gastric cancer, the origin of the tumor from the gastric tubules.
According to his description, a group of gastric tubules, ten to twenty
in number, sends prolongations downward into the submucous coat. These
tubular prolongations are filled with proliferating epithelial cells,
which make their way into the lymphatic spaces of the surrounding
tissue and give origin to the cells in the cancerous alveoli. A
small-celled infiltration of the surrounding connective tissue
accompanies this growth of the tubules.
The tissue beneath and at the margins of medullary cancer may be
predominantly fibrous in texture and contain comparatively few
cancerous alveoli. This scirrhous base is often exposed after the
destruction of the greater part of the soft cancer by ulceration and
sloughing. It is {564} probable that many of the scirrhous cancers are
formed in this way secondarily to medullary cancer (Ziegler).
Cylindrical-celled epithelioma presents the same gross appearances and
the same tendency to ulceration and to the formation of metastases
which characterize medullary cancer. The consistence of cylindrical
epithelioma may, however, be firm like that of scirrhus. Not
infrequently the alveoli are distended with mucus secreted by the
lining epithelium, and then the tumor presents in whole or in part
appearances similar to colloid cancer.
Upon microscopical examination are seen spaces resembling more or less
closely sections of tubular glands. These spaces are lined with
columnar epithelium. Often in certain parts of the tumor the alveolar
spaces are filled with cells, so that the structure is a combination of
that of ordinary cancer and of epithelioma. The stroma is generally
scanty and rich in cells, but it may be abundant. Cysts may be present
in this form of tumor, and in one case I have found such cysts nearly
filled with papillary growths covered with cylindrical epithelium, so
that the appearance resembled closely that of the so-called proliferous
cysto-sarcoma of the breast.
The origin of cylindrical epithelioma from the gastric tubules is
generally accepted, and is more readily demonstrable than the similar
origin claimed for the other forms of gastric cancer.
Scirrhous cancer assumes often the form of a diffuse thickening and
induration of the gastric walls, particularly in the pyloric region,
where it causes stenosis of the pyloric orifice. Scirrhus may, however,
appear as a circumscribed tumor. Irregular hard nodules frequently
project from diffuse scirrhous growths into the interior of the
stomach. Scirrhous cancer and medullary cancer are often combined with
each other.
The dense consistence of scirrhous cancer is due to the predominance of
the fibrous stroma, the cancerous alveoli being relatively small in
size and few in number.
Colloid cancer generally appears as a more or less uniform thickening
of the gastric walls. All of the coats of the stomach are converted
into the colloid growth. Nearly the whole of the stomach may be invaded
by the new growth.[82] The tumor has a tendency to spread to the omenta
and to the rest of the peritoneum, where it may form enormous masses,
but it rarely gives rise to metastases in the interior of organs.
Colloid cancer may, however, form a circumscribed projecting tumor in
the stomach, and in rare instances it causes abundant secondary colloid
deposits in the liver, the lungs, and other parts.
[Footnote 82: In a case reported by Storer the whole stomach, except a
little of the left extremity over an extent of about an inch, was
converted into a colloid mass in which no trace of the normal coats of
the stomach could be made out. The colloid growth replacing the gastric
wall measured seven-eighths of an inch in thickness in the pyloric
region. Digestion was less disturbed in this case than in most cases of
gastric cancer (_Boston Med. and Surg. Journ._, Oct. 10, 1872). In
Amidon's case (reported in the _Trans. of the N.Y. Path. Soc._, vol.
iii. p. 38) there seems to have been an equally extensive colloid
metamorphosis of the stomach.]
Colloid cancer presents, even to the naked eye, an exquisite alveolar
structure, whence the name alveolar cancer as a designation of this
tumor. Bands of opaque white or gray connective tissue enclose alveolar
meshes which are filled with the gelatinous, pellucid colloid {565}
substance. This colloid material is thought to be produced by a colloid
transformation of the epithelial cells in the alveoli, but the same
transformation seems to occur also in the stroma. Few or no intact
epithelial cells may be found in the alveoli. Colloid metamorphosis may
take place in all forms of gastric cancer, but it is particularly
common in cylindrical epithelioma. Colloid cancer may originate in the
peritoneum unconnected with any glandular structures. It occurs often
at an earlier age than other forms of cancer. Deep ulceration rarely
attacks colloid cancer.
