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Coexisting Ulcer and Cancer of the Stomach
COEXISTING ULCER AND CANCER OF THE STOMACH HARRY YARNIS, M.D.~
THE presence of a benign ulcer and an independent carcinoma in the same stomach is an unusual occurrence. The following three cases were admitted to the Gastric Surgical Service of the Mount Sinai Hospital within three years. CASE I.-F. M., a Puerto Rican male, aged 55 years, was admitted January is, 1941. For two years he had been subject to attacks of left upper quadrant pain beginning soon after meals and persisting for two hours. At the onset the pain recurred once weekly; during the four months preceding admission the pain was more frequent and severe, and was associated wth abdominal distention and vomiting. The vomitus was never bloody or foul. Bowel movements were regular and he passed an occasional tarry stool. Anorexia was marked and he lost 45 pounds. Fifteen years previously he had received intravenous and intramuscular injections, and ten years before this admission he was hospitalized for an extensive bilateral pneumonia. At that time the blood Wassermann was negative and he had no digestive complaints. Physical examination revealed a poorly nourished male, presenting evidence of marked weight loss. The heart, lungs and blood pressure were normal. The abdomen was soft; no mass was palpated. In the right axilla a firm lymph node was palpated. This was biopsied and revealed no evidence of tumor cells. The clinical impression was that this patient was suffering from a gastric malignancy. Examination of the blood revealed 64 per cent hemoglobin, S,800,000 erythrocytes, 6000 leukocytes with 45 per cent polymorphonuclear leukocytes, 43 per cent lymphocytes, 9 per cent monocytes and 3 per cent eosinophils. The stool contained occult blood. Gastric analysis after the Rehfuss test meal revealed a free acidity of 16 and a total acidity of 38. The blood Wassermann was negative. The blood chlorides were 560 mg. per 100 cc. and the carbon dioxide combining power was 71 volumes per 100 cc. Roentgen examination of the stomach after a barium meal revealed complete retention of the barium at the six hour observation. The antrum was incompletely visualized due to marked retention of food. The duodenal bulb was not visualized. The x-ray appearance suggested complete pyloric obstruction due to an organic lesion. The exact location of the lesion and whether it was benign or malignant could not be determined from this examination (Fig. 149). Gastroscopic examination of the stomach revealed an ulcer about 2 cm. wide, on the lesser curvature at the angularis. The margin of the ulcer was sharply From the Surgical Service of Dr. Ralph Colp, Mount Sinai Hospital, New York City. " Instructor in Medicine, Post-Graduate School of Medicine, Columbia University; Adjunct Gastroenterologist, Mount Sinai Hospital; Adjunct Surgeon for Peroral Endoscopy, Montefiore Hospital. 299
300
HARRY YARNIS
delimited and there were a few rugae radiating directly to the edge. This appearance was typical of a benign healing ulcer. Peristalsis was absent and the distal half of the antrum was not visualized.
Fig. 149.-Pyloric carcinoma causing complete gastric retention and benign ulcer at the re-entrant angle. The patient was treated wth antispasmodics, daily gastric lavages and intravenous blood and fluids. He gained 6 pounds, but his gastric retention still exceeded 500 cc., so that surgical exploration was perfo~ed. Laparotomy revealed a large mobile pyloric neoplasm adherent to the pancreas, and at the re-entrant angle there was a thickening which subsequently proved to be the
COEXISTING ULCER AND CANCER OF STOMACH
301
scar of a healed ulcer. A subtotal gastrectomy and gastrojejunostomy with the aid of a Murphy button were performed. Pathologic examination of the stomach revealed an ulcerated cauliflower mass in the pyloric region. This tumor encircled the entire pylorus and invaded the stomach wall completely. Numerous enlarged lymph nodes were found in the attached omentum. On the lesser curvature at the re-entrant angle was a shallow ulcer. Five centimeters of normal mucous membrane separated the ulcer from the prepyloric carcinoma. The pathologic diagnosis was infiltrating adenocarcinoma of the stomach with metastatic involvement of the gastric lymph nodes and a chronic peptic benign ulcer where no tumor cells were seen. The patient failed to report one year later to the follow-up clinic, and presumably died.
