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□ Fig. 147 a-g. Female patient A., age 56. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): organic changes are not detectable. b, c Stomach roentgenograms (tight filling, vertical position, left half-oblique projection), dosed compression: slight compression visualizes a depot of contrast medium on the anterior wall of the stomach body in the form of a spider surrounded by a ridge of infiltrated tissue with folds terminating at the periphery (arrows). d Stomach roentgenogram (double contrast, vertical position, left anterior oblique projection): the anterior wall of the upper third of the stomach body is thickened due to intramural infiltration (arrow); the folds converge toward the affected site. e Stomach roentgenogram (double contrast, vertical position, left lateral projection): with optimal projection, more distinctly visualized is thickening of the anterior wall of the upper third of the stomach body due to intramural infiltration (arrow) and the folds converging toward the involved part. Conclusion: Infiltrative-ulcerous cancer of the anterior wall of the upper third of the stomach body. f Macrospecimen of the resected stomach: ulceration with an atypical relief is seen on the anterior wall (arrows). g Fragment of the macrospecimen (strip): the stomach wall is thickened due to white intramural infiltration of mostly mucous and submucous coats (white arrows); initial invasion of the muscular coat (black arrow). Histologically, signet-ring cell carcinoma.

The complexity of the skiagram suggested the necessity of searching for optimal approaches to the diagnosis of cancer at this location. Some authors proposed special projections and techniques. The following seem to be the most important:

1. Left anterior oblique projection, more suitable for visualization of the pyloric ring

2. Left lateral projection

3. Posterior straight or left oblique projection in the horizontal position

In our practical work, we usually use the following techniques. Where it is necessary to examine the anterior wall of the antral part, we use tight filling of the stomach with a slightly excessive amount ofbar-ium sulfate suspension and turn the patient to the left lateral projection, taking a series of X-ray pictures under compression. The anterior wall of the stomach body is easy to image using one of the standard projections: left lateral projection in the vertical or horizontal position, both with tight filling and double contrast (□ Fig. 148).

With special emphasis on the diagnosis of cancer with its primary location on the anterior wall, we want to note once again how updated technical facilities can change our concept of the pathology under discussion. Information adequate for the preoperative establishment of diagnosis can be obtained only in cases where the methodology agrees with the technical components of the diagnostic process. As applied to infiltrative cancers located on the anterior wall, we want to discuss some problems we have encountered in our practical experience. We have observed situations in which such tumors spread to more vulnerable anatomical structures, such as the lesser curvature and the greater curvature of the stomach. Minor changes, often called partial changes on the contour, suggested early or minor cancer. But the projections used specifically for visualization of the anterior wall not only removed any doubt of the tumor, but also verified its primary location on the anterior wall. [28, 223].

Using the necessary additional methods, which differ depending on the location of the tumor in the stomach body or its antral part, we obtained quite specific signs of tumor infiltration. These included local thickening of the wall over short distances with converging folds, which produce an indistinct stellar pattern, or certain contraction, and asymmetry of mucosal relief. The signs detectable with double-contrast radiology are supplemented by the traditional signs of uneven contours in the presence of tight filling and disfiguring changes which become apparent with compression of the involved part of the stomach, if the tumor is found in the lower third of the stomach body and its antral part.

By filling the stomach with a slightly greater portion ofbarium sulfate suspension at the phase of tight filling and applying the minimal possible compression, it is possible to visualize such signs of early cancer of the anterior wall as spiders (under 0.6-0.8 cm) against the background of the relief of the anterior wall ofthe stomach (► Fig. 55). When dosed compression is applied in such situations, it is possible to see at this level a distinct (limited to 1 cm) thickening of the wall with one or two folds terminating at this level.

In other words, tight filling of the stomach with the above mentioned additional meals and dosed compression form a special complex in current radiological diagnosis which can reveal early manifestation of gastric cancer. This becomes feasible if the physician remembers that roentgenogastroenterol-ogy can give important results in diagnosis of gastric cancer, and if the radiologist disposes of sufficient knowledge and skills in using the methods and fundamental signs.

▲ Fig. 148 a.

□ Fig. 148 a, b. Patient D., age 62. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): organic changes are not detectable. b Stomach roentgenogram (double contrast, horizontal position, left lateral projection): the anterior wall of the lower third of the stomach body is thickened due to intramural infiltration with folds converging toward it (arrow). Conclusion: Minor infiltrative cancer of the anterior wall of the lower third of the stomach body. The patient was operated. Histologically, adenocarcinoma with the signet-ring cell component.