Flat-celled epithelioma is found at the cardiac orifice and as a
metastatic growth in other parts of the stomach. Originating in the
oesophagus, it may extend downward into the stomach. By noting whether
the structure is that of squamous or of cylindrical epithelioma it is
often possible to determine whether a tumor at the cardiac orifice
originates in the oesophagus or in the stomach.
Secondary cancer of the stomach, although rare, is not such a curiosity
as is often represented. Without aiming at completeness, I have been
able to collect 37 cases of secondary cancer of the stomach, of which
the larger number will stand critical examination.[83] Of these cases,
17 were secondary to cancer of the breast, 8 to cancer of the
oesophagus, 3 to cancer of the mouth or nose, and the remainder to
cancer of other parts of the body. The large number of cases secondary
to cancer of the breast is explained by the large statistics relating
to mammary cancer which were consulted. Gastric cancer is more
frequently secondary to cancer of the oesophagus than to cancer of any
other part. In this category of course are not included cases of
continuous growth of oesophageal cancer into the stomach, but only
metastatic cancers of the stomach. A part at least of the gastric
cancers secondary to cancer of the alimentary tract above the stomach I
refer, with Klebs, to implantation in the mucous membrane of the
stomach of cancerous particles detached from the primary growth in the
oesophagus, pharynx, or mouth. This view is supported by the absence in
some cases of any involvement of the lymphatic glands. The secondary
deposits in the stomach conform in structure to the primary growth.
They are usually situated in the submucous coat, where they form one or
often several distinctly circumscribed tumors. The secondary tumors may
or may not ulcerate. They rarely produce symptoms.
[Footnote 83: These cases are from Dittrich, 2 (the remainder of his
cases I rejected); Cohnheim, 1; Petri, 2; Klebs, 3; Lücke, 1; Weigert,
1; Coupland, 1; Cruse, 1; Hausmann, 1; Bartholow, 1; Oldekop, 5; Edes,
1; V. Török and V. Wittelshöfer, 8; Grawitz, 4; Haren Noman, 5.
So-called melanotic cancers, cancers involving only the serous coat of
the stomach, and those extending by continuous growth into the stomach,
are not included in this list.]
Primary cancers may be present at the same time in different organs of
the body; for instance, in the uterus and in the stomach.[84] The
possibility of multiple primary cancers is to be borne in mind in
considering some of the apparently secondary cancers of the stomach, as
well as in determining whether certain cancers are secondary to gastric
cancer or not. Here the microscopical examination is often
decisive.[85]
[Footnote 84: Case of A. Clark's (_Trans. N.Y. Path. Soc._, vol. i. p.
260), and a similar one reported by J. B. S. Jackson in _Extr. from
Records of the Boston Soc. for Med. Improvement_, vol. i. p. 335.]
[Footnote 85: The subject of multiple primary cancers is considered by
Kauffmann (_Virchow's Arch._, Bd. 75, p. 317), and by Beck (_Prager
med. Wochenschr._, 1883, Nos. 18 and 19). V. Winiwarter reports a
cancer of the stomach in a patient who died one year seven and a half
months after extirpation of a cancer of the nose. He regards the case
as one of multiple primary cancer.]
{566} Gastric cancer often causes important secondary changes in the
coats and the lumen of the stomach. In the neighborhood of the tumor
are often found hypertrophy of the muscular coat and fibrous thickening
of the submucous coat. Polypoid hypertrophy of the mucous membrane near
the cancer is not rare. Not only near the tumor, but over the whole
stomach, chronic catarrhal gastritis usually exists.
