Carcinoma of the Stomach

Abstract

My object in reporting this case of carcinoma of the stomach is not so much that I wish to present anything particularly different from other x-ray findings but that my pre-operative diagnosis was that of a benign tumor or papilloma. This case was referred by Dr. A. J. Walscheid for roentgenographic examination Feb. 14, 1927. Roentgenoscopic examination of stomach after a barium suspension meal shows that the stomach is situated to left of median line, greater curvature is even, and is 4.5 inches below the umbilicus. On palpation near the pylorus, a distinct mass about 1.5 inches in size, not movable, is felt between the palmar surfaces of the fingers. Films taken in the upright, prone, and in the right lateral view, show that near the antrum of the stomach there is a faint irregular rarefaction, ½ × ⅞ inch in size : the first portion of duodenum is somewhat irregular. Examination, six hours after the barium suspension meal, shows a faint residue in the stomach. Rest of gastro-intestinal tract is negative. History.—Seven months ago, J. P., aged 43 years, began to have discomfort about one hour after meals, frequently vomiting his entire meal. He has lost from 13 to 20 pounds in weight; at times he gains only to lose again. Operation was performed March 10, 1927. A subtotal gastrectomy, Balfour method, jejunal-jejunostomy was performed. Report from Pathological Laboratory.—The specimen is composed of a portion of tissue removed from the pyloric extremity of the stomach. There is an ulcerated area, 3⅓ cm. in diameter at the lesser curvature. This lesion presents a definite circumscribed margin with crater-like edges. Section shows that the lesion is confined to the mucosa and does not infiltrate the submucosa. Microscopic examination has been made of sections through the edge of the ulcerated area of the pylorus, and also at the base. Examination of the structure at the edge shows that a portion of the surface is covered with mucosa and its glands, but the submucosa has been replaced by a tumor process which is characterized by atypical columnar epithelial cells with an alveolar arrangement. These cells vary in size and shape and they contain a vesicular nucleus; an occasional mitotic figure is observed. The stroma is scanty, and is densely infiltrated with round inflammatory cells and polynuclear leukocytes. In areas in which the mucosa is not observed, there is some necrosis on the surface. Microscopic examination of sections at the base shows complete absence of the mucosa and muscularis mucosa. The submucosa is completely replaced by a tumor process characterized by various sized groups of atypical epithelial tumor cells in a cellular connective tissue stroma. This process has infiltrated the muscle coats but does not extend entirely through them. Diagnosis.—On March 13, 1927, the diagnosis was carcinoma of the stomach. The patient was referred to me again on April 26, 1927, for a series of deep roentgen treatments.