Comment.-The anorexia, vomiting, weight loss and cachexia produced a clinical picture suggestive of malignancy. This diagnosis was supported by the anemia, hypoacidity and blood in stool. Gastric x-rays revealed an almost complete pyloric obstruction, the nature of which could not be definitely determined. Gastroscopy revealed a benign healing ulcer. Despite daily lavages, a high degree of gastric retention persisted, and surgical intervention was necessary. CASE II.-L. P., a white man aged 64 years, was admitted September 20, 1943. For one year he had noticed burning epigastric pain recurring with hunger and relieved by food. The pain became progressively worse and frequently radiated to the back. Six weeks before admission he began to vomit; the vomiting recurred twice weekly and relieved the epigastric burning. The vomitus was never bloody. Bowels were constipated but there was no rectal bleeding. His appetite was poor and he lost 15 pounds in six months. He had undergone a right hernioplasty fourteen years previously. Chest x-ray disclosed a healed bilateral apical tuberculosis. Physical examination revealed a well developed Italian male and was essentially negative except for a recurrent inguinal hernia. Examination of the blood revealed 93 per cent hemoglobin, 5,100,000 erythrocytes and 7900 leukocytes with 65 per cent polymorphonuclear leukocytes, 33 per cent lymphocytes, and 2 per cent monocytes. The guaiac test of the stools was negative. Gastric analysis after the Rehfuss test meal revealed a free acidity of 56 and a total acidity of 70. The blood chlorides were 610 mg. per 100 cc. and the carbon dioxide combining power was 60 volumes per 100 cc. Gastrointestinal examination by means of a barium meal performed before he entered the hospital revealed a dilated stomach with a large ulcer crater on the lesser curvature of the body above the re-entrant angle. There was also a rather constant narrowing of the prepyloric region. The roentgen appearance suggested a benign gastric ulcer and the antral deformity was interpreted as due to spasm. There was a 30 per cent residue at the six hour observation (Fig. 150). Gastroscopy revealed an ulcer about 2.5 cm. wide on the lesser curvature just proximal to the angularis. The ulcer margin was sharp but reddened. On the posterior wall of the corpus near this ulcer there was a similar superfIcial ulcer about 5 mm. wide. The entire gastric mucosa was markedly reddened, edematous
302
HARRY YARNIS
and covered with translucent exudate. Peristalsis was sluggish and appeared to progress to the pylorus. The gastroscopic impression was active benign gastric ulceration with severe superficial gastritis.
,I
Fig. 150.-Benign ulcer above re-entrant angle and infiltrating prepyloric carcinoma. Because of the gastritis and gastric retention, the patient was treated with daily lavages for two weeks and then subjected to exploration. On the night before operation the gastric retention was 700 cc. Laparotomy revealed a distinct thickening at the re-entrant angle and adhesions around the pylorus and duodenum. The entire gastric wall was thickened and edematous. This thickening
COEXISTING ULCER AND CANCER OF STOMACH
303
was most pronounced in the prepyloric region, but the serosa here appeared normal. A subtotal gastrectomy and jejunostomy for alimentation were performed. Pathologic examination revealed a reddened gastric mucosa covered with bloodstained mucus. An ulcer measuring 1.5 cm. in diameter was found straddling the lesser curvature at the re-entrant angle. On the posterior wall near this ulcer was a stellate scar. The mucosa was freely movable everywhere except for the region 1.5 cm. proximal to the pylorus. Here the mucosa was fixed, firm and presented a serpiginous elevation which encircled the pylorus. The ulcers were separated from the carcinoma by 6 cm. of normal mucosa. The pathologic diagnosis was infiltrating adenocarcinoma of the prepylorus and chronic peptic ulcer of the lesser curvature. No involved lymph nodes were found. This patient was symptom-free when seen in May, 1946.
