Part 93

From 198 cases Brinton estimates the average duration of gastric cancer as about twelve and a half months, the maximum duration as about thirty-six months, and the minimum as one month. From 36 cases Katzenellenbogen estimates the average duration as eighteen months, the maximum as five years and five months, the minimum as one month. From 112 cases Lebert makes the average duration fifteen months and the maximum four years. In 4 per cent. of the cases Lebert found the duration less than three months, in 62 per cent. between six and eighteen months, in 42 per cent. between six and twelve months, in 17 per cent. between three and six months, and in the same number of cases between eighteen months and four years.

Estimates of several years' duration (such as nine years in the case of Napoleon) are to be received with scepticism. In these cases symptoms of gastralgia or of dyspepsia or of gastric ulcer have preceded the development of the cancer. It has already been mentioned that cancer may develop in a simple ulcer of the stomach.

Mathieu, from an analysis of 27 cases of gastric cancer occurring under thirty-four years, found the average duration in early life to be only three months. In only 2 out of 19 cases did the duration exceed one year. Although this analysis is based upon too small a number of cases, there {560} seems to be no doubt that gastric cancer pursues a more rapid course in early life than it does in old people.

COMPLICATIONS.--Some of the complications of gastric cancer have been mentioned under Symptomatology. Jaundice may appear in the course of gastric cancer from a variety of causes, such as catarrhal gastro-duodenitis, impaction of gall-stones in the common bile-duct, and pressure on the bile-duct by cancerous growths in the pancreas, in the portal lymphatic glands, or in the liver itself. Pylethrombosis, which is likely to be suppurative, is a rare complication. In a case of cancer of the anterior wall and greater curvature of the stomach reported by Wickham Legg the symptoms seem to have been mostly referable to a complicating suppurative pylethrombosis. Simple and cancerous pylethromboses also occur. Other forms of peritonitis than the cancerous may complicate gastric cancer, such as suppurative, sero-fibrinous, and chronic proliferative peritonitis. Catarrhal enteritis, and particularly diphtheritic colitis, are not infrequent complications, especially in the later stages of the disease. Chronic diffuse nephritis, both in the form of the large and of the small kidney, is a rare complication of cancer of the stomach. Hydrothorax, sero-fibrinous pleurisy, and emphysema may develop either with or without cancerous invasion of the pleura. Pericarditis is much less common; it is most likely to occur with cancer of the cardia. Pyo-pneumothorax, abscess, and gangrene of the lung may result from perforation of the pleura or of the lung by gastric cancer. Oedema of the lungs, splenization, and pneumonia, involving usually the lower lobes, are common in the last days of gastric cancer. Emboli derived from venous thrombi are sometimes carried into the pulmonary artery or its branches. Although much has been written as to the exclusion of tuberculosis by cancer, no such law exists. Both old and fresh tubercles have been repeatedly observed in cases of gastric cancer. Reference has already been made to the frequent development of aphthæ in the mouth, pharynx, and oesophagus in the final stage of gastric cancer. Fatty degeneration of the heart may develop in gastric cancer as in other anæmic states. Phlegmasia alba dolens has already been mentioned. It is not probable that insanity is to be regarded as more than an accidental complication of gastric cancer; still, it has been noticed in several cases--for instance, of Dittrich's 160 cases, 5 patients were insane, 2 with violent mania. Amyloid degeneration has been present in some cases. Purpura hæmorrhagica has been present in a few instances in the later stages (cachectic purpura). Chronic catarrhal gastritis and dilatation of the stomach are less complications than a part of the disease. The relation of cancer to simple ulcer of the stomach has already been considered. The various secondary cancerous deposits are most conveniently considered under the Morbid Anatomy. It is to be remarked that many of the complications of gastric cancer--as, for instance, pneumonia and peritonitis--may have a very obscure clinical history, as they often occur when the patient is greatly prostrated.

MORBID ANATOMY.--The following table gives the situation of the tumor in 1300 cases of cancer of the stomach: {561}

Pyloric region. 791 60.8% Lesser curvature. 148 11.4% Cardia. 104 8.0% Posterior wall. 68 5.2% The whole or the greater part of the stomach. 61 4.7% Multiple tumors. 45 3.5% Greater curvature. 34 2.6% Anterior wall. 30 2.3% Fundus. 19 1.5%

From this table it appears that three-fifths of all gastric cancers occupy the pyloric region, but it is not to be understood that in all of these cases the pylorus itself is involved. In four-fifths of the cases the comparatively small segment of the stomach represented by the cardia, the lesser curvature, and the pyloric region is the part affected by gastric cancer. The lesser curvature and the anterior and the posterior walls are involved more frequently than appears from the table, inasmuch as many cancers assigned to the pyloric region extend to these parts. The fundus is the least frequent seat of cancer. In the cases classified as involving the greater part of the stomach the fundus often escapes.

As was shown by Rokitansky, it is the exception for cancer of the pylorus to extend into the duodenum, whereas cancer of the cardia usually invades for a certain distance the oesophagus.

