diagnostic accuracy of gastroscopy in neoplasms of the stomach

DIAGNOSTIC ACCURACY OF GASTROSCOPY IN NEOPLASMS OF THE STOMACH

LESTER BAKER, M.D., EDMUND A. GORVETT, M.D., AND MITCHELL A. SPELLBERG, M.D.

HE VALUE OF GASTROSCOPY as a to01 in the T diagnosis of gastric lesions is now well established. During the last decatle, as more data have accumulated, better evaluation of the procedure has evolved. Of particular in- terest from the clinical viewpoint has been tlie diagnosis of gastric carcinoma. The problem of early diagnosis is frequently beyond the con- trol of the physician, since i t depends, in part at least, upon the patient’s presenting hiniself to the physician for aid while the gastric lesion is still localized. In the realin of accurate diagnosis, however, the problem is completely with- in the province of the attending physician. 111 the course of a diagnostic work-up, an upper gastrointestinal roentgenographic series and gastroscopy are procedures frequently used. While these two procedures are not diagnostically infallible, they are probably, where available, the techniques upon which most diagnostic reliance is placed. With this in mind and in an attempt to elucidate the comparative functional value of each procedure, we are presenting the following data.

METHODS

We have collected all the histologically proved cases of gastric neoplasms at the Vet- erans Administration Hospital, Hines, Illinois, for the five-year period of 1946 through 1950. All of these cases had one or more gastroscopic examinations with the Cameron omni-angle flexible instrument. Roentgenological and gastroscopic reports have been reviewed in their entirety. The following classification of diagnostic impressions was used in this report: (1 ) definite or compatible with, (2) probable, and (3) rule out. When the prefix “compatible

From the Medical Service, Veterans Administration Hospital, Hines, Illinois.

Reviewed in the Veterans Administration and puh- lished with the approval of the Chief Medical Director. The statements and conclnsions published hy the authors are the result of their own study and do not necessarily reflect the opinion or policy of the Veterans Administration.

The authors wish to acknowledge the valuable rccoiii- inendations and suggestions of Lyle A. Raker, M.D., Chief, General Medical Service, Veterans Administration Hospital, Hines, Illinois, in the preparation of this man- uscript.

-__

Received for publication, March 31, 1952.

with” or “probable” was used, the diagnosis was considered as correct. This is believed jus- tifiable for the “probable” prefix because, in most cases, attention was directed atid exploratory laparotoniy subsequently performed on the basis ot this diagnosis. When the prefix “rule out” was used, the case is considered as having been incorrectly diagnosed. I n regard to the lymphoma cases in this report, the dem- onstration of a lesion is not considered as correct unless tlie lesion itself had been called lymphoma.

i n many cases gastroscopic diagnosis is considered as incorrect, either because of technical inability to perform the gastroscopic exaniina- tion or because of arrest of the instrument at the cardia. Visualization at the point of obstruction was always attempted in these cases but was never successfully achieved because of the proximity ot the organ wall to the objective of the gastroscope. All such cases were considered as having an incorrect diagnosis.

I n addition to the proved cases of gastric neoplasms, this review includes all those cases in which suspicion of neoplasm was aroused by the gastroscopic examination but in which no cancer was subsequently shown to exist. Only by inclusion of the negative errors in this man- ner can a true evaluation of the diagnostic accuracy of gastroscopy be ascertained. Many large series in the past have failed to include these types of cases.

RESULTS

i n the five-year period reviewed, a total 01 106 patients with histologically proved neoplasms were subjected to gastroscopy. All had had roentgenological examination of the u p per gastrointestinal tract. These 106 cases included 100 ot gastric carcinoma, three of pri. inary lymphosarcomas, one of Hodgkin’s dis. ease of the stomach, and two of gastric leiomyo. sarcoinas. i n this same period, sixty-four patients having non-neoplastic gastric lesions un derwent gastroscopic examinations a t which time a diagnosis of neoplasm was directly made or suspected. T h e distribution of the cases in this review is listed in Table 1. Table 2 lists

1116

No. :

the comparative age and race distribution of the gastric-carcinoma and benign gastric-ulcer cases. I t is noteworthy that, although this series does not contain a single female patient, the average age distribution is about the same as that noted in other larger series of cases, both in regard to gastric carcinoma and benign gastric ulcerations. Only one benign gastric ulcer was present in patients more than 64 years of age, while gastric carcinoma was found in ten. Further, of the 100 carcinoma cases, fifteen were in Negroes-approximately the percentage of Negroes admitted to this hospital. However, in the benign ulcerations, Ne- groes constitute only 8 per cent of the cases.