Comment.-Despite the advanced age of the patient, the clinical aspects favored a benign lesion. The normal blood picture, hyperacidity and absence of blood in the stool were consistent with this diagnosis. Roentgen studies revealed a large dilated stomach with a benign ulcer at the incisura angularis. There was a prepyloric defect and a 30 per cent six hour residue. These were explained as due to reflex antral spasm. Gastroscopically, multiple gastric ulcers and a severe superficial gastritis were observed. On intensive ulcer therap) including lavages, the retention rose from 600 cc. to 700 cc. and operation was necessary. CASE IlL-H. B., a white man aged 58 years, was admitted on November 22, 1943. Eight years previously he had recurrent epigastric pain which was treated with diet and twenty-four daily injections. The pain disappeared after two months and he was relatively asymptomatic until eighteen months before this admission. Then the epigastric pain recurred almost daily for three months. He was again symptom-free until two weeks before he was admitted. The pain recurred two to three hours postprandially and was promptly relieved by food. He had one episode of nausea and vomiting associated with the pain during the last recurrence. His appetite was poor and he lost 9 pounds. The bowels were regular and there was no rectal bleeding. Physical examination revealed a well nourished male and a firm lymph node was palpated in the left axilla. This was biopsied and showed no involvement by tumor. The heart and lungs were normal. There was a sense of resistance in the right epigastrium but no definite mass was palpated. Examination of the blood revealed 84 per cent hemoglobin, 11,500 leukocytes with 83 per cent polymorphonuclear leukocytes, 13 per cent lymphocytes, 2 per cent monocytes and 2 per cent eosinophils. The guaiac test of the stools was negative. Gastric analysis after a Rehfuss test meal revealed a free acid of 16 and a total acid of 40. Roentgen examination of the stomach after a barium meal performed before he entered the hospital revealed a shallow projection from the' lesser curvature at the region of the re-entrant angle. There was a slight irregularity of the lesser curvature on each side of this ulceration, which measured 2.5 cm. in diameter. Opposite the latter on the greater curvature and posterior wall of the corpus, there was a filling defect about 3 cm. wide. In the center of this defect was a
304
HARRY YARNlS
projection, apparently an ulcer crater (Fig; 151). There was no residue at the six hour observation. Gastroscopy revealed a large ulcerating lesion on the posterior wall adjoining the lesser curvature. The edges appeared everted and the distal margin was at the angularis. Because of the marked friability and bleeding of the tissue on the
Fig. 151.-Ulcerated infiltrating carcinoma on greater curvature and shallow benign ulcer at re-entrant angle. posterior wall, the upper limits of the ulcer were not visualized. The gastroscopic impression was that the lesion was a large carcinomatous ulcer. At operation the stomach was found to be the seat of a carcinomatous ulceration on the greater curvature, and a distinct lesion on the les~er curvature opposite this which was also suspected as being a carcinoma. Because of the extent
COEXISTING ULCER AND CANCER OF STOMACH
305
of the carcinoma and the extensive involvement of the lesser curvature lymph nodes to the cardia, a total gastrectomy with esophagojejunostomy and jejunostomy for alimentation was performed. The patient made an uneventful recovery and was discharged from the hospital on the thirty-third postoperative day. The resected specimen consisted of the entire stomach from pylorus to cardia and in the region of the greater curvature 10 cm. proximal to the pylorus there was a Hat tumor mass 5 cm. wide. Its surface presented small irregular ulcerations. On section the tumor tissue showed streaky infiltration into the muscularis. Opposite this on the lesser curvature there was a separate ulcer with a grayishwhite base and a firm, slightly raised edge. There was an area of normal mucosa measuring 3 cm. between the ulcer and the cancer. The attached lesser and
Fig. 152.-Totally resected stomach with large peptic ulcer and infiltrating scirrhous carcinoma. greater omenta contained numerous nodes with irregular whitish areas, which suggested gross involvement by tumor. The pathologic diagnosis was infiltrating scirrhous carcinoma with involvement of the gastric lymph nodes and a large chronic peptic ulcer (Fig. 152). This patient was on a regular diet and worked hard for two years, when he died suddenly. Cause of death was infarction of the entire small intestine due to mesenteric thrombosis secondary to torsion about an adhesion. Postmortem examination revealed no evidence of metastases.
