Medical Arts and Sciences: A Scientific oJ urnal of the College of Medical Evangelists
Volume 2 | Number 2 Article 3
4-1948 The aG stric Cancer Problem Clarence E. Nelson College of Medical Evangelists
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VOLUME 2 APRIL, 1948 NUMBER 2
THE GASTRIC CANCER PROBLEM*
CLARENCE E. NELSON, M.D.t
The importance of gastric carcinoma as the ing to Collins, Gover, and Dom. Kirschner cause of death in the United States can be stated that 50 per cent of cancer deaths among appreciated when we consider that during men in Germany were due to cancer of the World War II, according to the former Sur stomach. It has been found that cancer of geon General Thomas Parran, as many people the stomach is higher in the Italians who came died from cancer of the digestive tract as were over from Italy to work in the mills in Connec lost in the armed forces of the United States ticut than it is in the general population of as the result of enemy action. It is estimated that State. However, in the second and third that of the people living in the United States generation Italians, the death rate from cancer today, between 4,000,000 and 5,000,000 will of the stomach is about the same as in the rest die of cancer of the stomach. Gastric carci of the population. noma causes more deaths than any other Genetics seems to have an influence upon cancer. Because of the difficulties in early diag the incidence of gastric carcinoma. The nosis, only 2 to 6 per cent of all patients that genetic influence is probably organ specific. have gastric carcinoma are alive at the end There are exceptional families known for of five years. Walters and co-workers at the their high incidence of cancer of the stomach. Mayo Clinic found that about 25 per cent are The family of Napoleon is perhaps the most suitable for curative surgery, and of these famous; as Napoleon, his father, his grand about 25 per cent are alive and well at the father, all three of his sisters, and one of his end of five years, and 20 per cent are alive at four brothers are said to have died from gas the end of ten years. tric carcinoma. It is a disease of later life, the average age Most forms of cancer found in human be of patients being 55 years. There is a prepon· ings are also known to occur in animals. Can derance in the male of nearly two to one. The cer of the esophagus and of the stomach, how death rate from cancer in certain countries is ever, are outstanding exceptions and are higher than in other countries. It is much among the rarest types of tumors in animals. higher in Holland than it is in England. It is Welles et al. described 8 cancers of the fore higher in the Northern States of the United stomach, which corresponds to the mouth, States than it is in the Southern States, accord- pharynx, and esophagus, and 3 adenocarci nomas of the pars glandularis, which corre M:J:'ri~::,e Cancer Conference of the Seq Diego Couaty sponds to the stomach, in 142,000 mice dying f From the Department of SwiJery, CoUege of Medk.al Eva118elilb. of natural causes, many of old age. This ex-
Copyright, 1948, by Review and Herald Publilhin1 Aaociation 51 52 Nelson-Gastric Cancer Problem tremely low incidence of carcinoma of the these animals he had been able to subject stomach in animals is remarkable considering them to irritants that humans commonly use, that if they had been human beings the inci such as tobacco, alcohol, condiments, hot bev dence of carcinoma of the stomach would have erages, and other types of irritants, undoubt been about 30,000 instead of I I. edly the incidence of carcinoma would have McCarrison, while a medical officer in the been much higher. Indian Army Medical Service, spent about Although nutritional deficiencies have an nine years among three remote tribes of north important bearing on the cause of carcinoma ern India. During that time he performed of the stomach, clinical surveys indicate that nearly 4,000 operations, many being for these irritants are significant exciting factors. hernia, goiter, cataract, etc., but he did not see Lintott compared a large group in Holland a single case of cancer, appendicitis, or colitis with a similar group in England. The inci during that whole time. He was so impressed dence of gastric cancer in Holland was about by the absence of many other diseases which twice that of England. The diet of the Hol are so prevalent in other parts of India that he landers contained large amounts of bread, made a careful study for possible reasons. He cheese, vegetables, and a smaller amount of concluded that it was because of their diet, meat. However, in Holland the food was taken inasmuch as they lived on natural foods at a higher temperature; and the consump direct from the soil, thus retaining their pro tion of spices, alcoholic beverages! and tobacco tective elements. He later set up a laboratory was higher. in southern India, where he put animals- Hurst has stated that approximately 75 per including pigeons, guinea pigs, rabbits, and cent of gastric carcinomas develop on a pre monkeyS-On diets which were common in existing gastritis. Among the causes of chronic various parts of India as well as on a diet made gastritis he gives the following: alcohol, espe up of foods