In the diagnosis of gastric neoplasms, it is noted from Table 3 that, on initial examination, sixty-one of the 106 cases (58 per cent) were correctly diagnosed by roentgenography. This is computed by adding the column listing correct by both procedures and that column listing correct by roentgenograms. Of the forty five cases incorrectly diagnosed initially, roentgenological examination was repeated in twenty-three and the diagnosis then correctly made in eleven. Thus, seventy-two of the 106 cases (68 per cent) were correctly diagnosed by roentgenography and the remaining 32 per

ACCURACY OF GASTROSCOPY IN G

TABLE 1

INCIDENCE, RACE, AND AGE DISTRIBUTION ~ ~ _ _ _ _ -

Race

no. White Negro av. Total Age,

Linitis plastica 3 3 0 5 2 7

Anaplastic carcinoma 8 7 1 5 1 4 Carcinoma, undet'd type 4 3 1 53.2

~ ~ --____-- Adenocarcinoma * 72 59 13 56.7

Scirrhous 10 10 0 56 4 "Signet cell" 2 2 0 3 6 0 Mucinous 1 1 0 64.0

Lymphoma Lymphosarcoma 3 3 0 27.3 Hodgkin's disease 1 1 0 60.0

Leiomvosarcoma 2 2 0 56.5

Gastric ulcer 55.8

39 36 3 52.6 Gastritis

Simple hypertrophy 11 11 0 47.3

Adhesions 3 3 0 60.7 Normal stomach 3 3 0 55.0 Gastric varices 1 1 0 56.0

1 0 24.0

51.0

* Although these adenocarcinoma cases are listed according to their gross and/or histological type, neither is of any value in distinguishing either rate of growth of the tumor or prognosis for the individual patient.'"