Comment.-The episode of epigastric pain eight years previously, and perhaps that one of eighteen months before, suggested the pos-
306
HARRY YARNIS
sibility of a long-standing peptic ulcer. The recent weight loss and anorexia, however, were suggestive of malignancy. The laboratory findings were equivocal. The blood picture was normal and the stools were guaiac negative; but there was a hypoacidity. Both x-ray and gastroscopic studies suggested malignancy. DISCUSSION
Two cases presented here were associated with the clinical picture of typical malignancy and the third appeared to have a benign ulcer. The laboratory findings were consistent with these diagnoses except in the third case in which blood was absent from the stools. In both of the cases with pyloric obstructions there was no alkalemia. Antral spasm secondary to ulceration above the incisura angularis may cause mild degrees of gastric retention. However, high-grade pyloric obstruction, causing six hour residues exceeding 50 per cent of the ingested barium meal, must be due to a pyloric or juxtapyloric lesion. In the first case the complete pyloric obstruction could not be attributed to the healing ulcer at the angularis. In the second case the gastric retention which persisted despite the healing of both corporic gastric ulcers should suggest, therefore, an associated benign or malignant juxtapyloric lesion. It is well to remember that in about 8 per cent of cases gastric ulcers are associated with duodenal ulcers. Resected specimen of the first case revealed the scar of a healed ulcer. In the second case the larger ulcer decreased to one-half its former size and the smaller ulcer healed, despite the presence of a prepyloric carcinoma. This is in contrast to the observation of Bockus, who noted the absence of healing of ulcers distant from the pylorus when there was a persistent or high-grade pyloric stenosis. In the third case, when the ulcer and the carcinoma were in the body of the stomach, no healing of the large peptic ulcer was observed. Gastroscopically, a small benign ulcer was discovered in the first case. The prepyloric region was not visualized because the pylorus was fixed to the posterior abdominal wall by an adherent carcinoma. In the second case, multiple benign ulcers and a severe gastritis were observed. The marked edema, producing a swollen, boggy mucosa, was sufficient to mask any mucosal abnormality caused by the infiltrating neoplasm. The gastroscopist in the third case noted a large ulcer with an irregular margin, erroneously suggesting a carcinomatous ulcer. In addition, the presence of a typical infiltrating neoplasm only 3 cm. away produced the gastroscopic picture of an extensive malignancy with ulceration.
COEXISTING ULCER AND CANCER OF STOMACH
S07
SUMMARY
I
I,
1. Peptic ulcers above the incisura angularis may cause mild degree of gastric retention. 2. Gastric retention exceeding 50 per cent of the ingested barium meal should suggest a benign or malignant pre- or postpyloric lesion. S. Persistent gastric retention should not be attributed to an ulcer at a distance froin the pylorus, particularly when healing of the ulcer is observed. 4. Peptic ulcers in the body of the stomach may heal in the presence of a malignant growth causing pyloric obstruction. 5. When the clinical picture is atypical the presence of a benign gastric ulcer should not preclude search for an independent carcinoma which does not originate in the ulcer.
THE presence of a benign ulcer and an independent carcinoma in the same stomach is an unusual occurrence. The following three cases were admitted to the Gastric Surgical Service of the Mount Sinai Hospital within three years. CASE I.-F. M., a Puerto Rican male, aged 55 years, was admitted January is, 1941. For two years he had been subject to attacks of left upper quadrant pain beginning soon after meals and persisting for two hours. At the onset the pain recurred once weekly; during the four months preceding admission the pain was more frequent and severe, and was associated wth abdominal distention and vomiting. The vomitus was never bloody or foul. Bowel movements were regular and he passed an occasional tarry stool. Anorexia was marked and he lost 45 pounds. Fifteen years previously he had received intravenous and intramuscular injections, and ten years before this admission he was hospitalized for an extensive bilateral pneumonia. At that time the blood Wassermann was negative and he had no digestive complaints. Physical examination revealed a poorly nourished male, presenting evidence of marked weight loss. The heart, lungs and blood pressure were normal. The abdomen was soft; no mass was palpated. In the right axilla a firm lymph node was palpated. This was biopsied and revealed no evidence of tumor cells. The clinical impression was that this patient was suffering from a gastric malignancy. Examination of the blood revealed 64 per cent hemoglobin, S,800,000 erythrocytes, 6000 leukocytes with 45 per cent polymorphonuclear leukocytes, 43 per cent lymphocytes, 9 per cent monocytes and 3 per cent eosinophils. The stool contained occult blood. Gastric analysis after the Rehfuss test meal revealed a free acidity of 16 and a total acidity of 38. The blood Wassermann was negative. The blood chlorides were 560 mg. per 100 cc. and the carbon dioxide combining power was 71 volumes per 100 cc. Roentgen examination of the stomach after a barium meal revealed complete retention of the barium at the six hour observation. The antrum was incompletely visualized due to marked retention of food. The duodenal bulb was not visualized. The x-ray appearance suggested complete pyloric obstruction due to an organic lesion. The exact location of the lesion and whether it was benign or malignant could not be determined from this examination (Fig. 149). Gastroscopic examination of the stomach revealed an ulcer about 2 cm. wide, on the lesser curvature at the angularis. The margin of the ulcer was sharply From the Surgical Service of Dr. Ralph Colp, Mount Sinai Hospital, New York City. " Instructor in Medicine, Post-Graduate School of Medicine, Columbia University; Adjunct Gastroenterologist, Mount Sinai Hospital; Adjunct Surgeon for Peroral Endoscopy, Montefiore Hospital. 299
300
HARRY YARNIS
delimited and there were a few rugae radiating directly to the edge. This appearance was typical of a benign healing ulcer. Peristalsis was absent and the distal half of the antrum was not visualized.