commonly used in England. His cially strong spirits on an empty stomach; control animals numbering a total of I, I 98 strong tea and coffee; tobacco; condiments; were put on the diet, mainly lacto-vegetarian, mechanical and thermal injuries; infections of these healthy tribes of northern India. Dur due to oral sepsis; and certain drugs, particu ing a period of two years they were watched, larly bromides, digitalis, mercury, and salicyl and at the end of that time they were autop ates. sied and carefully examined, and he found no Ivy and Peacock are of the opinion that the evidence of any disease whatsoever except a use of excessively hot foods is prob.ably a factor few tapeworm cysts. On the other hand, a in the development of gastritis and gastric group of 2,443 animals which were put on im carcinoma. The oral mucous membrane will proper diets common among the people of tolerate food 15 per cent hotter than will the other parts of India and in England showed skin; this explains why tea cups have handles. all kinds of diseases, including two cases of A patient whom I saw recently with carcinoma carcinoma of the stomach. Thus if the 142,000 of the stomach would tend to' bear this out. animals autopsied by Welles et al. had been This man, aged 40, an oil-well driller, states on the improper diets that McCarrison gave that for several years he drank up to 20 cups his animals, and their response had been the of hot coffee a day. Widmark has demonstrated same, the incidence of cancer of the stomach a substance from roasted coffee which pr<> would have been 3,300 instead of I I. On the duces cancer in the skin of miCe. other hand, if in addition to the diet given Vitamin A deficiency is known to have an Medical Arts and Sciences 53 adverse effect on the integrity of the mucous of the general population of gastrk,. cancer membrane of the digestive tract. Passey, Lees, age have achlorhydria. Approximate\y &5~: ~o. . and Knox have demonstrated that papilloma 75 per cent of gastric cancer patients .hav.e · tosis of the preventriculus of mice can be achlorhydria: It is in the group that has· fr.ee brought about by feeding them a diet deficient hydrochloric acid that there is the great~st in vitamin A. Studies of the metabolism of danger of not making adequate study. . Our. cancer patients which have been carried out most promising field in the early detection of at the Memorial Hospital in New York reveal cancer of the stomach lies in the frequeqt e~ several abnormalities, particularly that of vita amination (at least 3 times a year) of patie.nts min A deficiency and hypoproteinemia. How with achlorhydria and pernicic;>Us , anemia. ever, Peacock and Kirby have shown that large This should include X-rays as well as .gastro doses of vitamin A do not protect against the scopic examinations where X-ray findings al"e development of gastric papillomatosis when negative or are suspicious. All patients w:ith carcinogenic hydrocarbons are fed to animals. pernicious anemia should be watched: qtre Schindler • is also of the opinion that fully for the presence of gastric polyps. Large atrophic gastritis and ·pernicious anemia are "polyps probably should be removed; whereas frequent precursors of gastric cancer. Kaplan small polyps should be watched frequent,ly and Rigler have stated that the incidence of with the gastroscope. cancer of the stomach in patients dying ·with . There is considerable difference of opinion pernicious anemia is about 12.3 per cent. In a 'as to the relationship of gastric ulcer to gastric series of 259 apparently well pernicious ane cancer. Probably the most important feature mia patients, they found 18 cases of gastric of this problem is the danger of -confusing carcinoma, and 17 cases of benign tumor in the benign with malignant ulcers. It has been stomach. Bourne, of England, recently re found ~hat approximately 10 per cent of ulcers ported a study of 15 cases of asymptomatic per which' are believed to be benign under average nicious anemia patients observed by both diagnostic measures are malignant when re X-ray and gastroscopic examination, and in moved. S~mpson and Sosman believe ~at 15 patients he found three cases of cancer of cancerous ulcers outnumber benign -ul.c~rs the stomach. He points out that increased three to one. sedimentation rate is of value in suggesting Ulcers about- the cardia and the subcardia the onset of cancer in pernicious anemia pa as well as th.os~ 'of the anterior and pos~erior tients. walls are also more often malignant than be Gastric polyps are a frequent occurrence in nign, but ulcer of the greater curvatur~ is atrophic gastr.itis and pernicious anemia. almost always malignant. The fact that the Kaplan and Qigler are of the opinion that the ' patient who ,!ms a gastric ulcer is put on a demonsttation of a gastric polyp in association medical regime and is relieved. of ,his distress with pernicious anemia has almost the same and may even show some improvement in the significance as the demonstration of carcinoma X-ray film may not be an indication that the per se. Wangensteen found a high incidence lesion is not malignant. It is variously esti of gastric polyps in patients who were achlor mated that from between 10 to 20 per cent of hydtic to