Endoscopic signs of stomach cancer

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

[1], [2], [3], [4], [5],

Localization of gastric cancer

50-65% in the pyloric department (25-27% in small curvature), in the arch of the stomach - up to 2%, in the upper third - 3.4%, in the middle third - 16%, in the lower third - 36%. Total stomach damage occurs in 14% of cases.

Classification of stomach cancer

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

[6], [7], [8], [9], [10], [11], [12]

Polypoid gastric cancer

It makes up 3 to 18% of stomach tumors. This is a clearly outlined exophytally growing tumor with a wide base cylindrical or hemispherical, the size is usually 1.0 to 8.0 cm. The surface of the tumor can be smooth, knobby and knobby. The color can be greyish-greenish, with the infection - bright red. Often there are ulceration of a variety of shapes and sizes. Favorite localization: the body and the antrum, more often on a large curvature, less often on the anterior and posterior walls, very rarely on a small curvature. More often polypoid cancer is single, but can be plural (2%). Peristalsis in this area is absent, the peristalsis of the stomach as a whole is sluggish. With instrumental palpation, rigidity. At a biopsy - an insignificant bleeding.

Characteristic signs of polypoid stomach cancer

In single sites and the absence of infiltration, polypoid gastric cancer is difficult to differentiate from a benign tumor. With infiltration of the base of the foot, the tumor acquires a smoothing of the transition zone of the base to its surface ("waist"), forming a cylindrical elevation that precedes the base of the polyp along the periphery. In connection with the tendency to decay on the surface, early erosion and foci of hyperplasia are formed in the form of small knobs that swell above the surface of the polyp tissue, a knobby surface. With biopsy, increased bleeding, "fragmentation" of tissues. A biopsy confirms the true nature of tumor growth.

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

[13], [14]

Saucer-like stomach cancer

It constitutes 10 to 40% of stomach tumors. Localization: antral section, often along the front wall, large curvature, less often - along the back wall. The tumor looks like a saucer. Dimensions from 2.0 to 10.0 cm. Looks like a deep ulcer with high, wide, dented edges in the form of a tree, the height of which is not the same, the edges are tuberiform. The bottom is uneven, hilly, covered with a raid from dirty gray to brownish-black color, swims to the edges in the form of a crest.

Mucous around is not infiltrated. Peristalsis around is absent. With instrumental palpation, the edges are rigid. At a biopsy the bleeding is insignificant.

Infiltrative cancer ulcer

It is from 45 to 60%. Localization: small curvature of any part of the stomach. It looks like an ulcer with fuzzy, eroded contours, irregular in shape. Dimensions from 2.0 to 6.0 cm. The bottom of the ulcer is tuberous with a dirty gray coating. Inflammatory shaft around is absent or indistinctly expressed; in the latter case, it never completely surrounds the entire ulcer, and its tuberous bottom directly passes into the surrounding mucous membrane. This is the main difference between an infiltrative ulcer and a saucer-like cancer. The folds converge to the ulcer, but break off, not reaching it. The relief of the mucous membrane is frozen due to cancer infiltration: the folds are rigid, wide, low, not straightened by air, peristaltic waves can not be traced. With instrumental palpation, the edges are rigid. At a biopsy - an insignificant bleeding.

It is 10-30% of stomach tumors. With submucosal tumor growth, endoscopic diagnosis of this type of cancer is rather difficult and is based on indirect signs: rigidity of the organ wall at the site of injury, subtle smoothness of the relief and pale color of the mucous membrane. When involved in the process of the mucosa, a typical endoscopic picture of the "malignant" relief develops: the affected area somewhat bulges, the folds are fixed, frozen, poorly inflated by air, the peristalsis is reduced or absent, the mucous membrane,

Diffusive infiltrative stomach cancer

The color of the affected area can be bright pink or red, intra-ulcer hemorrhages, erosion and even ulcers are observed. Such an endoscopic picture of infiltrative cancer can be associated with the attachment of infection and the development of inflammatory infiltration. In these cases, infiltrative cancer is visually difficult to differentiate from the local form of superficial gastritis and benign ulceration, especially in the proximal part of the stomach. The acute acute ulceration that occurs during the subsidence of the inflammatory phenomena can heal. This should always be remembered and a biopsy of all acute ulcers.

In diffuse infiltrative cancer, the elasticity of the organ wall and the narrowing of its cavity are noted. When the process spreads, the stomach turns into a narrow, low-yielding tube. Even a small injection of air is accompanied by its regurgitation and painful sensations.

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Early forms of stomach cancer

The Japanese Society of Endoscopists (1962) proposed the classification of early forms of gastric cancer ("Early gastric cancer"), which refers to 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, stomach cancer can remain for up to 8 years, after which the infiltration begins to penetrate deep. Postoperative 5-year survival in mucosal carcinomas is 100%, with submucosal lesions - up to 83%.

Localized most often on a small curvature and in the middle 1/3 of the stomach (50%). Endoscopically and at a biopsy to establish the diagnosis very hardly, it is possible to suspect only the early form of a cancer. To establish the diagnosis, excision of the mucosa is necessary with subsequent histological examination.

According to the classification, three types of early gastric cancer are distinguished:

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

For type I (speaker cancer) include exophytic polypoid growths size of 0.5-2.0 cm unexpressed or short stalk, wide base, flat or concave tip. Their color is usually brighter than the color of the surrounding mucosa, which is to a certain extent due to hemorrhages and ulceration. With instrumental "palpation" and biopsy, bleeding occurs. Neoplasm usually shifts along with the mucosa relative to underlying tissues.

Subtype IIa (elevated cancer) is a surface formation that rises 3-5 mm above the surface of the mucosa in the form of a plateau, often having hemorrhages, areas of necrosis and indentations. This subtype is rare (up to 4%). More often the tumors have a depression in the center and a bulging along the edges. The color of the tumor differs little from the color of the surrounding mucosa, and therefore can not be detected. For better visualization it is necessary to stain with indigo carmine.

Subtype IIb (flat cancer) is presented in the form of a condensed section of the mucous membrane of a rounded shape, devoid of the typical relief of the mucous membrane, rigid with instrumental palpation. The zone of discoloration delineates the area of the lesion. This type is the least common, probably because of the complexity of its diagnosis.

Subtype IIc (crushed cancer) is characterized by visually clearly delineated flat erosive fields, located 5 mm below the level of the mucosa, which have uneven, well-delimited edges. In the lesion focus there is no gloss, characteristic for the mucous membrane, as a result of which it acquires the appearance of a moth eaten. In the area of the depression, parts of the intact mucosa in the form of islets and uneven protrusions are found. The base is often bleeding. The surrounding folds are "frozen", converge toward the tumor in the form of rays.

Type III (deepened (undercut) cancer) is a rare form that is not distinguishable from endoscopy from a peptic ulcer. It is a defect of the mucous membrane with a diameter of up to 1-3 cm with irregularly thickened stiff margins protruding above the surface of the mucous membrane and an uneven bottom, the depth of which may be more than 5 mm. This type is more often found not in pure form, but in combination with others.

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

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

Visual diagnosis of early forms of gastric cancer and differential diagnosis of them with benign polyps and ulcers is very difficult due to the lack of typical endoscopic features. For proper and timely diagnosis, additional endoscopic techniques (biopsy, chromo-strocopy) are necessary.

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