Fig. 149.-Pyloric carcinoma causing complete gastric retention and benign ulcer at the re-entrant angle. The patient was treated wth antispasmodics, daily gastric lavages and intravenous blood and fluids. He gained 6 pounds, but his gastric retention still exceeded 500 cc., so that surgical exploration was perfo~ed. Laparotomy revealed a large mobile pyloric neoplasm adherent to the pancreas, and at the re-entrant angle there was a thickening which subsequently proved to be the
COEXISTING ULCER AND CANCER OF STOMACH
301
scar of a healed ulcer. A subtotal gastrectomy and gastrojejunostomy with the aid of a Murphy button were performed. Pathologic examination of the stomach revealed an ulcerated cauliflower mass in the pyloric region. This tumor encircled the entire pylorus and invaded the stomach wall completely. Numerous enlarged lymph nodes were found in the attached omentum. On the lesser curvature at the re-entrant angle was a shallow ulcer. Five centimeters of normal mucous membrane separated the ulcer from the prepyloric carcinoma. The pathologic diagnosis was infiltrating adenocarcinoma of the stomach with metastatic involvement of the gastric lymph nodes and a chronic peptic benign ulcer where no tumor cells were seen. The patient failed to report one year later to the follow-up clinic, and presumably died.
Comment.-The anorexia, vomiting, weight loss and cachexia produced a clinical picture suggestive of malignancy. This diagnosis was supported by the anemia, hypoacidity and blood in stool. Gastric x-rays revealed an almost complete pyloric obstruction, the nature of which could not be definitely determined. Gastroscopy revealed a benign healing ulcer. Despite daily lavages, a high degree of gastric retention persisted, and surgical intervention was necessary. CASE II.-L. P., a white man aged 64 years, was admitted September 20, 1943. For one year he had noticed burning epigastric pain recurring with hunger and relieved by food. The pain became progressively worse and frequently radiated to the back. Six weeks before admission he began to vomit; the vomiting recurred twice weekly and relieved the epigastric burning. The vomitus was never bloody. Bowels were constipated but there was no rectal bleeding. His appetite was poor and he lost 15 pounds in six months. He had undergone a right hernioplasty fourteen years previously. Chest x-ray disclosed a healed bilateral apical tuberculosis. Physical examination revealed a well developed Italian male and was essentially negative except for a recurrent inguinal hernia. Examination of the blood revealed 93 per cent hemoglobin, 5,100,000 erythrocytes and 7900 leukocytes with 65 per cent polymorphonuclear leukocytes, 33 per cent lymphocytes, and 2 per cent monocytes. The guaiac test of the stools was negative. Gastric analysis after the Rehfuss test meal revealed a free acidity of 56 and a total acidity of 70. The blood chlorides were 610 mg. per 100 cc. and the carbon dioxide combining power was 60 volumes per 100 cc. Gastrointestinal examination by means of a barium meal performed before he entered the hospital revealed a dilated stomach with a large ulcer crater on the lesser curvature of the body above the re-entrant angle. There was also a rather constant narrowing of the prepyloric region. The roentgen appearance suggested a benign gastric ulcer and the antral deformity was interpreted as due to spasm. There was a 30 per cent residue at the six hour observation (Fig. 150). Gastroscopy revealed an ulcer about 2.5 cm. wide on the lesser curvature just proximal to the angularis. The ulcer margin was sharp but reddened. On the posterior wall of the corpus near this ulcer there was a similar superfIcial ulcer about 5 mm. wide. The entire gastric mucosa was markedly reddened, edematous
302
HARRY YARNIS
and covered with translucent exudate. Peristalsis was sluggish and appeared to progress to the pylorus. The gastroscopic impression was active benign gastric ulceration with severe superficial gastritis.