The most important alterations are those dependent upon obstruction of
the orifices of the stomach. This obstruction may be caused either by a
tumor encroaching upon the orifice or by an annular thickening of the
walls of the orifices. Even without apparent stenosis, destruction of
the muscular layer at or near the pylorus may be an obstacle to the
propulsion of the gastric contents into the duodenum. As a result of
obstruction of the pyloric orifice the stomach becomes dilated,
sometimes enormously, so as to occupy most of the abdominal cavity. The
walls of the dilated stomach, particularly the muscular coat, are
usually thickened, but exceptionally they are thinned. Sometimes with
pyloric stenosis the stomach is reduced in size. This occurs
particularly when a scirrhous growth extends diffusely from the pyloric
region over a considerable part of the stomach. Obstruction of the
cardiac orifice or in the oesophagus leads to atrophy of the stomach,
although here also there are exceptions. Above the obstruction the
oesophagus is often dilated. An existing obstruction may be reduced or
removed by ulceration or sloughing of the tumor.
Both dilatation and contraction of the stomach may attend gastric
cancer without any involvement of the orifices of the stomach in the
cancerous growth. The cavity of the stomach may be so shrunken by
scirrhous thickening and contraction of the gastric walls that it will
hardly contain a hen's egg. Irregular deformities in the shape of the
stomach, such as an hour-glass shape and diverticular recesses, may be
caused by gastric cancer.
Changes in the shape of the stomach and the weight of the tumor may
cause displacements of pyloric cancers, so that these tumors have been
found in nearly all regions of the abdomen, and even in the true
pelvis.[86] Such displaced cancers usually contract adhesions with
surrounding parts.
[Footnote 86: Lebert, _op. cit._, p. 420.]
It is not necessary to dwell upon the formation of adhesions which may
bind the stomach to nearly all of the abdominal organs, most frequently
to the liver, the pancreas, the intestine, and the anterior abdominal
wall. Adhesions of pyloric cancers are found in at least two-thirds of
the cases, and probably oftener.[87]
[Footnote 87: Gussenbauer and V. Winiwarter found adhesions recorded in
370 out of 542 pyloric cancers. In considering the propriety of
resection of gastric cancers it has become a matter of importance to
know in what proportion of cases adhesions are present. I agree with
Ledderhose and with Rydygier in believing that adhesions are present
oftener than appears from Gussenbauer and V. Winiwarter's statistics.
The fact that adhesions are not noted in post-mortem records of gastric
cancer cannot be considered proof of their absence. Little has been
done in the study of gastric cancer from a surgical point of view.
Metastases and adhesions were absent in only 5 out of 52 cases of
pyloric cancer in which either pylorectomy or exploratory laparotomy
was performed (Rydygier).]
Cancer of the stomach in the majority of cases is accompanied with
{567} metastases in other parts of the body. In 1120 cases of gastric
cancer secondary cancers were present in 710, or 63.4 per cent., and
absent in 410, or 36.6 per cent.[88] In about two-thirds of the cases,
therefore, secondary deposits were present.
[Footnote 88: These cases are from Habershon, _op. cit._; Lebert, _op.
cit._; _Trans. N.Y. Path. Soc._, vol. i.; and Gussenbauer and Von
Winiwarter, _loc. cit._]
In order to determine the relative frequency of the secondary deposits
in various organs of the body, I have constructed the following table,
based upon an analysis of 1574 cases of cancer of the stomach in which
the situation of the metastases were given:[89]
Lymphatic glands. 551 35.0%
Liver. 475 30.2%
Peritoneum, omentum, and intestine. 357 22.7%
Pancreas. 122 7.8%
Pleura and lung. 98 6.2%
Spleen. 26 1.7%
Brain and meninges. 9 0.6%
Other parts of the body. 92 5.8%
[Footnote 89: These cases include, in addition to those cited in the
preceding foot-note, those of Dittrich (_Prager Vierteljahrschr._, vol.
xvii.), Wrany (_ibid._, vols. xciv. and xcix.), Katzenellenbogen (_op.
cit._), and Lange (_op. cit._). Metastases in the intestine formed only
a small number of those under the heading peritoneum, omentum, and
intestine, but as they were all included together in Gussenbauer's
large statistics, the intestinal metastases could not well be placed
separately. In 673 cases the peritoneum and omentum were cancerous in
21.7 per cent.]
