Pathological anatomy and classification of stomach cancer

Striking at first only a short mucosa epithelial or ferrous tubes in the further development of gastric cancer spreads in all directions in the interstitial spaces and intramural lymphatic vessels on the principle cancer limfangoita. This process takes on the character of the creeping infiltration defeat all layers of the stomach wall.
Stomach cancer can develop vnutristennaya (in the wall of the stomach), move ia adjacent organs and form metastases. As established Borrman (1949), the direction of propagation of the cancer comes mainly from the pyloric stomach to the heart, following the flow of lymph.
Localization of cancer in different parts of the stomach has a different frequency. By S. A. Holdin (1952): cancer pyloro-antral observed in 60-70%, the cancer is small curvature (average Department is the body of the stomach) - 10-15%, cancer, cardiac part - 10%, cancer of the front and rear walls - 2-5%, cancer of the large curvature (middle section) - about 1%, cancer of the fundus of the stomach - 1%, and diffuse the incidence of seizure with most or all of the stomach is observed in 5-10%.
According to Trimble and Lunn (1955), localization of cancer in different parts of the stomach meets with a slightly different frequency.
It should be borne in mind that the cancer of a stomach has different type of growth: exophytic, endophytic and mixed. The most frequent mixed type of tumor growth with unequal ekzotichna-endophytic its growth in different areas.
Macroscopically there are 4 forms of a cancer of a stomach (Bormann, Konjetzny).
1. Polypoid or mushroom, when the tumor, with wide or narrow foot, sharply defined and acts in the stomach cavity. It is characterized exophytic growth.
2. Saucer-like with ulceration in the center. It has raised edges, sharply defined and has the appearance of a saucer. It is characterized by slow development, exophytic growth and late manifestation of metastases.
3. Diffuse with infiltrative growth, with no clear boundaries.
4. Mixed distinguished outwardly as if exophytic growth, but some infiltration of the gastric wall.
When saucer-like and polypoid form tumors of its macroscopic boundary coincides with microscopic, and so the border resection can be located on 1-2 cm from the edges of the tumor. In the diffuse and mixed form of cancer of the stomach with infiltros growth, when it is located on the lesser curvature of the stomach closer to the cardia, the most celebrated expressed tumor infiltration wall. This obliges in the production resection to retreat to 6-8 cm above the edges of the tumor and to the side of the duodenum at least 2-2,5 cm, so as to require the features of the lymph flow through the lymphatic pool stomach.
In infiltrative the form of stomach cancer, its wall is very dense. By its morphological structure is skirr or fibrous carcinoma (linitis plastica).
In addition, it should highlight stomach ulcers, turned into cancer (cancer ex ulcere) - 10-15% of cases and wounded cancer (cancer ulceriforme). The latter is a cancer with the collapse in the centre. Although he has more sluggish growth in comparison with infiltrative form of cancer, but metastases he gives fast. Proof that in this case there is cancer ex ulcere, usually is only supported by pathological study of tumors. Usually for cancer, developed from ulcers, typical changes on the edge of ulcers, addressed to the output Department. Here there are atypical epithelium. The cancer of the ulcer is happening not only in the output part of the stomach or in his body, but in the cardia that is not rare, as it was noted by A. Savinykh, (1949). Because of this cardiac ulcers are particularly dangerous.
Among the cardia cancers occur and exophytic, and endophytic form with earlier growth into adjacent organs. These cancers form a conglomerate and clinically especially malignant.
Particularly significant form of cancer is cardialna-esophageal cancer. At the junction of the esophagus to the stomach there is a change of the epithelium of different structures. Cancer can start from gastric and esophageal (flat) epithelium, and, starting from the esophagus, it can be a adenocarcinoma, not squamous cell tumor, as the source of his serve dystopia gastric epithelium in the lining of the esophagus.
Cancer of the middle third of the stomach (mediastrategy cancer) is less common, that is localized symmetrically (the small curvature, the greater curvature, the front and the back), then asymmetrically (small curvature with capture the front or back wall and a large curvature with capture the front or back wall).
Cancer on the transition of the stomach into the duodenum, the observed relatively rare, has features that depend on that as well as in the esophageal-cardiac localization, it occurs at the intersection of the two bodies, covered with mucous membrane of various structure; more common variant of the rising but the wall of the stomach tumor growth. These cancers are often germinate in the pancreas head, Central Department of mesocolon and especially often metastasize to the liver.
Noteworthy recommendation S. A. holdina to use the following morphological classification of stomach cancer:
I. Restricted growth of cancer (exophytic form):
a) polypoid, mushroom, capoetobrama form (5-10% lesions of the stomach). A tendency to bleeding, hence anaemia and weakness;
b) pan (saucer-like) cancer observed for 8-10% of all patients with gastric cancer and considered according to the forecast one of the most favourable form. The clinical course is characterized by analizarea and symptoms of intoxication;
C) flat (balashovrussia) cancer is rarely found (about 1% of all diseases of stomach cancer). Is often in pyloro-antrum. It is difficult recognized.
II. Infiltrative growing cancer (endophytic, diffuse form):
a) ulcerative inflammatory cancer is the most frequent type (about 60% of all cancer lesions of the stomach). Most often localized in pyloro-antral the small curvature, in subcardial part. Often spreads to the adjacent organs;
b) diffuse cancer - fibrous or skirosana form, is observed in 5-10% of cases of a cancer of a stomach. The process often begins at the pyloric Department. Rapid depletion, stomach shrinks. Another form of diffuse cancer - colloidal (or mucosa), proceeding with vague symptoms - is relatively rare, and the wall of the stomach is as if soaked viscous mass.
III. Transitional forms (mixed, vague form).

