It is commonly stated that secondary cancer of the stomach is extremely rare, and writers formerly accorded considerable prominence to a case in which Cohnheim discovered a nodule of scirrhus in the stomach after death from a similar affection of the breast. Eecent investigations, however, tend to show that the phenomenon in question is by no means so uncommon as is usually believed. Welch was able to collect thirty-seven examples without exhausting the available literature, Ely fourteen, and de Castro twenty-two; while in our own series of 265 necropsies upon cancer of the stomach, nineteen, or 7 per cent., were secondary to disease of some other organ. This latter estimate closely agrees with the conclusions arrived at by Hale White, who states that 6 to 7 per cent, of all gastric carcinomata are of secondary origin.
The relative frequency with which one or other viscus of the body is the site of the primary complaint is found to vary with the method employed in collecting the cases. Thus Welch, who appears to have consulted a great mass of statistics relative to mammary cancer, found that in nearly one-half the gastric complaint was secondary to disease of the breast; while in the statistics of Ely, de Castro, Torok, and Wittelshofer the mouth, oesophagus, uterus, and testicle were more frequently affected.
But when recourse is had to a large series of consecutive necropsies performed at a general hospital, thereby avoiding the errors incidental to an analysis of isolated cases, it at once becomes evident that secondary cancer of the stomach may arise in at least three different ways. Thus, we find that out of the nineteen instances to which reference has been made, no less than fourteen, or 73.6 per cent., were due to direct extension of the disease from some neighbouring organ ; that in four, or 21 per cent., the primary complaint was situated in the upper part of the digestive tract; while in only one, or 5 per cent., was the gastric affection of the nature of a true metastasis. These results are of sufficient importance to merit a detailed description.
(1) Invasion of the stomach by contiguity may ensue from cancer of any organ in its immediate vicinity. Out of our fourteen cases, the pancreas was the seat of the disease in six, the transverse colon in three, the lower end of the oesophagus in two, and the gall-bladder, liver, and uterus each in one. Less frequently the peritoneum, retro-peritoneal glands, the adrenals or ovaries are first involved. When the pylorus is invaded, it often presents a uniform infiltration, as in the primary complaint, with considerable thickening of the serosa ; but if the posterior wall of the organ or the fundus is implicated, the growth is comparatively localised, and ulceration of the mucous membrane is by no means infrequent. Cancer of the lower end of the oesophagus seldom spreads far into the stomach, and when it does so, it is usually along the line of the lesser curvature. It is nearly always a squamous-celled epithelioma, but examples of spheroidal-celled growths are more frequent than was once believed. In peritoneal cancer the stomach is invaded from without by numerous nodules, which form projections beneath the mucous membrane, and may even produce typical ulceration. In one of our cases cancer of the uterus spread by way of the great omentum into the pylorus, which became greatly contracted and proved the immediate cause of death.
(2) The undue frequency with which the stomach is affected in cancer of the tongue, mouth, nares, and oesophagus is probably due, as Kiebs suggested, to the detachment of particles of growth, which are swallowed, and subsequently become engrafted upon the gastric mucous membrane. In one case of this kind which came under our notice an ulcerated stricture of the oesophagus was found opposite the cricoid cartilage, and another and apparently more recent growth three inches lower down ; while at the inner side of the cardiac orifice, upon the posterior wall of the stomach, was a flattened ulcerated tumour which, like the oesophageal growths, was composed of flat-celled epithelioma. In another instance, where the primary disease occurred about three inches above the cardiac orifice, a large fun gating tumour occupied the middle of the lesser curvature. Both growths consisted of spheroidal-celled carcinoma. As a rule the gastric tumour is solitary, and grows in the cardiac region of the viscus, near its upper border. Ulceration is infrequent.
Fig. 19.- with a secondary growth in the stomach. (Museum of the Royal College of Surgeons.).
(3) Secondary deposits in the stomach from a growth in an organ remotely situated probably arise from infection of the blood-stream, and are usually associated with metastases in the liver or lungs. Out of thirty-one cases of this description which we collected, the breast was primarily affected in twenty, the right testicle in two, the uterus in three, the bowel in two, the skin in two, and the kidney and adrenals each in one. The tumour in the stomach was usually solitary, of variable size, situated in the submucous tissue, and rarely accompanied by ulceration.
It is difficult to trace the evolution of carcinoma in the stomach, owing to the extensive destruction of the tissues which occurs at an early period of the disease, and the changes that take place in the mucous membrane immediately after death. Most of our knowledge of this subject has been derived from the observations of Hauser upon the development of cancer in the base of a simple ulcer.
Although the different forms of growth vary considerably, both in their macroscopic appearances and histological structure, they nevertheless possess certain features that are common to all, and which serve to distinguish them from other tumours of the organ, both malignant and benign.