tube), its contours are uneven (arrows). c Stomach roentgenogram (double contrast, horizontal position, anterior projection): failure to distend the stomach walls by double contrast because of their rigidity due to intramural infiltration (arrows). Conclusion: Infiltrative cancer of the stomach. In order to verify the extent of tumor spreading onto the neighboring anatomical structures, the patient was given MRI examination. d MR image (sagittal projection, T2 FSE): marked thickening of all walls due to infiltration extending from the subcardiac to the pyloric part (arrows); outer contours of the affected wall are indistinct, the outer contours are uneven. e MR image (coronary projection, FSPGR out of phase); the lower border of infiltration is distinctly visualized (arrow); the pyloric part is not changed. Irregular hypointense stripe at the level of the thickened wall of the stomach on the greater curvature, which does not exclude growth into the serous membrane. Intravenous contrast enhancement. f MR image (axial projection, FSPGR out of phase, with intravenous contrast enhancement - 20 ml Magnevist); marked accumulation of contrast medium in the thickened wall of the stomach; more vivid affection of the serous membrane and spread of infiltration to left lobe of the liver (arrow). g MR image (coronary projection, FSPGR out of phase, with intravenous contrast enhancement - 20 ml Magnevist); marked accumulation of contrast medium in the thickened wall of the stomach, more obvious growth into the serous membrane of the stomach and spread of infiltration onto the pancreas (arrow). h MR image (coronary projection, FSPGR out of phase, with intravenous contrast intensification - 20 ml Magnevist); marked accumulation of contrast medium in the thickened wall of the stomach; more vivid affection of the serous membrane and spread of infiltration to transverse colon and left lobe of the liver (arrows). i MR image (sagittal projection, FSPGR out of phase, with intravenous contrast enhancement - 20 ml Magnevist); marked accumulation of contrast medium in the thickened wall of the stomach; more vivid affection of the serous membrane and spread of infiltration to the pancreas (arrows). Conclusion: Infiltrative cancer of the stomach with invasion of left lobe of the liver, pancreas, and transverse colon.

□ Fig. 96a-g. Female patient V., age 36. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): the lesser curvature is pulled up, the contours are uneven; the angular notch is straightened, a flat niche in its projection (arrow). b Stomach roentgenogram (double contrast, horizontal position, right oblique projection): a depot of contrast medium on the lesser curvature (black arrow) with pronounced convergence of infiltrated folds; wall of lesser curvature is thickened and rigid due to intramural infiltration (white arrows). c Stomach roentgeno-

▲ Fig. 96 a.

gram (double contrast, horizontal position, left half oblique projection): more distinctly visualized is thickened anterior wall closer to the lesser curvature due to intramural infiltration with convergence of the folds towards the involved part (arrows). In order to verify the spread of tumor, the patient underwent MRI. d MR image (coronary projection, position on the right side, T2 SSFSE): marked infiltration of the stomach walls in its lower half with marked deformation and circular narrowing of the lumen at this level. The cavity of the upper part is ectatic. e MR image (axial projection, FSPGR out of phase): infiltration spreads to upper parts of the stomach body by the lesser curvature. f, g MR images (coronary and axial projections, FSPGR out of phase): tumor infiltration spreads beyond boundaries of the stomach to form a single tumor conglomerate with enlarged lymph nodes of the lesser omentum and anterior and posterior pancreas; grows through the entire body and tail of the pancreas (arrows). Conclusion: Infiltrative-ulcerous cancer of the stomach with infiltration spreading to the pancreas and the lymph nodes of the abdominal cavity and the retroperitoneal space.

▲ Fig. 96 g.

As can be seen from this section on the MR signs of gastric cancer, this method falls within a stable scheme of radiological signs, although there are some specific MR signs. In our opinion, this is convincing proof of the necessity of using this method in some diagnostic situations. We are convinced that an orientation to both endoscopy and traditional radiology as basic landmarks makes it possible to use the potential of MRI in the diagnosis of stomach tumors to its maximum extent.

To conclude this section of our monograph let us emphasize some basic concepts. The condition of the stomach contours at the phase of its tight filling with barium sulfate suspension and thickening of the stomach wall in the region of its infiltration should be considered the main signs in the traditional X-ray of gastric cancer. For reliable detection of infiltration using these two signs, it is necessary to correct the entire method of conducting an X-ray examination of the stomach according to recommendations given in ► Chap. 4 and here.

Obligatory examination of a tightly filled stomach and the use of double-contrast radiology repre sent the optimal version of the traditional X-ray examination of the stomach for gastric cancer. The introduction into practical health-care systems of high-tech radiological methods markedly strengthens the role of radiological diagnosis of gastrointestinal pathologies, and gastric cancer in particular. Ultrasonography, computed tomography, and magnetic-resonance imaging used as additional methods of examination are an important contribution to the verification of blastomatous affection of the stomach and significantly enhance the role of radiological diagnosis on the whole.

Each of the methods that was introduced into radiological diagnosis during the last years of the twentieth century broadens the diagnostic potential of radiology in gastric cancer. Each of these methods has is own specific field of application in particular diagnostic situations. These include the estimation of the spread of tumor infiltration along the walls of the stomach and the adjacent anatomical structures, and some other aspects characterizing the anatomical feature of gastric cancer in each particular

It should be noted that the described signs of gastric cancer detectable with the use of these methods have one common base, depending on the same postulates that underlie the semiotics of traditional radio logy. Thus, these technologies are additional diagnostic methods, and their assessments should be based on findings of traditional radiology. Only so can their potentials be used to maximum effect. Each of these methods has its own specific features. Ultrasonography (when applied to cases of distal cancer and cancer of the lower half of the stomach body) can be used to determine sufficiently accurately the borders of tumor infiltration at the initial stage of its growth (3-4 cm). Computed tomography has the same advantages when used to examine the upper part of the stomach. MRI of the stomach has its own particular advantages.

Each of these methods makes its own specific contribution to cancer staging. They are especially helpful in cases where endoscopy and subsequent histological examination ofbioptates fail to confirm the presence of tumor infiltration because of its most minute manifestations on the mucosal surface (intramural, diffuse - endophytic cancers). Thus, discovery of a small tumor infiltration by traditional radiology supplemented by double-contrast radiology may be confirmed by ultrasonography, computed tomography, or magnetic-resonance imaging. In some cases, the results of examinations by two of these techniques are sufficient to substantiate the necessity of a radical operation.

However, despite the clear advantages of these methods in the diagnosis of gastric cancer, they should be regarded only as additional techniques, whereas traditional radiology (an integral part of modern radiological diagnosis) and endoscopy remain the main methods for effective detection of gastric cancer.

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