Microscopically, classification Bormann (1949), it is necessary to distinguish adenomatous, alveolar, diffuse, polymorphonuclear and mixed cancer of the stomach. Because they all come from the cells of glandular epithelium, then the right to consider them as adenocarcinoma of different degree of differentiation and the functional completeness. So it is recommended to do Broders. He distinguished between all forms of a cancer of a stomach at 4 degrees of differentiation depending on the prevalence of differentiated or undifferentiated cells. In his opinion, the degree of dedifferentiation regulation epithelium and explains the severity of malignancy growth of this cancer. These 4 degrees in Broders are:
I degree of dedifferentiate (3%). Here are purely adenomatous forms with high cylindrical, properly placed cells, with elongated oval kernel with brightly painted chromatin.
II degree dedifferentiate (20%). It adenocarcinoma glandular structure. Pavement glands consisting mostly of cubic epithelial cells with round multifaceted kernel, rich chromatin.
III degree dedifferentiate (38%). It adenocarcinoma with lower ability of cells to the formation of glandular structures. Cells incorrectly polymorphic type with oval or round the nucleus and intensively increased the chromatin.
IV degree dedifferentiate (39%). It adenocarcinoma, consisting entirely of the less differentiated cells, not forming glandular structures. The contours of their wrong, the core of rounded or many-sided, very rich chromatin.

It does not refer to individual cancers cardio-esophageal area of the stomach that may be ploscockletocny cancer, not adenocarcinoma.
The degree of dedifferentiate in a significant number of cases coincides with the clinical manifestations of the disease; the lower dedifferentiate, the more intensive growth of the tumor and more pronounced metastasis (first and second degree - 25%, in the third and fourth degree - 62%), and the number of cases of prolonged recovery instead 86,2% at the first degree of dedifferentiate falls to 23.3% at its fourth degree.
Following the wall of the stomach cancer may invade into adjacent organs. Germination usually occurs most often in the left lobe of the liver, in the tail of the pancreas, rarely gate in the spleen. If the tumor spreading all layers of the wall of the stomach may occur implantation of cancer cells in the parietal and visceral peritoneum in the form of carcinomatosis.
Practical importance of the metastasis of gastric cancer through the lymphatic ducts. According to Cuneo, Bormann, Century A. Melnikov and others in the lymph pool stomach lymph flows away from its walls in 3 directions - currents:
I. Lymph current is sent from the pylorus, small curvature, front and back walls of the stomach in the 1st collector regional lymph nodes, which are located on the lesser curvature, in a small gland to the cardia and along the right gastroepiploic artery. 2nd collector lymph nodes are located along the left gastric artery in the stomach and pancreas together.
II. Lymph current goes from the lower section of the stomach from the greater curvature, duodenal ulcer and gastric body in the lymph nodes gastrocolic ligament (3rd collector lymphatic basin of the stomach). This connection is represented by two sheets, among which are the lymph nodes at a considerable distance from the wall of the stomach, which is why it is necessary to cross the gastrocolic ligament near the transverse colon and be sure to remove all of the greater omentum. Further lymph, breaking for this 3rd reservoir, goes to lymph nodes in the small intestine mesentery and retroperitoneal - along the aorta.
III. Lymph current goes from the bottom of the stomach and the adjacent part of the greater curvature, its front and back walls along the splenic artery and short vascular fundus of the stomach to the lymph nodes, gastrointestinal splenic ligaments, lymph nodes gate of the spleen, the spleen.