□ Fig. 149 a-d. Female patient S., age 56. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): horn-shaped stomach. b Stomach roentgenogram (double contrast, horizontal position, anterior projection): no organic changes are found; stomach walls are elastic and of normal thickness. c Stomach roentgenogram (double contrast, horizontal position, left lateral projection): anterior wall of upper third of the stomach is thickened (arrow). d Stomach roentgenogram (double contrast, vertical position, left lateral projection): anterior wall of upper third of the stomach body is thickened due to intramural infiltration with the folds converging toward it (arrow). Conclusion: Minor infiltrative cancer of the anterior wall of the stomach body. The patient was operated. Histologically, signet-ring cell carcinoma.

▲ Fig. 149 c.

The additional tools available to radiological diagnosis and the improved methodological approaches to detecting gastric cancer can provide a new assessment of the structure of tumors not only by their localization, but also, in most cases, by the character of spread of the malignant process. The accumulated material shows the necessity of revising the role of radiological examination in the early diagnosis of diffuse cancer. Potentials of radiological diagnosis are important not only to create optimal conditions for taking tissue specimens for histological examinations, but also to solve some problems in situations where endoscopy fails to supply the necessary information owing to the special nature of the blasto-matous process. In such cases, complicated diagnostic problems associated with endophytic cancers can be solved by radiological examinations, which visualize signs that can be considered sufficiently objective (D Fig. 149).

In view of what has been said, the problems of diagnosing cancer in those parts of the stomach that are inaccessible for adequate examination due to their specific anatomical features can be considered in quite a new aspect. While the studies on the anterior wall were started only recently, such anatomical parts of the stomach as the upper and the pyloric parts are discussed in any manual or study worthy of mention. These manuals and studies, however, do not consider the methodological and semiotic »supplements« to radiological examination of the stomach that we have mentioned here, made necessary by the substantial changes that have taken place in the morphogenesis of cancer and regarding its primary localization in various parts of the stomach.

The methods currently used to examine the upper part of the stomach rely on adequate impregnation of its mucous membrane with barium sulfate suspension. This is attainable by tight filling of the stomach and (in view of the specific relief of the mucous membrane) by adequate stretching of the stomach fundus using a gas-producing mixture with double contrast. Adequate selection of a projection for taking X-ray pictures is another important prerequisite to a good examination of the upper part of the stomach (□ Fig. 125). Although the current standardized method calls for inspection of this region with the patient in several positions, additional techniques must be used in each particular case in the presence of even minimal deviations from the X-ray »standard« [27, 33, 35]. The main projections for examination of the upper part of the stomach are the following:

™ Vertical position:

a. Anterior b. Left lateral

™ Horizontal plus half-vertical positions:

a. Left posterior oblique b. Left lateral c. Left anterior oblique d. Right anterior oblique

The most effective positions (as proved by practical experience) are left posterior oblique and left lateral projections with the patient in the horizontal position or half-vertical position, especially when the cardia is examined (□ Fig. 126).

▲ Fig. 125 c.

D Fig. 125 a-d. Patient K., age 68. Diagnosis: gastric cancer. According to the patient's estimate, he had been ill for a month, since the day when he first experienced difficult passage of food through the esophagus. A week earlier, epigastric pain developed, for which the patient sought medical aid. Anamnesis revealed the following: for about 8 months the patient had experienced attacks of unmotivated general weakness, occasional discomfort after ingesting solid food, which made him drink water. Later the patient adapted to a special diet and no longer felt discomfort. a Stomach roentgenogram (tight filling, vertical position, anterior projection) at the moment of contrast medium passage through the gastroesophageal junction: marked deformation of the upper part of the stomach, the wall of the lesser curvature is thickened, the abdominal segment of the esophagus is strongly disfigured and narrowed in the immediate vicinity of the cardia, its walls are uneven and rigid due to infiltration, supras-thenic dilation of the esophagus over the point of narrowing (arrows) which suggests long-standing difficult patency. b Stomach roentgenogram (double contrast, vertical position, left lateral projection) at the moment of contrast medium passage through the gastroesophageal junction: the abdominal segment of the esophagus near the cardia is narrow; atypical relief of the cardioesophageal junction. c Stomach roentgenogram (double contrast, vertical position, left lateral projection) at the moment of contrast medium passage through the gastroesophageal junction: uneven narrowing and disfiguring of the abdominal segment of the esophagus,