Adenom. hyperplasia 3 1 2 37.7 Gastric polyposis 3 2 1 50.3

Aberrant pancreas 1 - _.______ ._ __

,ASTRIC TUMORS - Baker et al. 1117

TABLE 2

.\GE AND RACE DISTRIBUTION OF GASTRIC CARCINOMA AND BENIGN GASTRIC

ULCERATION

Carcinoma Age. yr. Total White Negro

Less than 40 5 5 0

40-44 1 1 0 45-49 11 10 1 50-54 21 16 5

~~~ - ~~~~ - ~~

55-59 39 32 7 60-64 13 11 2 65-69 4 4 0 70 and

more 6 6 0 - - -

TOTALS 100 85 15

Benign ulcer

Total White Negro

12 11 1 14 13 1 4 4 0 1 1 0

0 0 0

39 36 3 - - -

cent incorrectly diagnosed. With gastroscopy the diagnosis was correctly made in the initial examination in seventy-five of the 106 cases (70 per cent)-computed by totaling the column listing correct by both and the column listing correct by gastroscopy. Of the remaining thirty-one incorrectly diagnosed cases, only four were subsequently resubmitted to gastroscopy, and the diagnosis then correctly revised in two. Thus, a corect diagnosis was made by gastroscopy in seventy-seven cases (73 per cent); and an incorrect one, in twenty-nine cases (27 per cent). If we now consider both procedures together, in only fourteen of the 106 cases did neither procedure permit the correct diagnosis (13 per cent). Of these fourteen cases, eight had re-examinations-four by roentgen rays alone, two by gastroscopy alone, and two by both procedures-and the diagnosis was correctly revised in five. Thus in only nine of the 106 cases did neither procedure produce a correct diagnosis (8.5 per cent). In these nine cases there was sufficient clinical suspicion to war- rant exploratory laparotomy at which time a definitive diagnosis was made. In no case in this series was the definitive diagnosis made at necropsy.

In an attempt to break down the errors in gastroscopic diagnosis, the twenty-nine cases in which gastroscopy failed were analyzed. These cases can be further subdivided into those in which (1) the errors were due to an inadequate examination, and (2) those in which there was misinterpretation of the lesion observed. In the first group are included twenty-three cases in which the gastroscopic examination was considered as inadequate (Table 4). In nine of these twenty-three cases,

1118 CANCER November 1952 VOl. 5

TABLE 3

COMPARATIVE DIAGNOSTIC ACCURACY OF ROENTGENOGRAPHY AND GASTROSCOPY IN 106 PROVED GASTRIC NEOPLASMS

Initial examination Subsequent examination -

Agree Disagree X-ray Gast roscopy

Total Both Both X-ray Gastrosc. Neither Cor- Not cor- Cor- Not cor Neoplasm no. wrong correct correct correct correct rected rected rected rected

Carcinoma Adenocarcinoma

Simple 72 2 31 11 Linitis plastica 3 1 1 Scirrhous 10 5 2 Signet-cell 2 1 1 Mucinous 1 1

Anaplastic 8 4 2 Type undetermined 4 1

L ymphosarcoma 3 1 Hodgkin’s disease 1 1

Leiom yosarcoma 2 Lymphoma

- - - - 44 ’ 17

the instrument became arrested at the cardia and further attempts at passage were discon- tinued. In all of these nine cases, the gastroscopist noted in his report that the obstruction was presumably due to malignant tumor in this region. In three cases, the instrument could not be properly inserted because of severe kyphoscoliosis, and, in four others, visualization was considered inadequate either because of excessive gastric secretion or fresh bleeding with coagulation of blood on the objective lens. Other technical reasons for an inadequate examination included one case each of inability of the patient to retain inflated air, excessive sustained spasm, and hourglass constriction of the stomach. In four cases, adequate visualization was obtained but the lesion was missed because of errors inherent in the instrument. These were lesions located in the “gastroscopic

- TOTALS 106 4

22 6 8 7 1 1 1 1 1 2 1

1 1 2 1 3 1 2

n L

2

I

1

blind areas”-distal to the angulus on the lesser curvature of the antrum. No cases in this series were missed gastroscopically because of their location in the other “gastroscopic blind areas” -the posterior wall or the blind area in the fundus. Six of the twenty-nine cases misdiagnosed gastroscopically were due to direct misinterpretation by the gastroscopist. In two of these cases, an ulcerating lesion was seen but diagnosed as benign; one had had two gastroscopic examinations.

Case 1. C. J. H., a 51-year-old white man, entered the hospital complaining of left upper- quadrant abdominal pain of two and a half months’ duration and a 10 Ib. weight loss. The distress bore no relation to meals or food, other than occasional relief by warm milk. T h e past history was essentially noncontributory except

TABLE 4

“FALSE NEGATIVE” ERRORS OF ROENTGENOGRAPHY IN GASTRIC CARCINOMA ~~

Gastroscopic errors Roentgenological errors

I. Inadequate examination 23 I. Inadequate examination 2 1. Obstruction a t cardia 9 1. Retained food 1 2. Gastroscopic “blind areas” 4 2. Excessive sustained spasm 1

3. Excessive secretion and/or 1. High-grade pyloric obstruction 4 fresh bleeding 4 2. Called benign ulcer 12

4. Kyphoscoliosis 3 3 . Called gastritis 5 5 . Couldn’t retain air 1 4. Nothing abnormal noted 5 6. Hourglass constriction 1 5 . Noted only larqe rugal folds 2 7. Excessive sustained spasm 1 6. Lymphoma called carcinoma 1

11. Misinterpretation of observed lesion 6 7 . Carcinoma called lymphoma 1 1. Cancer called benign ulcer 2 8. Cancer called benign polyp 2 2. Cancer called benign polyp 2 3. Carcinoma called lymphoma 2

Lesser curvature of antrum 11. Misinterpretation of observed lesion 32

TOTALS 29 34

No. 6 ACCURACY OF GASTROSCOPY IN GASTRIC TUMORS Baker et al . 1119