Secondary cancerous deposits are probably even more frequent in the
lymphatic glands than appears from the table. In 1153 cases of gastric
cancer in which the situation of the affected lymphatic glands is
specified, the abdominal glands, and chiefly those near the stomach,
were the seat of cancer in 32½ per cent. In Lange's 210 cases the
cervical glands were affected in 4.3 per cent. In other statistics this
percentage is much smaller. In nearly one-third of the cases there are
secondary cancers in the liver. These may attain an enormous size in
comparison with the tumor of the stomach. Cancer of the peritoneum and
of the omentum is found in about one-fifth of the cases of gastric
cancer. The spleen is rarely involved, except by continuous growth of a
cancer of the fundus or in cases of widespread distribution of cancer
through the aortic circulation. Cancer of the liver increases the
liability to metastases in the lungs, but the latter may be present
without any cancerous deposits in the liver. Secondary cancers may be
present in the suprarenal capsules, the kidneys, the ovaries, the
heart, the thoracic duct, the bones, the skin, etc. In an interesting
case reported by Finlay[90] the subcutaneous tissue of the trunk was
thickly studded with small nodules, of which two were excised during
life and found to be cylindrical epitheliomata. This led to the
diagnosis of a primary tumor of the same nature in the stomach or in
the intestine. At the autopsy was found a cylindrical epithelioma of
the stomach which had not given rise to characteristic symptoms.
Secondary cancer of the intestine is rare if the deposits in the
peritoneal coat be {568} excepted. Several cancerous ulcers or multiple
cancerous nodules may be found along the intestinal tract, involving
the mucous and the submucous coats.[91] These metastases seem best
explained by the theory of implantation of cancerous elements which
have been carried from the primary growth in the stomach into the
intestine. In some of the cases the idea of multiple primary cancers
may also be entertained.
[Footnote 90: _Trans. Path. Soc. London_, vol. xxxiv. p. 102.
Unfortunately, in Röseler's case of multiple skin-cancers with an
ulcerated cancer of the stomach no microscopical examination of the
skin-nodules was made. The interpretation of this case is therefore
doubtful (_Virchow's Archiv_, Bd. 77, p. 372).]
[Footnote 91: Cases in point are recorded by Wrany (_loc. cit._), Blix
(_Virchow u. Hirsch's Jahresbericht_, 1876, ii. p. 207), Lange,
Katzenellenbogen, and Lebert.]
It is not rare for gastric cancer to cause secondary deposits in the
stomach itself. Sometimes it is difficult to decide which of two or
more cancers in the stomach is the primary growth, as in Ripley's case
of ulcerated cancer of the cardiac orifice with a similar growth around
the pyloric orifice.[92] It is probable that in very rare instances
multiple primary cancers may develop in the stomach.
[Footnote 92: J. H. Ripley, _Trans. N.Y. Path. Soc._, vol. iv. p. 121.
Maurizio has also reported a case of scirrhous cancer of the cardia
with scirrhous cancer of the pylorus (_Annal. univ. di Medicina_, Oct.,
1869). A similar case was observed by Barth (_Gaz. hebdom._, 1856, No.
24, p. 424).]
Cancerous metastases are produced by the transportation of cancerous
elements by the lymphatic current or by the blood-current. In a number
of instances the portal vein or some of the branches which help to form
it have been found plugged with a cancerous mass which may or may not
be organized.[93] The cancer in these cases has burst through the walls
of the vessel into the lumen, where it may grow both in the direction
and against the direction of the current. On serous surfaces, and
probably also, although rarely, on mucous surfaces, secondary cancers
may develop from cancerous particles detached from a parent tumor and
scattered over the surface as a kind of seminium.
[Footnote 93: Cases of this kind have been reported with especial
fulness by Spaeth (_Virchow's Archiv_, Bd. 35, p. 432), Acker
(_Deutsches Arch. f. kl. Med._, Bd. 11, p. 173), and Audibert (_De la
Généralisation du Cancer de l'Estomac_, Paris, Thesis, 1877).]