histamine. True histamine fast patients with gastric ulcer will develop carci achlorhydria is a common condition. It is not noma of the stomach. Ogilvie and Schi~dler b present at birth but tends to appear in early on the other hand believe that gastric uker adult life. Barrett states that 20 to 25 per cent ral"ely. ever becomes malignant,: and that .one 54 Nelson-Gastric Cancer Problem of the most important services that the gastro high gastric acidity. This is particularly true scopist can perform is to differentiate between in cases where there is a malignant gastric benign ulcer and malignant ulcer. Yamis has ulcer. reported three cases with benign ulcer with an Marshall and Aronoff, in reporting 464 independent carcinoma in the same stomach, cases with tumor of the stomach who were and states that peptic ulcers in the body operated on at Lahey Clinic, stated that 98 per of the stomach may heal in the presence of a cent of the tumors were malignant and only malignant growth causing pyloric obstruction. 2 per cent were benign. The benign lesions Wangensteen suggests that since gastric re included fibro-adenomas, myomas, lipomas, section for ulcers can be performed by the hemangiomas, and neurofibromas. experienced surgeon at risks well below 5 per Benign tumors have a tendency to hemor cent, there seems little justification for the rhage, and pedunculated polyps which arise physician to assume so conservative an attitude most frequently in the pyloric antrum may toward gastric ulcers as a patient's future may prolapse through and produce symptoms of be compromised thereby. obstruction. Most mafignant gastric tumors Since there is no characteristic symptom are carcinomas, but there are several types of complex of cancer of the stomach, it is not sarcomas that are seen, such as lymphosar surprising that notable members of the medi· comas, leiomyosarcomas, and Hodgkins dis· cal profession have died of the very disease ease. There are no characteristic symptoms of which they spent their lives combating. These sarcoma of the stomach. Epigastric distress, include such illustrious surgeons as W. J. loss of appetite, loss of weight, and massive Mayo, Mikulicz, Martin Kirschner, and hemorrhage are the more common ones. others. Ogilvie reports that during the past Syphilis of the stomach is usually confused five years two famous surgeons suddenly dis with gastric cancer. On X-ray examination covered that they had carcinoma of the stom there is a filling defect in the stomach which ach by feeling a mass bump against the oper cannot be distinguished from carcinoma. Gas· ating table, that one celebrated radiologist troscopically, the findings are very much the swallowed a cup of barium to try out a newly same in the two conditions. A patient under installed apparatus, and much to his horror, my care recently demonstrated this difficulty when the film was developed it showed a large very graphically. X-ray examination revealed cancer of the stomach. a large filling defect in the stomach which was Among the early symptoms of carcinoma diagnosed as cancer. He was referred to an of the stomach may be mentioned the follow expert gastroscopist, who stated that the gas ing: fatigue, dyspepsia, loss of appetite, loss troscopic picture was that of an extensive in of weight, distaste for certain foods, particu filtrating carcinoma, and advised a total gas larly meat, and epigastric distress. Anyone de trectomy. At surgery, in addition to the lesion veloping digestive disturbances after the age of the stomach, large nodes were found near of 40 should be thoroughly investigated. the cardia and at the pylorus. A total gastrec· About one fourth of patients with carcinoma tomy was performed and a large jejuna) pouch of the stomach, however, give a long dyspeptic was made just below the anastomosis of the history. About 65 to 75 per cent of patients jejunum to the esophagus. This was done in with gastric cancer will have no free hydro order to provide him with as large a "bread chloric acid. On the other hand, we may see basket" as possible, as he was a laborer and in patients with gastric carcinoma with relatively his 40's. Unfortunately the patient's serology Medical Arts and Sciences 55 report was not received until after surgery. present a problem in diagnosis. A Swiss phy The pathological findings were compatible sician, Seneque, recommends the administra with that of syphilis of the stomach. The pa tion of 40 grams of syrup of ipecac (occasion tient got along very nicely postoperatively and ally in addition the patient may be given has been completely relieved of all digestive 0.1-1.2 gm. powdered ipecac) one-half hour symptoms and has gained 12 pounds in weight before studies. This, in his hands, emptied the within the past four months in spite of doing stomach and gave good visualization of the hard manual labor. stomach. He was dlen able to diagnose carci Marshall and Aronoff state that because noma, which was not visible otherwise, the syphilis of the stomach is rarely seen, even in lesion being located in the pyloric region. He the presence of a positive Wassermann where also recommended the use of ipecac to im X-~ays shows a definite defect, laporotomy prove diagnosis of lesions of the lesser curva should