Malignant Degeneration of Gastric Ulcer: (Section of Surgery).

Malignant degeneration is the most serious complication of gastric ulcer. Its recognition is difficult both in the early stage and in advanced cases in which only the evidence of a previous ulcer-cavity, and the radiating folds of the mucous membrane indicate progressive development of carcinoma from an original ulcer.It is impossible to say how often gastric ulcer becomes malignant; one can only state the frequency of ulcer-carcinoma, found in gastric resections.One hundred and forty-one personal cases of ulcer-carcinoma are recorded, and are divided into three groups.GROUP I: 41 which were diagnosed clinically and at operation as cases of ulcer, but in which histological examination showed incipient cancer.GROUP II: 55 diagnosed clinically as cases of ulcer, but in which a diagnosis of ulcer-carcinoma was made during operation and afterwards histologically confirmed.GROUP III: 45 diagnosed both clinically and macroscopically (from the typical folding of the mucous membrane) as cases of ulcer-cancer, in which the cancer had entirely overgrown the ulcer.Therefore in the series of 532 resections for gastric ulcer the frequency of ulcer-carcinoma was 20.9%, or 15.2% if the third group is omitted.In a series of 718 resections for gastric cancer, the frequency of ulcer-carcinoma was 19.6% (or 14.2% if the third group is omitted).The mortality in simple two-third resection of the stomach is low (four deaths in 99 cases = 4%). When the pancreas, liver, colon, or oesophagus, is involved, the resection mortality is high (14 deaths in 42 cases = 33.3%), but even in these cases the operation is justifiable because permanent cures were achieved in a number of cases.The prognosis in cases of ulcer-cancer is very grave. In many cases, judging from the author's own experience, patients suffering from incipient ulcer-cancer-only histologically diagnosed as cancer-die from liver metastases, in spite of radical resection. It will thus be seen that the end-results of resection for ulcer-carcinoma are actually worse than those of resection for primary carcinoma.A. Ulcer-cancer: In Group I, 35 cases were operated on before 1933, and in 18 of these (51.4%) the patients have been free from symptoms for more than five years; in Group II, 27 cases were operated on before 1933, and in four of these (14.8%) the patients are still symptom-free. In Group III, out of 37 cases operated on, only two patients (5.4%) have been symptom-free for the same period.B. Primary cancer: Out of 260 cases of resection for primary cancer before 1933, 77 patients (29.6%) are permanently cured.If the ulcer-cancer is so far advanced that the diagnosis can be made clinically, or during operation, the prognosis is extremely bad (permanent cures having been only 9.3% in the series).In cases of gastric ulcer the best plan is to carry out resection before malignant degeneration begins. The result would then be that not merely 51% but at least 90% of the patients would be alive and well after five years.