for a previous admission to the hospital for a benign antral ulcer, visualized roentgenographically. Physical examination, on this occasion, was essentially normal except for an irregular, very firm mass in the right upper quadrant of the abdomen extending to the epigastrium. There was moderate tenderness in the right upper quadrant. There was a mild anemia and gastric: analysis failed to show any free acid after two doses of histamine. An upper gastrointestinal roentgen-ray series showed an ulcer crater on the lesser curvature of the pars media (Fig. l), interpreted as benign. Gastroscopy showed a small ulcer crater well down on the anterior wall of the pars media. The edge of this crater was slightly raised. Gastroscopically this ulcer was noted to appear benign but, because of the unusual location and the patient’s clinical status, surgery was recommended. At about this time, nodes appeared in the left supraclavicular region and a biopsy showed metastatic carcinoma. Despite this, exploratory laparotoiny was performed and metastases were found throughout the abdominal cavity. The lesser curvature of the stomach was fixed to the liver in an area where there was a metastatic lesion. No other primary tumor in the abdomen was found and the primary lesion was believed to be in the stomach.

FIG. 1. Case 1, C. J. H. Ulceration defect on lesser curvature of pars media. This was interpreted roentgenographically as benign.

FIG. 2. Case 2, j. S. An ulcerative defect high on the lesser curvature not seen on two previous roentgen-ray examinations. The defect is not typical of the usual benign ulcer.

Case 2. J. S., a 58-year-old white man, entered the hospital complaining of epigastric pain and anorexia of three months’ duration. He had had a massive hematemesis three weeks before admission to the hospital. Physical examination was essentially negative except for pallor of the mucous membranes. The red-cell count was 2.7 million per cubic millimeter and stool analysis showed the presence of persistent four plus occult blood. A fractional gastric analysis showed a peak of 46 units of free acid. Two upper gastrointestinal roentgen-ray series, including Trendelenburg views of the fundus, were reported as essentially normal. Finally gastroscopy was performed, and a large, irregular depression covered by grayish material was noted on the anterior fundic wall, 3 cm. from the cardioesophageal junction. The surrounding mucosa appeared irregular and hyper- plastic. The depression was not sharply de- marcated from the surrounding mucosa but, rather, faded into it gradually. A diagnosis of malignant ulcer of the fundus was made. At this time a third gastrointestinal roentgen-ray series was done and a large niche on the lesser curvature o€ the fundus was found (Fig. 2). On the compression roentgenograms, some filling defect surrounded the niche with encroachment on the gastric air bubble. A repeat gastroscopic examination was performed and the previously noted crater-like defect was not visualized. A small whitish area was seen and thought to be the site of the healed ulcer. However, the


FIG. 3. Case 4, R. J. E. Rounded filling defect of the pars media which was mobile, as though attached to a pedicle, and nontender. Gastroscopically this lesion arose on the angulus and extended into the antruin.

likelihood of another lesion that had been missed because of its proximity to the cardioesophageal junction could not be ruled out. A fourth gastrointestinal roentgen-ray series showed persistence of the previously noted crater. An exploratory laparotomy revealed an inoperable gastric carcinoma arising high in the fundus with widespread metastases.

In two of the cases a lesion was seen, but, because of its extensive nature and other gastroscopic features, the lesion was called a lymphoma rather than carcinoma.

Case 3. J. V. C . , a 60-year-old white man, entered the hospital complaining of abdominal pain and weight loss of two months’ duration. The physical examination revealed only tenderness on deep palpation in the epigastrium. A hemogram revealed a rather severe micro- cytic anemia, stools were persistently positive for occult blood, and the gastric analysis failed to show free acid after two doses of histamine. An upper gastrointestinal roentgen-ray series failed to show evidence of peristalsis during fluoroscopy. On the radiographs a large defect was noted on the lesser curvature of the media and was thought to be not typical of an ulcer in outline. A diagnmis of probable gastric

cancer was niade and gastroscopy recom- nientled. Gastroscopy revealed the distal two thirds of the stomach to be fixed and tubular and without peristalsis. On the lesser curvature 01 the posterior wall was noted a hemor- rhagic projecting area “reminiscent of the projecting heniorrhages that Schindler described as diagnostic of lyniphosarcoma.” Sim- ilar type tissue was noted on the anterior wall extending to the cardia. Surgical exploration was carricd out a n d revealed a large tumor, about 12 cni. in diaineter and 1 cm. in height, that had perforated in two areas, one into the pancreas antl the other into the liver. A total gastrectoniy was performed. Histological examination revealed the tumor to be limited chiefly to the niucosa but with much invasion into the niuscularis for variable distances. T h e diagnosis was atlenocarcinoma.

1 n the 1-elria-ining two cases, a localized lesion l v a s mistakenly diagnosed as a benign leiomyoma. One subsequently proved to be a polyp with malignant degeneration and the other, a leioniyosarcolna. The clinical distinction between leioniyonia a n d leiomyosarcoma, in the absence ol loral spread or metastases, is rarely niade prior to histological examination.

Case 4 . R. J . E., a 76-year-old white man, was admitted to the hospital for the treatment of rheumatoid arthritis. There was a history of abdominal surgery for “ulcers” twenty years previously, and, because of persistent abdominal distress, a roentgenological examination of the upper gastrointestinal tract was performed. This revealed a large filling defect of the upper pars media (Fig. 3). freely mobile, nontender, and thought to be benign roentgenographically. Gastroscopy revealed a round, globular mass arising on the angulus and extending into the antrum. T h e mass was covered with normal mucosa and did not appear fixed. The mu- C O S ~ at the tip of the mass was noted to be macerated, but a diagnosis of benign intramural tumor, probably leiomyoma, was made. At surgery a local excision was performed. Studies of the tissue showed a soft, lobulated, red-brown, vascular mass that proved to be a papillary adenocarcinoma on histological examination.