Metastasis of gastric cancer in the regional lymph nodes are rare. However, the frequency of this applied to various types of cancer and type of growth.
Metastases to internal organs are observed mostly in the liver (30%), rarely in the pancreas, lungs, and even rarer in the kidneys, spleen, bones. They are not rare in lig. tores hepatis, and on her and in skin navel.
To distant metastasis is the so-called tumor of Krukenberg (metastasis in the ovary), metastases in the peritoneum, her pelvic-pryamokishechnye deepening (metastasis Schnitzler), lymph nodes, usually the left supraclavicular fossa (Verhovsky metastasis).
In the development of stomach cancer there are 4 stages. The doctrine of stages of development of malignant tumours has been developed particularly in our country.
There are many classifications of stomach cancer by type of illness. Very rational classification S. A. holdina. Is based on the division of all cases of gastric cancer clinical type of its course, for a particular type of symptoms that accompany its various forms. So, we should distinguish:
a) stomach cancer with a predominance of local gastrointestinal manifestations (starting with minor phenomena of "discomfort" and ending sharp functional disorders);
b) stomach cancer with a predominance of common disorders (nature anemia, cachexia, weakness, fatigue);
in) stomach cancer "masked"flowing with symptoms of diseases of other organs;
g) asymptomatic (latent flowing) stomach cancer. His classification is quite close to the division proposed Century A. Melnikov.
But this is not enough. Summarizing the literature data and own experience, we can offer the following scheme morphological and clinical classification (characteristics) of gastric cancer (table. 2).

TABLE 2. Morphological and clinical classification (characteristics) of stomach cancer
  Characteristics of gastric cancer
The structure of the tumor Adenocarcinoma, solid cancer, mucous cancer, skirr or fibrosarcoma; linitis plastica
The microscopic appearance of the tumor Polypoid or mushroom, saucer-like with ulceration in the centre, diffuse infiltration without clear boundaries, mixed, izyaslavichi cancer; cancer of ulcers
Localization Pyloric, small curvature (middle section), cardiac part, the front or back wall, large curvature (middle section), the bottom of the stomach, diffuse prevalence
The type of growth Exophytic, endophytic, mixed
The degree of dedifferentiate tumor cells (Broders) The first, second, third, fourth
Clinical features of the course Cancer dominated local gastric symptoms, cancer, with a predominance of common disorders, cancer, masked the symptoms of other bodies, asymptomatic (fast current) cancer
Oslojnenny intoxication Without intoxication, with a weak intoxication, with sharp toxicity and cachexia
Tumor stage (according to the scheme of Ministry of health USSR) The first, second, third, fourth
The germination of neighboring organs Lig. gastro-colicum, liver, peritoneum, covering the pancreas, the head of the pancreas, the body of the pancreas, foot spleen, mesocolon, cross the intestine, hepatic and gastrointestinal link, gallbladder, bile ducts
The incidence of cancer of the lymphatic collectors of the basin of the stomach First, second, third, fourth
The presence of distant metastases Round ligament of the liver, the peritoneum, the nodes Virchow, metastases of Kruckenberg, metastases Schnitzler, other bodies
Note. It further noted pathogenesis (gastritis, ulcers, polyps), gender, and especially the age of the patient