Out of 390 patients with early gastric cancer (EGC) who underwent gastric resection between Jan. 1968 and Jul. 1987, four patients developed pyloric stenosis and one patient developed prepyloric stenosis. Macroscopic types of EGC were II c in three cases and II c + III in two cases. Histologic types were tubular adenocarcinoma in four patients, and poorly differentiated adenocarcinoma in one patient. Cancer existed just right on or immediately adjacent to the pyloric ring in all patients; and extended transversely to the gastric axis in four patients, and longitudinally in one patient. An associated open ulcer and/or ulcer scar in the cancer lesion was seen in four patients, and submucosal fibrosis in three patients to a variety of degree, both of which were thought to be greatly attributed to pyloric or prepyloric stenosis. A duodenal ulcer was not present in any patients

Hirano Tatsuo

Ishikawa Hiroshi

Kajiwara Keiji

Mine Yoshikazu

Miura Toshio

Miyashita Kosei

Nakamura Akihiro

Nakao Haruhiko

Oh Shimei

Satoh Tetsuya

Shimoyama Takatoshi

Shiraishi Enju

Takahira Ryoji

Tashiro Hikaru

Tomita Masao

Watabe Seiichiro

Yokota Mitoshi

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Aeta Med. Nagasaki 33 : 179-184Early Gastric Cancer Presenting Pyloric or Prepyloric StenosisTatsuo HIRANO, Toshio MIURA, Hikaru TASHIRO, Akihiro NAKAMURA,  Ryoji TAKAHIRA, Seiichiro WATABE, Enju SHIRAISHI, Shimei OH,       Hiroshi ISHIKAWA, Yoshikazu MINE, Keiji KAJIWARA,        Mitoshi YOKOTA, Kosei MIYASHITA, Tetsuya SATOH,      Haruhiko NAKAO, Takatoshi SHIMOYAMA, Masao TOMITA    First Depertment of Surgery Nagasaki University School of Medicine Received for publication, June 21, 1988ABSTRACT : Out of 390 patients with early gastric cancer (EGC) who underwent gastric resection between Jan. 1968 and Jul. 1987, four patients developed pyloric stenosis and one patient developed prepyloric stenosis. Macroscopic types of EGC were II c in three cases and II c + III in two cases. Histologic types were tubular ade-nocarcinoma in four patients, and poorly differentiated adenocarcinoma in one pati-ent. Cancer existed just right on or immediately adjacent to the pyloric ring in all patients; and extended transversely to the gastric axis in four patients, and longitudi-nally in one patient. An associated open ulcer and/or ulcer scar in the cancer lesion was seen in four patients, and submucosal fibrosis in three patients to a variety of degree, both of which were thought to be greatly attributed to pyloric or prepyloric stenosis. A duodenal ulcer was not present in any patients.       INTRODUCTION  Pyloric stenosis can be caused by numerous benign and malignant conditions, including gas-tric and duodenal ulcers, gastric cancer, sub-mucosal lesions and extragastric diseases. EGC, however, rarely develops pyloric stenosis. 1)2)3) 1) 5) We describe five patients with EGC who developed this comparatively rare complication. Since little information is available about pylo-ric stenosis caused by EGC, this study was un-dertaken to clarify the mechanism of constitu-ents of pyloric or prepyloric stenosis in EGC on the basis of histologic examination.    PATIENTS AND METHODS  Out of 390 patients who underwent gastric resection for EGC between Jan. 1968 and Jul. 1986 at the First Department of Surgery, Nagasaki University Hospital, only five patients had developed pyloric or prepyloric stenosis be-fore operation. The diagnosis of pyloric and prepyloric stenosis was established, based on clinical symptoms, and radiographic and en-doscopic findings. There were three men and two women; and the age was 51.2 years on ave-rage, ranging from 33 to 74. Four patients un-derwent distal gastric resection and one patient had total gastrectomy. All surgical specimens were examined macroscopically and microscop-ically, making the sequential step-sections approximately 5mm in width.          