Case 5. (This case was previously reported in detail elsewhere.2) C . S., a 62-year-old white man, entered the hospital because of melena of six weeks’ duration. On admission, physical examination revealed only a marked pallor. An upper gastrointestinal roentgen-ray series showed a rounded filling defect, 3.5x3.5 cm., in the antrum, in the center of which was a smaller crater with retention of a large barium fleck. T h e duodenal bulb was irritable with

No. 6 ACCURACY OF GASTROSCOPY IN GASTRIC TUMORS . Baker et al.

irregularity and deformity. A diagnosis of duodenal ulcer and ulcerated polypoid neoplasm was made. Leiomyoma and leiomyosarcoma were considered as possibilities. Gastroscopi- cally, this mass was noted to have slightly hyper- emic niucosa and at the apex an oval ulceration, 1 cm. in diameter, was seen. At the base of the central ulceration there was a dirty greenish- brown exudate and the ulceration was surrounded by a red areola. A diagnosis of leiomyoma was made. At surgery this lesion was localized and resected and proved to be a leiomyosarcoma microscopically.

In an analysis of the thirty-four cases in which a correct diagnosis was not made by roentgenograms, we note fewer errors caused by an inadequate examination but more caused by misinterpretation. Only two examinations were considered as inadequate for interpretation, one because of retained food particles in the stomach and the other because of excessive sustained sDasm. In four cases a definitive etio-

1121

logical diagnosis was not made because of high- grade pyloric obstruction. In twelve cases, all of which were carcinomas, the lesion was called a benign ulceration roentgenographically. Five cases were diagnosed as gastritis, and two showed only large rugal folds. One case of polypoid adenocarcinoma and one of leiomyosarcoma were diagnosed as benign polyps. In one case, a carcinoma was misdiagnosed as a lymphoma and in five others nothing abnormal was noted in the stomach. In the remaining case a primary lymphosarcoma of the stomach was misdiagnosed as a carcinoma, this despite four repeated roentgen-ray examinations.

Case 6. (This case was previously included in a review of intestinal lymphosarcoma.~~) R. J. B., a 26-year-old white man, was admitted to the hospital with signs and symptoms of acute appendicitis. After emergency appendectomy, the patient did poorly, complained of persistent epigastric distress and dysphagia, and failed to gain weight. Anamnesis at this time revealed that the patient had had similar distress five months previously and an upper gastrointestinal roentgen-ray series done at that time was reported as normal. Two weeks previous to the acute appendicitis there had been an episode of heniatemesis. The family physician, at that time, instituted treatment for a peptic ulcer. With this history in mind an upper gastrointestinal roentgen-ray series was performed at this hospital and was reported as showing a filling defect of the antrum (Fig. 4). This was interpreted as carcinoma, but certainly not typical of the usual gastric carcinoma. There was a question of a perforation into the lesser

FIG. 4. Case 6, R. J. B. A large ulceration defect of the entire lesser curvature with nonfilling of the antrum. This was reported as atypical for the usual gastric carcinoma.

peritoneal sac. At gastroscopy a very extensive neoplasm filling most of the stomach was noted. The rugal folds were large and appeared stiff and rigid. The patient was unable to retain very much of the inflated air. The gastroscopic impression was lymphosarcoma. Thereafter deep roentgen-ray therapy to the abdomen was instituted. Regression of the gastric tumefac- tion occurred and exploratory laparotomy was then carried out. At surgery a very extensive tumor of the entire stomach with widespread intraperitoneal metastases was found. A biopsy of the tumor mass revealed a lymphosarcoma. The course thereafter was progressively down- hill and the patient subsequently died. At necropsy a massive (1 5x20 cm.) ulceration was noted on the lesser curvature of the stomach with rolled edges and submucosal infiltration (Fig. 5).

In this series of 106 malignant tumors, five patients had had previous subtotal gastric re- sections. In three of these cases roentgenography delineated the correct diagnosis, but completely missed the remaining two cases. Gastroscopy on the other hand permitted a correct diagnosis of gastric carcinoma in all five cases.

Previous reviewers have criticized this meth- od of direct comparative evaluation of diagnostic adequacy. Templeton emphasized the relation between the anatomical gross type of

1122 CANCER Noi

lesions and diagnostic accuracy. We thought that this anatomical classification might be use- ful in making such an evaluation of the procedures under discussion. We then reclassified the cases in this review in accordance with their gross pathological type, location of the lesion, and diagnostic accuracy. According to their intraluminal appearance, the lesions were clas- sified as (1) predominantly polypoid or fun-

!ember 1952 VOl. 5

in thirty-nine of forty-one polypoid cases (95 per cent), nineteen of twenty-six ulcerating cases (73 per cent), and in six of seven “diffuse” cases (86 per cent). Considering lesion location as a single factor, there was little significant difference, although lesions of the antrum were missed a little more frequently.

If we add to these seventy-four localized cases, the more extensive lesion involving mare than one subdivision of the stomach, the final combined diagnostic error changes from the 14 per cent noted in Table 5 to the previously noted 8.5 per cent.

TABLE 5

TRIC CARCINOMAS BY GROSS ANATOMICAL TYPE AND LOCATION

ANALYSIS O F SEVE NTY-FOUR PROVED GAS-

Correct Neither

X-ray Gastroscopy correct ____ Total Lesion no. No. % No. % No. %

Polypoid 41 33 80 30 73 2 5 Ulcerative 26 10 38 17 65 7 26 Diffuse 7 3 43 6 86 1 14 Fundus 18 10 55 12 66 2 11 Media 27 20 74 22 82 3 11 Antrum 29 16 55 20 69 5 17

FIG. 5 , Case 6 , R. J. B. Primary lymphosarcoma of the stomach.