suprasthenic dilatation of the esophagus above the infiltrated part, a depot of contrast medium surrounded by a ridge of infiltration (arrow). d Stomach roentgenogram (double contrast, horizontal position, left lateral projection): anterior wall of the upper part is thickened due to intramural infiltration; more distinctly visualized is a depot of contrast medium surrounded by a ridge of infiltration (arrow). Conclusion: Infiltrative-ulcerous cancer of the upper part of the stomach with invasion of the esophagus. The patient was operated. Histologically, signet-ring cell carcinoma. □ Fig. 126 a-c. Female patient T., age 68. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection) at the moment of contrast medium passage through the gastroesophageal junction: moderately pronounced deformation of the subcardiac part, insignificantly shortened lesser curvature, its contour is uneven, marked deformation of the abdominal segment of the esophagus. b Stomach roentgenogram (double contrast, vertical position, left lateral projection) at the moment of contrast medium passage through the gastroesophageal junction: the abdominal segment of the esophagus is unevenly narrowed. c Stomach roentgenogram (double contrast, horizontal position, left posterior oblique projection): atypical relief of the cardiac rosette (cardioesophageal junction), the specific radiating pattern is absent. Conclusion: Infiltrative cancer of the upper part of the stomach with invasion of the esophagus. The patient was operated. Histologically, signet-ring cell carcinoma.

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▲ Fig. 126 c. ▼ Fig. 127 a.

□ Fig. 127 a-f. Female patient B., age 60. Diagnosis: gastric cancer. a Roentgenogram of upper part of the stomach (vertical position, anterior projection): the air bladder is disfigured due intramural infiltration of the upper part of the stomach, the abdominal segment of the esophagus is narrowed unevenly (arrow). b Roentgenogram of upper part of the stomach (vertical position, left lateral projection): the walls of the subcar-diac and cardiac parts are thickened due to intramural infiltration, light central spot of the ulcer crater (arrows). c Roentgenogram of upper part of the stomach (vertical position, left lateral projection) at the moment of contrast medium passage through the gastroesophageal junction: the abdominal segment of the esophagus is narrowed uneven ly, its contour is eroded and uneven (arrow), atypical relief of the cardiac cardioesophageal junction. d Roentgenogram of upper part of the stomach (double contrast, horizontal position, left lateral projection): a ridge of infiltration with the light center (arrows) is visualized in the projection of the subcardiac part and cardioesophageal junction. Conclusion: Infiltrative-ulcerous cancer of the upper part of the stomach with invasion of the esophagus. e Macrospecimen of the resected stomach: tumor tissue of the upper part of the stomach with the ulcer in the center (black arrows). Infiltration spreads onto the esophagus (white arrows). f Fragment of the macrospecimen (strip): stomach wall is thickened due to white intramural infiltration (arrows). Histologically, adenocarcinoma with the signet-ring cell component.

▲ Fig. 127 b.

Before discussing radiological semiotics, it is necessary to dwell on some aspects that are characteristic for this localization. Opinion has it that cardio-esophageal cancers are different in some aspects from tumors in other parts of the stomach. This pertains mostly to exophytic growth, considerable association with intestinal metaplasia, histological differentiation which is more conspicuous compared with cancers of other localizations in the stomach, etc. Therefore, the sign proposed by Kirklin (1939) is still considered to be the main one in roentgenolog-ical diagnosis of proximal gastric cancer. However, according to our observations, diffuse tumors generally prevail in the upper part of the stomach. We observed a predominantly intramural character of tumor propagation in more than 70% of cases of bla-stomatous affection of the upper part of the stomach. In other cases, we usually observed mixed growth of the tumor (D Fig. 127).

While appreciating the serious research conducted by many authors, we explain this phenomenon as follows. Keeping in mind the role of submucous in-filtrative cancers, we think that the tumor most probably spreads from the underlying parts (the greater curvature in particular). Infiltrative cancer known as linitis plastica, which affects the entire

stomach, has long been known. Spread of the tumor in the proximal direction was reported by T. Oka-moto et al. (1988), and Levin at al. (1990). They noted that affection of the upper part of the stomach is characteristic more of young patients than of the elderly. At the same time, the problem of diagnosing infiltrative cancer of the upper part of the stomach remains unsolved.

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