Endoscopic signs of gastric cancer

In Ukraine, stomach cancer ranks second among men and third among women among oncological diseases.

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Localization of gastric cancer

50-65% in the pyloroantral region (25-27% along the lesser curvature), in the vault of the stomach - up to 2%, in the upper third - 3.4%, in the middle third - 16%, in the lower third - 36%. Total damage to the stomach occurs in 14% of cases.

Classification of gastric cancer

1. Polypoid carcinoma (Bormann I).
2. Non-infiltrative cancerous ulcer (saucer-shaped cancer, Bormann II).
3. Infiltrative cancerous ulcer (Bormann III).
4. Diffuse infiltrative cancer (solid cancer, Bormann IV).

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Polypoid gastric cancer

It accounts for 3 to 18% of gastric tumors. It is a clearly defined exophytic tumor with a wide base, cylindrical or hemispherical in shape, usually ranging in size from 1.0 to 8.0 cm. The tumor surface may be smooth, bumpy, or nodular. The color may be grayish-greenish, or bright red when infected. Ulcers of various shapes and sizes are common. The favorite location is the body and antral section, most often on the greater curvature, less often on the anterior and posterior walls, and very rarely on the lesser curvature. Polypoid cancer is most often solitary, but may be multiple (2%). Peristalsis in this area is absent, and gastric peristalsis is generally sluggish. Rigidity is observed on instrumental palpation. Minor bleeding is observed on biopsy.

Characteristic signs of polypoid gastric cancer

In case of single nodes and absence of infiltration, polypoid gastric cancer is difficult to differentiate from a benign tumor. When the base of the stalk is infiltrated, the tumor acquires a smoothed transition zone of the base to its surface ("waist"), forming a ridge-like elevation preceding the base of the polyp along the periphery. Due to the tendency to decay, erosions and foci of hyperplasia in the form of small nodes bulging above the surface of the polyp tissue - a tuberous surface - are formed early on the surface. Biopsy reveals increased bleeding, "fragmentation" of tissue. Biopsy confirms the true nature of tumor growth.

To increase the probability of establishing a correct histological diagnosis, it is advisable to take a biopsy from several places of the suspicious mucous membrane. This is due to the fact that gastric tumors are usually surrounded by inflammatory tissues, and necrosis is often detected in the center of the tumor. Quite often, histological examination of tissue taken during biopsy in altered areas of the mucous membrane in the area of a malignant tumor does not reveal cancer cells. For example, with a biopsy performed only at one point of a malignant gastric ulcer, the probability of establishing a correct diagnosis is 70%, and with a biopsy performed at eight points, this probability increases to 95-99%. When using more than eight points for biopsy, the probability of establishing a correct diagnosis does not increase. It is also advisable to take a biopsy from the same place several (2-3) times to obtain material from deeper layers.

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Saucer-shaped gastric cancer

It accounts for 10 to 40% of gastric tumors. Localization: antral section, more often along the anterior wall, greater curvature, less often - along the posterior wall. The tumor has the shape of a saucer. Sizes from 2.0 to 10.0 cm. It looks like a deep ulcer with high, wide, undermined edges in the form of a shaft, the height of which is not the same, the edges are bumpy. The bottom is uneven, bumpy, covered with a coating from dirty gray to brown-black color, flows to the edges in the form of a ridge.

The surrounding mucosa is not infiltrated. There is no peristalsis around. The edges are rigid during instrumental palpation. There is minor bleeding during biopsy.

Infiltrative cancerous ulcer

It accounts for 45 to 60%. Localization: lesser curvature of any part of the stomach. It looks like an ulcer with unclear, corroded contours, irregular shape. Sizes from 2.0 to 6.0 cm. The bottom of the ulcer is bumpy with a dirty gray coating. The inflammatory ridge around is absent or not clearly expressed, in the latter case it never completely surrounds the entire ulcer, and its bumpy bottom directly passes into the surrounding mucous membrane. This is the main difference between an infiltrative ulcer and a saucer-shaped cancer. The folds converge to the ulcer, but break off before reaching it. The relief of the mucous membrane is frozen due to cancerous infiltration: the folds are rigid, wide, low, do not straighten with air, peristaltic waves are not traced. During instrumental palpation, the edges are rigid. During biopsy - minor bleeding.

It accounts for 10-30% of gastric tumors. With submucous tumor growth, endoscopic diagnostics of this type of cancer is quite difficult and is based on indirect signs: rigidity of the organ wall at the site of the lesion, barely perceptible smoothness of the relief and pale color of the mucous membrane. When the mucous membrane is involved in the process, a typical endoscopic picture of a "malignant" relief develops: the affected area bulges slightly, the folds are motionless, frozen, do not straighten out well with air, peristalsis is reduced or absent, the mucous membrane is "lifeless", the color of which is dominated by gray tones.