The varieties of carcinoma which develop primarily in the stomach are scirrhous, medullary, colloid, and cylindrical epithelial carcinoma. The distinction between scirrhous and medullary cancer is based upon the difference in consistence, the former being hard and the latter soft. Cylindrical-celled epithelioma cannot be recognized as such by the naked eye. It presents usually the gross appearances of medullary cancer. Soft cancer (including both cylindrical-celled epithelioma and medullary carcinoma) is the most frequent form of gastric cancer. Next in frequency is scirrhous cancer, and then comes colloid cancer, which, although not rare, is much less frequent than the other varieties.

As all degrees of combination and of transition exist between the different forms of cancer, and as a large number of cancers of the stomach are of a medium consistence and would be classified by some observers as scirrhous and by others as medullary, statistics as to the relative frequency of the different varieties have very little value. Moreover, in most statistics upon this point there is no evidence that simple fibrous growths have not been confounded with scirrhous cancer, and as a rule {562} little or no account is taken of cylindrical-celled epithelioma, which is a common form of gastric cancer--according to Cornil and Ranvier, the most common.

Cancer of the stomach may grow in the form of a more or less complete ring around the circumference of the stomach, or as a circumscribed tumor projecting into the cavity of the stomach, or as a diffuse infiltration of the walls of the stomach. The annular form of growth is observed most frequently in the pyloric region. Cancerous tumors which project into the interior of the stomach are sometimes broad and flattened, sometimes fungoid in shape, but most frequently they appear as round or oval, more rarely irregular, crater-like ulcers, with thickened, prominent walls and ragged floor. The free surface of the tumor presents sometimes a cauliflower-like or dendritic appearance, which characterizes the so-called villous cancer. Diffuse cancerous infiltration is seated oftenest in the right half of the stomach, but it may occupy the cardiac region or even the entire stomach.

The relation of the cancerous growth to the coats of the stomach varies in different cases. The tumor usually begins in the mucous membrane and rapidly extends through the muscularis mucosæ into the submucous coat. In this lax connective-tissue coat the tumor spreads often more rapidly than in the mucous membrane, so that it may appear as if the cancer originated in the submucosa. The mucous membrane, however, is usually invaded, sooner or later, over the whole extent of the tumor. The dense muscular coat offers more resistance to the invasion of the tumor. Cancerous masses, however, penetrate along the connective-tissue septa between the muscular bundles, which often increase in number and size. In the muscular coat thus thickened can be seen the opaque white fibrous and cancerous septa enclosing the grayish, translucent bundles of smooth muscular tissue. Often, however, the whole muscular coat beneath the tumor is replaced by the cancerous growth, and can no longer be recognized. The serous and subserous connective tissue, like the submucous coat, offers a favorable soil for the growth of the tumor, which here appears usually in the form of large and small nodules projecting from the peritoneum. Adhesions now form between the stomach and surrounding parts, and opportunity is offered for the continuous growth of the cancer into these parts. In the manner described the tumor grows in all directions, sometimes more in depth, sometimes more laterally, sometimes more into the interior of the stomach.

Ulceration occurs in all forms of gastric cancer. The ulceration is caused either by fatty degeneration and molecular disintegration of the surface of the tumor or by the separation of sloughy masses. Doubtless the solvent action of the gastric juice aids in the process. The softer and {563} the more rapid the growth of the cancer, the more extensive is likely to be the ulcer. Such ulcers are usually round or oval in shape, but their contours may be irregular from the coalescence of two or more ulcers or from serpiginous growth. The edges are usually high, soft in consistence, and often beset with polypoid excrescences. The floor is generally sloughy and soft, and often presents warty outgrowths. The edges and floor may, however, be hard and smooth. In the more slowly-growing scirrhous and colloid cancers the ulcers are more likely to be superficial. Partial cicatrization of cancerous ulcers may take place. The development of cicatricial tissue may destroy the cancerous elements to such an extent that only by careful microscopical examination can the distinction be made between cancer and simple ulcer or fibroid induration. The examination of secondary cancerous deposits in adjacent lymphatic glands or other parts becomes, then, an important aid in the diagnosis.

Suppuration has been known to occur in gastric cancers, but it is extremely rare.

Each form of gastric cancer has certain peculiarities which require separate consideration.

Medullary carcinoma grows more rapidly than the other varieties of cancer. It forms usually soft masses, which project into the stomach and are prone to break down in the centre and develop into the crater-like ulcers already described. All of the coats of the stomach are rapidly invaded by the growth. The consistence of the tumor is soft, the color upon section whitish or reddish-gray, sometimes over a considerable extent hemorrhagic. Milky juice can be freely scraped from the cut surface of the tumor. The so-called villous cancer and the hæmatodes fungus are varieties of medullary carcinoma. Medullary carcinoma is more frequently accompanied by metastases than the other forms. In consequence of its tendency to deep ulceration medullary cancer is more liable to give rise to hemorrhage and to perforation than is scirrhous or colloid cancer. The continuous new formation of cancerous tissue in the floor of the ulcer and the formation of adhesions, however, greatly lessen the danger of perforation into the peritoneal cavity.

Histologically, medullary cancer is composed of a scanty stroma of connective tissue enclosing an abundance of cancerous alveoli filled with polyhedrical or cylindrical epithelial cells. The stroma is often richly infiltrated with lymphoid cells, and contains blood-vessels which often present irregular dilatations of their lumen.

Waldeyer describes with much detail, for this as for the other forms of 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. 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.

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. 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.