RESULTS  Tables 1 and 2 list patients' characteristics. Symptoms included nausea, vomiting, abdomi-nal fullness in all patients; and weight loss in four patients, which ranged from 2 to 10 kg. Radiologically, the diagnosis of pyloric stenosis was made in four patients and that of prepylo-ric stenosis in another patient. IIc type EGC was preoperatively diagnosed in three patients, Borrmann 3 in one patient, and benign gastric ulcer in one patient. On the basis of endoscopic findings, the lesion was diagnosed as gastric ulcer in one patient, advanced cancer simulat-ing EGC of type IIc in two patients, and Borrmann 3 in one patient. Only one patient was diagnosed correctly as having EGC of He c type. Endoscopic biopsy was done in three cases and adenocarcinoma was proved. On the basisof microscopic findings, the lesions of the five patients were diagnosed as IIc in three and II c + III in two patients.  To clarify the mechanism of formation of pyloric or prepyloric stenosis due to EGC, sev-eral measurements of the resected specimen were applied as shown in Fig. 1 and Table 3. The maximal transverse length of cancer to the gas-tric axis was from 35 to 60 mm. An ulcer in EGC was seen in four patients and maximal transverse length ranged from 0 to 45 mm. Out of these, an open ulcer was seen in four patients, measuring from 5 to 20 mm. Submucosal fibro= sis was observed in all patients and transverse length varied from 10 to 65 mm. The extent of cancer spread was mainly of transverse direc-tion to the gastric axis in four patients, and the ratio of the transverse length of gastric cancer to the transverse length of the gastric wall at the site of the maximal transverse Table 1. Patients' characteristics, clinical manifestations and macroscopic types of the lesions   Case Duratiom of Preoperative Macroscopic   No. Sex Age Symptoms Symptoms Diagnosis Types 1 730375 M 50 1 month N, V, AF, WL (5 kg) GU, PS lie + III 2 800260 F 47 3 months N, V, AF, WL (2 kg) Borrmann 3, PS IIc 3 820208 F 33 1 month N, V, AF IIc, PS IIc 4 830527 M 74 8 months N, V, AF, WL (10 kg) IIc adv., PS IIc 5 840208 M 52 1 day N, V, AF, WL (2 kg) Ile adv., PPS lie + III Abbreviations used : M : male, F : female, N : nausea, V : vomiting, AF: abdomina fullness, WL : weight loss, GU : gastric ulcer, lie adv. : advanced cancer simulating early gastric cancer of type IIe, PS : pyloric stenosis, PPS : prepyloric stenosis       Table 2. Histological findings of the lesions causing pyloric or prepyloric stenosis Case Location Size* of Depth of Distance No. of tumor tumor (mm) tumor Histology (mm)** Ulcer SMF  1 AD, Circ 50 X 34 m tub, 0 U1-III + + +  2 AD, Circ 80 X 60 sm tub, 0 - +  3 AD, Circ 42 X 32 sm por 0 Ul-III + + +  4 MAC, Min 32 X 107 m tub, 7 U1-I, II +  5 A, Circ 75 X 20 m tube 5 U1-II, III + + +  Abbreviations used : AD : antrum and duodenum, Circ : circumferencial, MAC : middle, antrum,  and upper portions of the stomach, Min : lesser curvature side of the stomach, m : mucosal cancer,  sm : submucosal cancer, tub, : well differentiated adenocarcinoma, tube : moderately differenti- ated adenocarcinoma, por : poorly differentiated adenocarcinoma, Ul : ulcer, SMF : submucosal  fibrosis, *size of tumor : transverse length x longitudinal length, "distance distance : distance between the  distal edge of cancer lesion and pyloric ring.A : maximal transverse length of early gastric cancer B : transverse length of the pyloric canal at the site of    maximal length of cancer along the transverse gast-   ric axis C : transverse length of ulcer in cancer D : transverse length of open ulcer in cancer E : transverse length of submucosal fibrosis F : distance between pyloric ring and distal edge of     cancer G : average thickness of each section specimen at the py    loric ringFig. 