be performed early, as waiting for ture, and particularly of ulcers of the posterior antiluetic treatment may convert an operable aspect of the stomach, which are difficult to lesion into an inoperable one. Biopsies of su~ show by ordinary roentgenographic methods. picious stomach lesions should be done more The ipecac assists in emptying the stomach frequently than are being done at the present and stimulates peristaltic action; which allows time. visualization of some lesions which cannot be Carcinoma not infrequently develops upon seen in the atonic stomach. tuberculous lesions of the stomach. White, in Mass surveys by fluoroscopic methods have a series of 300 cases of tuberculosis of the proved to be impractical. St. John, Swenson, stomach, found that 10 per cent had gastric and Harvey studied 2,413 well people over 50 carcinoma. It is also known that lupus is fre years of age with a brief fluoroscopic survey of quently followed by epidermoid carcinoma. the stomach. In this group two gastric cancers Ivy b has discussed the possible relationship and one lymphosarcoma were found, an inci of bile as being a factor in the production of dence of 1.24 per thousand patients. These gastric cancer. The reason for this is that patients were visitors to the hospital and were methylcholanthrene, a highly potent carcino unselected other than for their age. gen, has a very close chemical relationship to Routine physical examination alone is not the normal constituents of the bile. Another of much value in detecting carcinoma of the reason for this suspicion is that practically all stomach. A careful history is essential, and pa cancers of the duodenum are located in the tients with suspicious histories should receive ampulla of vater, being the area of the duo a complete work-up, including blood counts, denum which comes most intimately in con gastric anal:ysis, stool tests for occult blood, t.act with the bile. A third fact that adds to and sedimentation rate. If barium me~l is the suspicion of bile is that subcutaneous in negative, a gastroscopic examination should jections of desoxycolic acid into rats has pro be performed. duced subcutaneous sarcomas. Ivy also sug Wangensteen states that 2 to 4 cc. of blood gested that other possible actions of the bile is sufficient to give a positive guiac test in the may be due to the action of the bile salts upon stool, and that it takes approximately 70 cc. fat-soluble substances and would influence of blood to produce a stool in which the pres the action of the carcinogenic hydrocarbons ence of blood may be detected gros.dy. A plan in the stomach. that we have been using of late is to give pa Patients having gastric residue sometimes tients who come in for examination Hematest 56 Nelson-Gastric Ctince.r Problem
Reagent Tablets,• with proper instructions showed the pyloric antrum to be. narrowed, to the patient to run an occult blood test on with normal peristaltic waves, and distensable. his stool. Those having occult blood in their Gastroscopic examination revealed a small stooi would then bring a specimen of stool to reddish nodule at the angulus. Gastric resec· the laboratory for examination. These pa· tion was carried out and an early carcinoma tients are given a more careful examination of was demonstrated. the entire gastro-intestinal tract. Bourne believes that ~he general contrac· The value .of early diagnosis of cancer of tion of the pyloric area, when seen in perni the st?mach 'is well illustrated in the report of cious anemia patients,.may be the first indica Rene Gutmann. He reports 19 cases of early tion of carcir10matous change. especially when carcinoma of the stomach consisting of two associated with abnormal antral mucosa, and types: one is carcinoma in situ, or malignant that these conditions "should be viewed with degeneration of the epithelial cells in situ as much suspicion as hyperchlorhydric cases without invasion of underlying tissue; the with prepyloric ulcers." He suggests that the secamd •type is a small cancer confined to an common prepyloric carcinoma in pernicious area of approximately I cm. in diameter, show anemia patients does not arise in localized ing
SenCHue, J.: Pharmacodynamic study of ipecac in roent· Wells, H. Gideon; Slye, Maud; and Holmes, Harriet F.: i.rm diagnosis of gastric lesions, Yearbook of Radiology, Comparative pathology of cancer of the alimentary canal 1946, p. 181. IVith report of cases in mice, Am. J. Cancer 33:223 (June) St. John, F. B.; Swenson, P. C.; and Harvey, H. D.: Ex 1938. periment in early d iagnosis of gastric carcinoma, Ann. Surg. White, R. R.: Simultaneous carcinoma and tubeml 119:225, 1944. losis of the stomach in a case of pernicious anemia, Proc. Walters, W.; Cray, H.; and Priestley, J.: Carcinoma and Staff Meet., Mayo Clinic, 18:165-172, 1943. other malignant lesions of the stomach, Philadelphia, Widmark, E. M. P.: Presence of cancer producing sub W. B. Saunders Company, 1942. stance in roasted food, Nature 143:984 Qune 10) 1959. Wangensteen, 0 . H.: The problem of gastric cancer, \'amis, H.: Co-existing ulcer and cancer of the stomach, J. A. M .. A. 154:1161 (Aug,) 1947. Sur~. Clin. of North America (April) 1947, pp. 299-507.
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