Diffuse infiltrative gastric cancer

The affected area may be bright pink or red, intramucosal hemorrhages, erosions and even ulcers are observed. Such an endoscopic picture of infiltrative cancer may be associated with the addition of an infection and the development of inflammatory infiltration. In these cases, infiltrative cancer is visually difficult to differentiate from a local form of superficial gastritis and benign ulcers, especially in the proximal part of the stomach. Acute ulcers that arise may heal when the inflammatory phenomena subside. This should always be remembered and a biopsy of all acute ulcers should be performed.

In diffuse infiltrative cancer, the elasticity of the organ wall decreases and its cavity narrows. As the process spreads, the stomach turns into a narrow, inflexible tube. Even a small inhalation of air is accompanied by regurgitation and painful sensations.

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Early forms of stomach cancer

The Japanese Society of Endoscopists (1962) proposed a classification of early gastric cancers, which are understood as carcinomas localized in the mucosa and submucosal layer, regardless of the area of their spread, the presence of metastases in regional lymph nodes and histogenesis. At this early stage, gastric cancer can remain for up to 8 years, after which infiltration begins to penetrate into the depth. The postoperative 5-year survival rate for mucosal carcinomas is 100%, for submucosal lesions - up to 83%.

They are most often localized on the lesser curvature and in the middle 1/3 of the stomach (50%). It is very difficult to establish a diagnosis endoscopically and by biopsy; one can only suspect an early form of cancer. To establish a diagnosis, excision of the mucosa with subsequent histological examination is necessary.

According to the classification, there are three types of early stomach cancer:

1. Type I - protruding (protruded type);
2. Type II - superficial (superficial type), subdivided into subtypes:
   1. elevated type,
   2. flat type,
   3. depressed type,
3. Type III - excavated type.

Type I (protruding cancer) includes exophytic polypoid neoplasms measuring 0.5-2.0 cm with an indistinct or short stalk, a wide base, and a flat or retracted apex. Their color is usually brighter than the color of the surrounding mucous membrane, which is to some extent due to hemorrhages and ulcerations. Bleeding occurs during instrumental "palpation" and biopsy. The neoplasm usually shifts together with the mucous membrane relative to the underlying tissues.

Subtype IIa (elevated cancer) is a superficial formation, rising 3-5 mm above the surface of the mucous membrane in the form of a plateau, often with hemorrhages, areas of necrosis and depressions. This subtype is rare (up to 4%). Most often, tumors have a depression in the center and bulging at the edges. The color of the tumor differs little from the color of the surrounding mucous membrane, and therefore may not be detected. For better visualization, staining with indigo carmine is necessary.

Subtype IIb (flat cancer) appears as a compacted area of the mucous membrane, round in shape, lacking the typical relief of the mucous membrane, rigid on instrumental palpation. A zone of discoloration outlines the area of the lesion. This type is the least common, probably due to the difficulty of diagnosing it.

Subtype IIc (depressed cancer) is characterized by visually clearly defined flat erosive fields located 5 mm below the level of the mucous membrane, with uneven, well-defined edges. The lesion lacks the luster characteristic of the mucous membrane, as a result of which it acquires a moth-eaten appearance. In the area of the depression, areas of intact mucous membrane are found in the form of islands and uneven protrusions. The base is often bleeding. The surrounding folds are "frozen", converging towards the tumor in the form of rays.

Type III (deep (undermined) cancer) is a rare form, indistinguishable from a peptic ulcer during endoscopic examination. It is a mucosal defect up to 1-3 cm in diameter with unevenly thickened rigid edges protruding above the surface of the mucosa, and an uneven bottom, the depth of which can be more than 5 mm. This type is more often found not in its pure form, but in combination with others.

In addition to those described above, early forms of cancer include initial cancer in a polyp and malignant chronic ulcers.

Metastases of early cancer localized in the mucous membrane are rare. Their frequency can still reach 5-10%, and with localization of malignant infiltration in the submucosal layer - up to 20%. The size of the tumor is important in determining the frequency of metastases and the prognosis of the disease. The diameter of the lesion in early forms of gastric cancer usually does not exceed 2 cm. However, foci of significantly larger sizes have been described. Tumors with a diameter of less than 2 cm are usually operable.

Visual diagnostics of early forms of gastric cancer and their differential diagnostics with benign polyps and ulcers is very difficult due to the absence of typical endoscopic signs. For correct and timely diagnostics, it is necessary to use additional endoscopic methods (biopsy, chromogastroscopy).

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