1. Measurements of several factors that may attribute to the constituents of pyloric or prepylori<        stenosis (dimensions of numbers are shown as millimeter, numbers in parentheses show per-      centages).Table 3. Results of measuring of the length of several factors and thickness of the pyloric ring (mm) Case No. A B C D E F G B/A C/A E/A   1 50 50 10 5 50 0 10.4 (100) ( 20) (100)   2 60 60 0 0 15 0 10.0 (100) ( 0) ( 25)   3 60 55 15 10 55 0 8.5 ( 92) ( 25) ( 92)   4 45 35 10 10 10 7 8.6 ( 78) ( 22) ( 22)   5 65 55 45 20 65 5 7.7 ( 85) ( 70) (100)                           Numbers in parentheses indicate percentageslength of the cancer ranged from 78% to 100%. The distal edge of the lesion was located at the pyloric ring area per se in three out of five pa-tients, and being 7 mm or less from the pylo-ric ring at maximum in all patients. The aver-age length between the distal edge of the lesion and the pyloric ring was 2.4 mm. The thickness of the wall at the pyloric ring in five patients was 9.0 mm in average, ranging from 7.7 to 10.4 cm.  Case report (Case 5 : prepyloric stenosis due to EGC of type II c + III) : A 5 2-year-old man developed abdominal fullness, nausea and vomit-ing. He had lost 2 kg during the last month. On the basis of UGIS (Fig. 2, 3) and endoscopic findings (Fig. 4 ), prepyloric stenosis due to advanced gastric cancer simulating EGC of type II c was diagnosed. The distal f our-fifths of the stomach was resected with lymph node dissec-tion. The resected specimen showed a linear ul-cer along the transverse axis of the stomach (Fig. 5). Fig. 6 shows microscopic findings of the pyloric area. An open ulcer, U1-III, and sub-mucosal fibrosis are seen at the prepyloric area.Fig. 2. Barium swallow study in the upright position       shows a markedly dilated stomach with prepy-      loric stenosis and a delayed passage of barium       meal. The shortening of the lesser curvature       of the stomach is also noted.Fig. 3. Double contrast study in the suprine       position. Prepyloric stenosis is apparently       seen. Pliability of the stomach proxi-      mal to the stricture is well preserved,       unlike in advanced gastric cancer.Fig. 4. Endoscopic picture. Prepyloric stenosis       forms pseudopyloric ring. Deformed and        narrowed prepyloric area accompanied       by irregular mucosal surface with ero-      sions and bleeding is noted. It is diff-      icult to determine the depth of the cancer      invasion from these findings.         COMMENTS  Pyloric or prepyloric stenosis is mostly seen in benign ulcers and advanced gastric cancer. EGC rarely causes this complication. The inci-dence of pyloric stenosis in benign ulcer ranges from 1. 5 to 8.6 %.2)6 ) From the radiologic study, Ti\KADA 3) reported that the incidence of pyloric stenosis in EGC of depressed type to be 2.9%. In our present series, pyloric or prepylo-ric stensis accounted for 1.3% of the patients with EGC.  Mechanism of constituents of prepyloric or pyloric stenosis due to EGC is complicated, and appears to be attributed to several determinants including the length between the pyloric ring and the distal edge of the cancer lesion, the extent of cancer, especially its spread along the transverse axis of the stomach, submucosal edema and fibrosis, inflammatory cell infiltra-tion, and coexistent ulcer in carcinoma. Amongthese factors, the short length between the pyloric ring and the distal edge of cancer, and the wide transverse spread of cancer to the long-itudinalgastric axis appeared to be attribut-able to pyloric stenosis to a great extent, because these findings were of consistence in all cases. The former factor ranged from 0 to 7 mm in the present study, and the latter factor (B/A) was 78% or over. MuR:\[ \-n 7) showed that all patients developed pyloric stenosis when the central portion of the lesion existed within 2 cm from the pyloric ring, even if it was a small lesion; but did not when the lesion was locatedfarther than 3 cm from the pyloric ring. Therefore, the short length between the lesion and the pyloric ring is a major factor in developing a pyloric stenosis.  