gating, (2) predoininantly ulcerative, and ( 3 ) diffuse with predominant infiltration and in- duration of the gastric wall. In eighty-six of the 100 cases of gastric carcinoma, the anatomical type and primary location were well delineated. Ten of these eighty-six cases were so extensive that they involved more than one subdivision of the stomach. Two other cases presented more than one isolated lesion in each case-a lesion in the antruin and another in the fundus. This left a total of seventy-four cases in which the lesion localized to a particular section of the stomach and the gross pathological type was known. These are listed i n Table 5.

Considering gross anatomical type as a single factor, roentgenograms permitted a correct diagnosis in thirty-three of forty-one polypoid cases (80 per cent), in ten of twerity-six ulcerating lesions (38 per cent), and in three of seven “diffuse” types (43 per cent). Gastroscopy re- sulted in a correct diagnosis in thirty of forty- one polypoid cases (73 per cent), in seventeen of twenty-six ulcerating cases (65 per cent), and in six of the eight “diffuse” cases (75 per cent). The combined procedures were correct

During this same five-year period, the gastroscopic examination of sixty-four subsequently proved non-neoplastic gastric lesions aroused the suspicion of neoplasm. In about 40 per cent of these cases (twenty-four of sixty-four), the lesions were diagnosed as benign, a1 though the gastroscopist could not positively eliminate the possibility of cancer. These cases are included here, nonetheless, because there was some state- ment in the gastroscopic write-up that directed attention toward some suspected neoplastic feature. A comparative analysis of these cases is listed in Table 6. A correct diagnosis was made by gastroscopy in only twelve of the thirty-nine benign gastric ulcers on initial examination. These are listed as correct because, despite the notation that some features suggested carcinoma, the final diagnosis established gastroscopically was that of a benign ulcer. T h e procedure was repeated in twenty of the twenty-seven incorrectly diagnosed cases and then correctly revised in eight of these. Thus, in nineteen of this group of thirty-nine benign ulcers, a diagnosis of cancer was made after two or more gastroscopic examinations. Gastroscopy was thus correctly interpreted in only twenty of the thirty- nine benign gastric ulcers (51 per cent), while thirty-three of these same thirty-nine cases

No. 6 ACCURACY OF GASTROSCOPY IN GASTRIC TUMORS . Baker et al.

TABLE 6

GASTROSCOPICALLY SUSPICIOUS OF NEOPLASIA DIAGNOSIS OF SIXTY-FOUR PROVED BENIGN GASTRIC LESIONS,

1123

Initial examination Subsequent examination

X-ray Gastroscopy

Total X-ray Gastroscopy Neither Not Not Condition no. correct correct correct Corrected corrected Corrected corrected

Gastric ulcer 39 28 12 Gastritis

Simple hypertrophy 11 4 6 Adenom. hyperplasia 3 2 2

Gastric polyposis 3 2 2 Adhesions 3 1 2 Normal stomach 3 0 0 Gastric varices 1 0 0 Aberrant pancreas 1 0 0

TOTALS 64 37 24

(84 per cent) were correctly diagnosed by roentgenograms. Of the remaining non-neoplastic gastric lesions, the diagnostic efficacy of each procedure was about 50 per cent. The comparison of gastroscopy to roentgenography in so far as diagnostic accuracy is concerned is of little value in this group because of the nature of the cases chosen. It should be noted here that the gastroscopists at this institution always call attention to the diagnosis of “neoplasm” if there is anything in the gastroscopic picture that is the least bit suspicious.

- - - ___.~

DISCUSSION

The differential diagnosis of gastric neoplasms is frequently difficult. The relative un- importance of age in the clinical distinction of carcinoma and benign gastric ulcer has been well substantiated, both tending to occur at the same mean age of 52 years.8 In this series of cases the incidence of benign ulceration occurring in Negroes is about half of that of cancer occurring in this race. This is mentioned only in passing, and no statistical significance can be ascribed to this difference because of the selection of cases and the numerical difference in the two series.

From Table 3, a comparison of the accuracy of roentgenography and gastroscopy in the diagnosis of gastric neoplasms, one notes that a correct diagnosis was made by roentgenography in 68 per cent of the cases and by gastroscopy in 75 per cent-not a significant difference. Combining the two procedures, a correct positive diagnosis was made in 91.5 per cent and an incorrect diagnosis in 8.5 per cent. By combining the figures in two separate series of a simi-

lar nature compiled a decade lo it was found that a correct roentgenographic diagnosis had been made in 77 per cent and a correct gastroscopic diagnosis in 80 per cent on initial examinations-little significant difference in this ten-year period. Benedict, in a comparison of the two procedures, found roentgenograms to be valuable diagnostically in thirty-two of fifty-two cases in which there was disagreement between roentgenography and gastroscopy in a series of 125 proved cases of gastric carcinoma. Our figures show gastroscopy to be of more value in thirty-one of fifty-eight cases in which there was disagreement between the two procedures on initial examination; roentgenography, in the other twenty-seven. In Benedict’s series, gastroscopy failed to permit a correct diagnosis in thirty-two cases (25 per cent), the same error as occurred in our series. In the analysis of these thirty-two errors, Benedict found that twenty-five were due to inadequate visualization of the lesion-again about the same propor- tion as in our series. Moersch,6 in a series of 100 cases of proved carcinoma, reported 64 per cent correct initial diagnoses by gastroscopy, increased to 70 per cent by subsequent re-examination. In that series, a correct initial diagnosis was made by roentgenography in 38 per cent, increased to 52 per cent by repeated examinations. LaDue, in a recent report on 144 gastric carcinomas, correctly diagnosed 84 per cent us- ing, the flexible gastroscope, whereas diagnosis by roentgenography was correct in 89 per cent; combined, a positive diagnosis was made in 96.5 per cent. Niemetz correctly diagnosed 69 per cent of gastric cancers gastroscopically and 73 per cent roentgenographically. In these combined series the figures for diagnostic accuracy