Mention has already been made of the invasion of parts adjacent to the
stomach by the continuous growth of gastric cancer. In this way
lymphatic glands, the liver, the pancreas, the omenta, the transverse
colon, the spleen, the diaphragm, the anterior abdominal wall, the
vertebræ, the spinal cord and membranes, and other parts may be
involved in the cancerous growth.
Under the head of Complications reference has already been made to
various lesions which may be associated with gastric cancer. As regards
the manifold complications caused by perforation of gastric cancer, in
addition to what has already been said the article on gastric ulcer may
be consulted. In general, the various fistulous communications caused
by gastric cancer are less direct than those produced by gastric ulcer.
The wasting of various organs of the body in cases of gastric cancer
may be found on post-mortem examination to be extreme. Habershon
mentions a case in which the heart of a woman forty years old weighed
only 3½ ounces after death from cancer of the pylorus. As in other
profoundly anæmic states, the embryonic or lymphoid alteration of the
marrow of the bones is often present in gastric cancer.
PATHENOGENESIS.--The problems relating to the ultimate causation and
origin of gastric cancer belong to the pathenogenesis of cancer in
general. Our knowledge with reference to these points is purely
hypothetical. It will suffice in this connection simply to call
attention to {569} Virchow's doctrine, that cancer develops most
frequently as the result of abnormal or of physiological irritation,
hence in the stomach most frequently at the orifices; and to Cohnheim's
theory, that cancer as well as other non-infectious tumors originate in
abnormalities in development, more specifically in persistent embryonic
cells. According to the latter view, gastric cancer develops only in
those whose stomachs from the time of birth contain such embryonic
remnants. These unused embryonic cells may lie dormant throughout life
or they may be incited to cancerous growth by irritation, senile
changes, etc. According to Cohnheim's theory, the orifices of the
stomach are the most frequent seat of cancer on account of complexity
in the development of these parts.
For a full consideration of these theories the reader is referred to
the section of this work on General Pathology.
DIAGNOSIS.--The presence of a recognizable tumor in the region of the
stomach outweighs in diagnostic value all other symptoms of gastric
cancer. The detection of fragments of cancer in the vomit or in
washings from the stomach is of equal diagnostic significance, but of
rare applicability. The discovery of secondary cancers in the liver, in
the peritoneum, or in lymphatic glands may render valuable aid in
diagnosis. Of the local gastric symptoms, coffee-ground vomiting is the
most important. The relation between the local and the general symptoms
may shed much light upon the case. While anorexia, indigestion,
vomiting, and epigastric pain and tenderness point to the existence of
a gastric affection, the malignant character of the affection may be
surmised by the development of anæmia, emaciation, and cachexia more
rapid and more profound than can be explained solely by the local
gastric symptoms. The value to be attached in the diagnosis of gastric
cancer to the absence of free hydrochloric acid from the contents of
the stomach must still be left sub judice. The age of the patient, the
duration, and the course of the disease are circumstances which are
also to be considered in making the diagnosis of gastric cancer. These
symptoms of gastric cancer have already been fully considered with
reference to their presence and absence and to their diagnostic
features.
It remains to call attention to the differential diagnosis between
gastric cancer and certain diseases with which it is likely to be
confounded. The points of contrast which are to be adduced relate
mostly to the intensity and the frequency of certain symptoms. There is
not a symptom or any combination of symptoms of gastric cancer which
may not occur in other diseases. Hence the diagnosis is reached by a
balancing of probabilities, and not by any positive proof.
Notwithstanding these difficulties, gastric cancer is diagnosed
correctly in the great majority of cases, although often not until a
late stage of the disease. Errors in diagnosis, however, are
unavoidable, not only in cases in which the symptoms are ambiguous or
misleading, but also in cases in which all the symptoms of gastric
cancer, including gastric hemorrhage and tumor, are present, and still
no gastric cancer exists. Cases of the latter variety are of course
rare.
In the absence of tumor the diseases for which gastric cancer is most
liable to be mistaken are gastric ulcer and chronic gastric catarrh. In
the following table are given the main points of contrast between these
three diseases: {570}