Although it seems that coexistence of ulcer or ulcer scar in cancer and subsequent constric-tion play an important role in causing the pylo-ric stenosis, the present study showed a variety of the lengths of ulcer: from 0 to 45 mm, andFig. 5. Gross appearance of the antrum of the resected specimen opened along the greater curvaturE       with schematic illustration. The linear ulceration and widespread submucosal fibrosis arE       noted along the transverse gastric axis at the prepylorus.Fir. 6. Microscopic findings. Ul-III and submucosal fibrosis are noted at the prepvloric areaa variety of the lengths of open ulcer: from 0 to 20 mm. I'i' o, et al. described six cases of EGC with pyloric stenosis, and concluded that the pyloric stenosis might occur when an ulcera-tion in a depressed type cancer existed, the length between the pyloric ring and the anal edge was less than 1.5 cm or there was duode-nal invasion, the ratio of the length of the le-sion to the pyloric canal is over 65% and the ratio of the diameter of the ulceration to the lesion was over 50%. In the present study, how-ever, ulceration in cancer lesion was not neces-sarily present, and it was seen in one of five patients.  TAxA:nn5) emphasized the importance of sub-mucosal fibrosis which was seen in all patientsin the present study. But, since its severity var-ied, it may be difficult to determine how much submucosal fibrosis attributes to a cause of pyloric or pyloric stenosis.  Presumably a certain functional change of the antrum may also contribute to development of pyloric stenosis.s)   In summary, we described five rare cases of EGC causing pyloric or prepyloric stenosis. The mechanism of development of pyloric stenosis is complicated. Although this rare complication may be attributed to many factors, we conclude that EGC developing pyloric or prepyloric sten-osis is mostly of depressed types (II c or II c + III ) which spread transversely to the gastric axis, and often is associated with an open or healed ulcer and submucosal fibrosis in the lesion.         REFERENCES  1) BAi.1 ixv JA, SPi;NcE. MD : Pyloric stenosis. Br    Med J 4 : 890-894, 1959.  2) Aji.\G1 M, MlsuMJ A, Ilo o)., T : The problem of  pyloric stenosis and malignant change. In   Geka Mook No. 1 Kanehara Shuppan,   Tokyo pp. 181-186, 1978. 3) YoiwCo ni M, et al. : A case of early cancer of   the stomach showing ring-shaped stenosis.   Stomach and Intestine 13 : 1281-1287, 1978. 4) I'i' o S, et al. : Relation of early cancers to   complications-111. Early cancers and pyloric   stenosis. Mie Igahu 25 : 58-61, 1981. 5) TnKAi):\ T : Histologic and radiologic study   on narrowing of the pyloric portion in peptic   ulcer and early carcinoma of the stomach.   Nippon Igaku Houshasen Gakkai Zasshi 38   293-318, 1978. 6) H,\\ nrtici WH : Complication of peptic ulcer   disease. In Gastroenterology, edited by   Boci ius HL, W. B. Saunders. Philadelphia-  London-Toronto. 3rd Ed. Vol. 1, pp. 720-76   2, 1976. 7) MuIZAKnvii T : Percentage of ulcerocancer on   the small pyloric cancers. GANN 43, 206-208,   1952. 8) Nncno F, NAK.,,.%lrn\ N : Pathogenesis and   treatment of pyloric stenosis. Gekachiryo 16   215-220, 1982.

Early Gastric Cancer Presenting Pyloric or Prepyloric Stenosis

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Early Gastric Cancer Presenting Pyloric or Prepyloric Stenosis

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