by the roentgenogram vary from 52 per cent to 89 per cent and by gastroscopy, from 52 per cent to 84 per cent. In a report dealing only with conflicting diagnosis by roentgenography and gastroscopy, Ricketts noted that eleven of nineteen gastric carcinoma cases were correctly diagnosed from roentgenograms and only three of the same nineteen cases by gastroscopy.

FIG. 6. Case 7, J. L. I. Giant rugal folds with some fixation, diagnosed as lymphoma.

The errors in diagnosis by gastroscopy in gastric carcinoma have been due, in more than 80 per cent of the cases, to lack of adequate visualization of the lesion. In our series, inadequate visualization of the lesion was the source of the error in twentyfour of the twenty-nine incorrect diagnoses. Benedict failed to visualize the lesion in twenty-five of the thirty-two cases in which gastroscopy was at fault. Twelve of these lesions were located in the “blind areas” of the antruin and prepyloric areas. Of the errors caused by misinterpretation of observed lesions, three cases of ulcerative antral carcinomas were mistakenly diagnosed as benign, in one case a fixed angulus was misinterpreted, in one case a prepyloric contraction was mistaken for a normal pylorus and a small carcinoma was missed, and in one case a carcinoma was mistakenly called verrucous gastritis. In the seventh case, a lesion was not seen but surgery was recommended because of persistent symp-

toms. Benedict apparently correctly diagnosed all polypoid carcinonias, whereas in our series two polypoid carcinomas were mistakenly thought to be benign.

T h e gastroscopic differentiation of gastritis from gastric carcinoma has previously been emphasized by Moersch5 and 0thers.1~. In 100 cases, Moersch erred gastroscopically in twenty, in nineteen of which there had been no previous surgery. Twelve of these twenty cases were carcinomas. Actually the distinction was so difficult that the diagnosis could not be made gross- ly at surgery in six of the twelve. He concluded that the error in differential diagnosis between the two lesions is 10 per cent. T h e gastroscopic features of hypertrophic gastritis have been adequately described.15

The overdistention test13 may often aid in distinguishing large folds from hypertrophic gastritis. The former are effaced by inflation while the latter may diminish somewhat in size but do not disappear nor does the “cobblestoning” disappear.

As has been pointed out by Palmer,s Rick- etts, and others, chronic antral gastritis is a lesion very frequently mistaken for carcinoma. In Ricketts’s series, three cases of antral pseudopolypoid gastritis were diagnosed roentgenographically. In our series, there were fourteen cases of simple hypertrophic and/or pseudopolypoid gastritis in which the question of cancer was at one time or another seriously entertained. I n five of these cases a correct diagnosis was not established until histological examination of the surgically removed stomach.

Case 7. J. L. I., a 28-year-old white man, was admitted to this hospital because of lymphe- dema of both lower extremities. Because of persistent abdominal distress, an upper gastrointestinal roentgen-ray series was performed and revealed tremendous gastric rugae (Fig. 6). A diagnosis of probable lymphoma was made. Gastroscopy revealed extensive large nodules with bleblike structures at the apex having slight depressions and some with central hem- orrhagic areas. These occurred mainly on the greater curvature of the media but also extended to the fundus. A diagnosis of lymphoma was made and exploratory laparotomy recommended. At surgery, polypoid hypertrophic rugae were noted-many with umbilication and superficial erosions (Fig. 7). A subtotal gastric resection was performed. Histological examination revealed adenomatous hyperplasia.

One of the most difficult differential diagnostic features of gastric carcinoma is the accu-

No. 6 ACCURACY OF GASTROSCOPY IN GASTRIC TUMORS . Baker et al. 1125

rate delineation of primarily ulcerative lesions. This is confirmed by the present series in which false-negative diagnoses amount to 26 per cent of the primarily ulcerative carcinomas by combined use of roentgenography and gastroscopy. In this series the two methods compare favor- ably in primarily fungating lesions, but gastroscopy is significantly more reliable in the diagnosis 01 primarily ulcerative carcinoma (gastroscopy, 65 per cent correct; roentgenography, 38 per cent correct). In the differentiation of these types of lesions exist one of the most fruitful fields of gastroscopic usefulness. Willis believes that in any statistical study ol tumors, both false-negative and false-positive diagnoses must be considered. The iormer, including those proved cases in which cancer was not diagnosed clinically, has already been considered and amounts to 25 per cent. The false-positive diagnoses include cases diagnosed as cancer but in which no carcinoma was subsequently found on histological examination, either froin surgical excision or at necropsy. During the five- year period under discussion the gastroscopic “falsepositive” diagnoses number fifteen of 134 proved benign ulcerative cases (11.2 per cent). This ratio of false-posi tive diagnoses to verified positive diagnosis is 15:17 or about 1: 1, e.g., for every verified positive diagnosis of malignant gastric ulcer made gastroscopically there is one benign gastric ulcer called malignant. Consid- ering the entire group of sixty-four non-neoplastic gastric lesions, a positive diagnosis of gastric carcinoma was made by gastroscopy in twenty-four of the thirty-two cases in which an incorrect diagnosis was made. This gives a ratio

FIG. 7 . Case 7, J . L. I . Pseudopolypoid hypertrophic Iugae with some adenomatous hyperplasia.

FIG. 8. Case 8, W. B. Intramural filling defect with barium filling a central ulceration. This lesion was not seen gastroscopically and surgery eventually proved the lesion to be aberrant pancreas.