,I
Fig. 150.-Benign ulcer above re-entrant angle and infiltrating prepyloric carcinoma. Because of the gastritis and gastric retention, the patient was treated with daily lavages for two weeks and then subjected to exploration. On the night before operation the gastric retention was 700 cc. Laparotomy revealed a distinct thickening at the re-entrant angle and adhesions around the pylorus and duodenum. The entire gastric wall was thickened and edematous. This thickening
COEXISTING ULCER AND CANCER OF STOMACH
303
was most pronounced in the prepyloric region, but the serosa here appeared normal. A subtotal gastrectomy and jejunostomy for alimentation were performed. Pathologic examination revealed a reddened gastric mucosa covered with bloodstained mucus. An ulcer measuring 1.5 cm. in diameter was found straddling the lesser curvature at the re-entrant angle. On the posterior wall near this ulcer was a stellate scar. The mucosa was freely movable everywhere except for the region 1.5 cm. proximal to the pylorus. Here the mucosa was fixed, firm and presented a serpiginous elevation which encircled the pylorus. The ulcers were separated from the carcinoma by 6 cm. of normal mucosa. The pathologic diagnosis was infiltrating adenocarcinoma of the prepylorus and chronic peptic ulcer of the lesser curvature. No involved lymph nodes were found. This patient was symptom-free when seen in May, 1946.
Comment.-Despite the advanced age of the patient, the clinical aspects favored a benign lesion. The normal blood picture, hyperacidity and absence of blood in the stool were consistent with this diagnosis. Roentgen studies revealed a large dilated stomach with a benign ulcer at the incisura angularis. There was a prepyloric defect and a 30 per cent six hour residue. These were explained as due to reflex antral spasm. Gastroscopically, multiple gastric ulcers and a severe superficial gastritis were observed. On intensive ulcer therap) including lavages, the retention rose from 600 cc. to 700 cc. and operation was necessary. CASE IlL-H. B., a white man aged 58 years, was admitted on November 22, 1943. Eight years previously he had recurrent epigastric pain which was treated with diet and twenty-four daily injections. The pain disappeared after two months and he was relatively asymptomatic until eighteen months before this admission. Then the epigastric pain recurred almost daily for three months. He was again symptom-free until two weeks before he was admitted. The pain recurred two to three hours postprandially and was promptly relieved by food. He had one episode of nausea and vomiting associated with the pain during the last recurrence. His appetite was poor and he lost 9 pounds. The bowels were regular and there was no rectal bleeding. Physical examination revealed a well nourished male and a firm lymph node was palpated in the left axilla. This was biopsied and showed no involvement by tumor. The heart and lungs were normal. There was a sense of resistance in the right epigastrium but no definite mass was palpated. Examination of the blood revealed 84 per cent hemoglobin, 11,500 leukocytes with 83 per cent polymorphonuclear leukocytes, 13 per cent lymphocytes, 2 per cent monocytes and 2 per cent eosinophils. The guaiac test of the stools was negative. Gastric analysis after a Rehfuss test meal revealed a free acid of 16 and a total acid of 40. Roentgen examination of the stomach after a barium meal performed before he entered the hospital revealed a shallow projection from the' lesser curvature at the region of the re-entrant angle. There was a slight irregularity of the lesser curvature on each side of this ulceration, which measured 2.5 cm. in diameter. Opposite the latter on the greater curvature and posterior wall of the corpus, there was a filling defect about 3 cm. wide. In the center of this defect was a
304
HARRY YARNlS
projection, apparently an ulcer crater (Fig; 151). There was no residue at the six hour observation. Gastroscopy revealed a large ulcerating lesion on the posterior wall adjoining the lesser curvature. The edges appeared everted and the distal margin was at the angularis. Because of the marked friability and bleeding of the tissue on the
Fig. 151.-Ulcerated infiltrating carcinoma on greater curvature and shallow benign ulcer at re-entrant angle. posterior wall, the upper limits of the ulcer were not visualized. The gastroscopic impression was that the lesion was a large carcinomatous ulcer. At operation the stomach was found to be the seat of a carcinomatous ulceration on the greater curvature, and a distinct lesion on the les~er curvature opposite this which was also suspected as being a carcinoma. Because of the extent
COEXISTING ULCER AND CANCER OF STOMACH
305
of the carcinoma and the extensive involvement of the lesser curvature lymph nodes to the cardia, a total gastrectomy with esophagojejunostomy and jejunostomy for alimentation was performed. The patient made an uneventful recovery and was discharged from the hospital on the thirty-third postoperative day. The resected specimen consisted of the entire stomach from pylorus to cardia and in the region of the greater curvature 10 cm. proximal to the pylorus there was a Hat tumor mass 5 cm. wide. Its surface presented small irregular ulcerations. On section the tumor tissue showed streaky infiltration into the muscularis. Opposite this on the lesser curvature there was a separate ulcer with a grayishwhite base and a firm, slightly raised edge. There was an area of normal mucosa measuring 3 cm. between the ulcer and the cancer. The attached lesser and
Fig. 152.-Totally resected stomach with large peptic ulcer and infiltrating scirrhous carcinoma. greater omenta contained numerous nodes with irregular whitish areas, which suggested gross involvement by tumor. The pathologic diagnosis was infiltrating scirrhous carcinoma with involvement of the gastric lymph nodes and a large chronic peptic ulcer (Fig. 152). This patient was on a regular diet and worked hard for two years, when he died suddenly. Cause of death was infarction of the entire small intestine due to mesenteric thrombosis secondary to torsion about an adhesion. Postmortem examination revealed no evidence of metastases.
