Malignancy in gastric ulcers

Malignancy in gastric ulcers

In contrast to chronic duodenal ulcers, gastric ulcers are associated with malignancy . There are two clinical scenarios that should be distinguished: one in which a benign chronic gastric ulcer undergoes malignant transformation (rare) and the more common scenario in which a gastric ulcer is assessed as benign either endoscopically or on contrast radiology but biopsies reveal malignancy . In this situation, the patient has - - -

Figure 67.12 Benign incisural gastric ulcer shown at gastroscopy (courtesy of Dr GNJ Tytgat, Amsterdam, The Netherlands). (a) (b) Large gastric ulcer Figure 67.13 Benign gastric ulcer shown on barium meal. (a) Radiograph; (b) diagrammatic outline.

peptic ulcer. Therefore, all gastric ulcers should be regarded as being malignant, no matter how classical the features of a benign gastric ulcer. Multiple biopsies should always be taken, perhaps as many as 10 well-targeted biopsies, before an ulcer can be tentatively accepted as being benign. Even then it is important that further biopsies are taken while the ulcer is healing and when healed. Modern antisecretory agents can frequently heal the ulceration associated with gastric cancer but, clearly , are ine ff ective in treating the malignancy itself. At operation, even experienced surgeons may have di ffi culty distinguishing between the gastric cancer and a benign ulcer. Operative strategies di ff er so radically that it is essential that a confident diagnosis be made before operation. At ation for a perforated gastric ulcer, even if it is considered that the ulcer is benign, the ulcer should be excised and submitted for histological examination.