of false-positive diagnoses to verified positive diagnoses of 24:75 or about 1:3. Willis, in 1948, in an analysis of the clinical diagnostic accuracy of 155 proved (necropsy) cases of gastric carcinoma noted a similar ratio of 1:3.

In the breakdown of our false-positive diagnoses of gastric carcinoma, the erroi in each case was based on the presence of one 01 inore of the following: surrounding nodular gastritis, absence of peristalsis, distortion of the lu- men owing to previous inflammatory changes, or a dirty, grayish ulcer base. Three cases showed the latter abnormality and each of these had been a benign ulceration that had perforated into an adjacent organ-pancreas and/ or liver. In each of these cases surgery was recommended by the gastroscopist and subsequently performed.

Henedict felt that roentgenography was definitely superior to gastroscopy in 80 per cent of those cases in which there was disagreement between the two procedures. However, Ricketts felt that it was of more value in 40 per cent and gastroscopy in 58 per cent of forty-five similar cases. Hardt felt that gastroscopy was more valuable in all types of gastric ulcers, including stoma1 ulcers. Niemetz notes that, gastroscopically, benign ulcers were called malignant

1126 CANCER November 1952 Vol. 5

more than twice as often as malignant ulcers were called benign. In our series of gastrosco- pies, nine of twenty-six malignant ulcers were called benign (35 per cent), whereas fifteen of 134 proved ulcers (1 1 per cent) were diagnosed definitely as malignant.

With gastric lymphomas, gastroscopy al- lowed a correct diagnosis in all four cases, whereas the roentgenogram was correct in only two of the four. The gastroscopic criteria of lymphoma includes the recognition of widespread, very thick gastric folds with marked cobblestoning of the mucosa and multiple erosions and u1cerations.l The diffuse form, which is frequently primary in the stomach, is char- acterized by the very thick and stiff stomach wall. The localized form with projecting sub- mucous masses is frequently a part of the general lymphoblastoma. In three of the four cases in this series the diagnosis had previously been established clinically. In the fourth case, R. J. B., a primary lymphosarcoma of the stomach was established only by gastroscopic examination.

In the one case of aberrant pancreas of the stomach in this series, neither procedure pro- duced a definitively positive diagnosis, although the roentgenologist considered the possibility. Palmerlo in a recent review emphasized that this diagnosis has seldom been correctly made preoperatively. When a central duct opening can be distinguished, the diagnosis may be suspected.

Case 8. W. B., a 24-year-old white man, was admitted to the hospital because of periodi- cally recurring nausea and vomiting of four years’ duration. An upper gastrointestinal roentgen-ray series showed an antral intramural filling defect with a central ulceration (Fig. 8). Among the diagnoses to be considered were benign ulcer, carcinoma, aberrant pancreas, and leiomyoma. At gastroscopy large rugal folds were the only abnormality noted. However, because of the roentgenogram, surgery was recommended. At surgery a 1 x 1.5-cm. firm, rounded mass was found 1 y2 in. proximal to the pylorus. A wedge resection was performed. Histological examination of this tissue revealed aberrant pancreas.

Before concluding certain pertinent remarks should be made. T h e roentgenological examinations in this series were performed by at least twenty different examiners, the majority of whom were Residents in Radiology. The gastroscopic examinations, on the other hand, were all made by or directly under the super-

vision of two of the authors (M. A. S. and E. A. G,). At this hospital the gastroscopists are also the clinical consultants on the Gastro-En- terologic Service, so that the clinical data that they have available are, a t times, decisive in determining the formal gastroscopic impression. Because of the adaptability of roentgenology to mass diagnosis of gastric lesions, that procedure is almost always performed prior to gastroscopy at this hospital. The latter procedure is used as a “fine adjustment,” particularly for ulcerative gastric lesions.

CONCLUSIONS

1. On initial examination 59 per cent of 106 gastric cancers were correctly diagnosed from roentgenograms. Re-examination of doubtful cases raised this figure to 68 per cent. A correct diagnosis was made by gastroscopy in 70 per cent of these same cases on initial examination and this figure is raised to 73 per cent by re- examination of doubtful cases. Roentgenogra- phy plus gastroscopy permitted a correct diagnosis in 91.5 per cent of malignant gastric tumors.

2. Of the gastroscopic errors, 83 per cent were due to inadequate visualization of the lesion. When the lesion can be seen, diagnosis by gastroscopy is more accurate than by roentgenography.

3. In gastric cancer the greatest diagnostic error by roentgenography and/or gastroscopy occurs in the primarily ulcerative lesions. Gas- troscopy is slightly more accurate than roentgenography in the diagnosis of primary ulcerative gastric cancers.

4. Lesion location has little significance in the determination of diagnostic accuracy of roentgenography and/or gastroscopy in gastric cancers.

5. Of subsequently proved benign gastric ulcers, 11.2 per cent were incorrectly diagnosed gastroscopically as cancers.

6. The ratio of false-positive diagnoses to verified positive diagnoses by gastroscopic examination was 1:3 for gastric neoplasms in this series.

7. False-positive gastroscopic diagnoses are occasioned by misinterpretation of surrounding nodular gastritis, absent peristalsis, luininal distortion, and/or a necrotic ulcer base.

8. Gastroscopy is an adjunct to, and not a substitute for, roentgenology in the diagnosis of gastric neoplasms.

No. G ACCURACY OF GASTROSCOPY IN GASTRIC TUMORS - Baker et al. 1127

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diagnostic accuracy of gastroscopy in neoplasms of the stomach

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