Comment.-The episode of epigastric pain eight years previously, and perhaps that one of eighteen months before, suggested the pos-
306
HARRY YARNIS
sibility of a long-standing peptic ulcer. The recent weight loss and anorexia, however, were suggestive of malignancy. The laboratory findings were equivocal. The blood picture was normal and the stools were guaiac negative; but there was a hypoacidity. Both x-ray and gastroscopic studies suggested malignancy. DISCUSSION
Two cases presented here were associated with the clinical picture of typical malignancy and the third appeared to have a benign ulcer. The laboratory findings were consistent with these diagnoses except in the third case in which blood was absent from the stools. In both of the cases with pyloric obstructions there was no alkalemia. Antral spasm secondary to ulceration above the incisura angularis may cause mild degrees of gastric retention. However, high-grade pyloric obstruction, causing six hour residues exceeding 50 per cent of the ingested barium meal, must be due to a pyloric or juxtapyloric lesion. In the first case the complete pyloric obstruction could not be attributed to the healing ulcer at the angularis. In the second case the gastric retention which persisted despite the healing of both corporic gastric ulcers should suggest, therefore, an associated benign or malignant juxtapyloric lesion. It is well to remember that in about 8 per cent of cases gastric ulcers are associated with duodenal ulcers. Resected specimen of the first case revealed the scar of a healed ulcer. In the second case the larger ulcer decreased to one-half its former size and the smaller ulcer healed, despite the presence of a prepyloric carcinoma. This is in contrast to the observation of Bockus, who noted the absence of healing of ulcers distant from the pylorus when there was a persistent or high-grade pyloric stenosis. In the third case, when the ulcer and the carcinoma were in the body of the stomach, no healing of the large peptic ulcer was observed. Gastroscopically, a small benign ulcer was discovered in the first case. The prepyloric region was not visualized because the pylorus was fixed to the posterior abdominal wall by an adherent carcinoma. In the second case, multiple benign ulcers and a severe gastritis were observed. The marked edema, producing a swollen, boggy mucosa, was sufficient to mask any mucosal abnormality caused by the infiltrating neoplasm. The gastroscopist in the third case noted a large ulcer with an irregular margin, erroneously suggesting a carcinomatous ulcer. In addition, the presence of a typical infiltrating neoplasm only 3 cm. away produced the gastroscopic picture of an extensive malignancy with ulceration.
COEXISTING ULCER AND CANCER OF STOMACH
S07
SUMMARY
I
I,
1. Peptic ulcers above the incisura angularis may cause mild degree of gastric retention. 2. Gastric retention exceeding 50 per cent of the ingested barium meal should suggest a benign or malignant pre- or postpyloric lesion. S. Persistent gastric retention should not be attributed to an ulcer at a distance froin the pylorus, particularly when healing of the ulcer is observed. 4. Peptic ulcers in the body of the stomach may heal in the presence of a malignant growth causing pyloric obstruction. 5. When the clinical picture is atypical the presence of a benign gastric ulcer should not preclude search for an independent carcinoma which does not originate in the ulcer.