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2 pp. 365-371, 1990 Journa l 01 Ko rean Rad iological Society , 26 (2) 365-371 , 1 990 Ultrasonography of Gastric Cancer after Water Ingestion Jong Chul Kim, M.D. Department of Ra diology, College of Medicin e, Chungnam National University 500-900 5M Hz 1. 2. 3. 1 4. 5 Index Words: S tomach can cer , 7 2.3 21 Stomach , ultrasoun d stud ies , 7 2. 1 298 1 Received November 4. 1989. accepted Janu ary 13. 199 0

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Page 1: Ultrasonography of Gastric Cancer after Water Ingestion · 2017. 4. 6. · early gastric cancer by UGIS, and a case of advanced gastric cancer involving all gastric layers was mistal‘en

大 짧 放 射 線 쩔 쩔 會 誌 第26卷 第 2 號 pp . 365-371, 1990 Journal 01 Korean Rad iological Society , 26 (2) 365-371, 1990

Ultrasonography of Gastric Cancer after Water Ingestion

Jong Chul Kim, M.D.

Department of Radiology, College of Medicine, Chungn am National University

〈 國文沙綠 〉

톱혐의 물 먹인 後 超품波 所見

忠、南大學校 醫科大學 放射線科學敎室

金 鍾 哲

著者는 放射線學的 上部뿜陽造影í'i!tj여 나 內視鏡檢흉로 몹 7흙이 發見된 40명의 뿔、者를 對象으로

500-900 cc의 보리차를 먹인 後 5MHz 트랜스듀서로 超흡波檢훌를 實施하여, 그 所見을 前記의

두 檢흉와 手術後의 病理學的 所見과 比較分析해 보아, 다음과 같은 結論을 얻었다.

1. 正常 뿜용좋은 다섯 層의 單層構造를 보여 組織學的 構造에 相應하였다.

2. 몹찮의 睡塊 自體의 3次元的 立體構造를 力動的으로 잘 보여주고, 周圍 림프節 睡大나 周圍 驗

器의 慢犯 與否 決定에 많은 도움을 주었다.

3. 몹찮이 몹뿔의 어 느 層까지 f룻犯하였는지 그 깊이를 알 수 있어 早期 뿜찮 ( n = 4 ) 과 進行몹혐(n

=36 ) 의 錯別을 可能하게 했고, 進行몹훨의 境遇 固有節肉層까지 f훌犯한 境遇 ( n =4)를 짧別할

수 있었다. 하지 만 固有觸 l최層까지 홈犯한 進行몹}흙을 윷體까지 홉犯한 境遇로 誤談한 例도 1

例 있었다.

4. 몹훨이 몹휠좋을 따라 測防으로 어디까지 흡犯했는지 그 範圍도 알 수 있어 서 外科的 切除時 安

숲한 切除部圍 決定에 도움을 주었는데, *~~莫I룡에 局限된 早期몹협 1例에 서는 正確한 뼈IJ防範

圍 決定이 容易하지 않았다.

5 放射線科學的 上部몹1꺼造影術이나 內視鏡檢효 所見上의 몹훨內 궤양部f立는 超音波檢흉로 相

應시키기가 쉽지 않았는데, 特히 早期몹찮內의 작은 궤양部位를 찾기가 힘 들어 早期뿜찮의 分

類가 힘 들었다. 앞으로 이에 對한 따究가 必要할 것으로 思料된다.

물 먹인 後의 뿜 超音波檢훌는 뿜혐의 立體的, 力動的 內部構造, 몹 1훨의 뿜 용좋 f훗犯 깊이 및 測

防 範圍, 周圍 驗器나 림프節과의 關係에 關한 많은 情報를 提供해주므로, 몹홉의 짧7JIJ장斷, 切除

部(立 決定 및 手術後의 追없;檢훌로 簡便하고 容易하게 使用될 수 있는 좋은 方法으로 思料되는데 ,

向後 手術切除 뿜標本의 超音波檢훌와의 比較Iitf究가 더 必要할 것으로 생각된 다.

Index Words: S tomach can cer, 72.321

Stomach , ultrasound studies , 7 2. 1298 1

본 論文은 1 990年 忠南大學校病院 臨tiÇ li자究됐의 支援으로 이 루어졌음 이 논문은 1 989년 11월 4일 접수하여 1990년 1월 13일에 채택되었음 Received November 4. 1989. accepted January 13. 1990

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- 大韓放射線홉學會誌 第 26卷 第 2 號 1990 -

Introduction

Double contrast upper gastrointestina1

series (UGIS) and f1exible fiberoptic gastro­

scopy with or without ultrasonographic trans­

ducer tip have significantly improved the dia­

gnosis of gastric pathology. Although the ab­

dominal ultrasonography may detect the gas­

tric wall lesions 1-3), precise and detai!ed in­

formation about the relationship of the lesion

to the gastric wall , such as depth of pene­

tration or latera1 wall extension of the tumor ,

is difficult to obtain , especia11y when bowel

gas inhibits the transmission of the ultra­

sound beam.

Ultrasonographic features in 40 patients

with pathologica11y proven gastric cancer were

described. Sonographic findings were com­

pared with those of upper gastrointestina1

series , gastroscopy with biopsy, CT, oper-

ation , and pathologic specimen. The author wants to stress the usefullness

of sonography in the diagnosis and dif­

ferential diagnosis of gastric cancer during

pre-treament and postoperative follow-up

periods.

Materials and Methods

Ultrasonography after water ingestion was

performed in 100 patients with gastric and

duodenal pathology demonstrated by endos­

copy and/ or UGIS , from Feb ., 1987 to June ,

1989, in Chungnam and Gyeongsang National

University Hospital, using 5 MHz linear or sec­

tor transducer of Siemens Sonoline SL-2 or

Diasonics DRF-400.

The findings of pathologica11y proven gas­

tric cancer in 40 patients among 100 patients

were compared with those of other methods

(UGIS , gastroscopy , CT), and were analysed.

When a gastric cancerous lesion was detec-

ted by UGIS in the morning, the patient was

recommended to drink barley water to wash

out the barium in the stomach , and the ultra­

sonogram was usually done in the afternoon

on the same day.

The amount of ingested bo i!ed barley water

varied with previously ingested water amount

after UGIS , but the usua1 amount at the ultra­

sonographic examination was 500-900 cc

without causing discomfort to patients.

The examining positions of patients were

supine, sitting, prone or left (right) anterior

oblique. The scan orientation was transverse ,

longitudinal, or oblique.

Results

Ultrasonography of the stomach after water

ingestion revealed the normal gastric wa11 as

five layers of different echoic structures con­

sisting of three hyperechoic layers and two

hypoechoic zones between them (Fig. 1) . The

innermost hyperechoic structure was con­

sidered to be corresponded to the mucosa , the

second hypoechoic zone to muscularis mu­

cosae , the middle hyperechoic layer to sub­

mucosa , the fourth hypoechoic zone to mus­

cularis propria, and the outermost hyper­

echoic structure to serosa-subserosa.

The final classification of the gastric cancer

was as follows (Table 1) .

The sites of pathologically proven early and

advanced gastric cancer were as follows (Table

2).

Ultrasonographic findings of gastric cancer

were (1) destruction or loss of the normal five­

layer appearance of the gastric wall, indicating

the depth of penetrating tumor and the extent

of lateraI extension along the stomach wall ,

and (2) thickening of the gastric wall with

usually hypoechoic mass (sometimes hyper­

echoic or mixed echoic due to hemorrhage ,

-366-

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- Jong Chul Kim: Ul trasonography of Gastric Cancer after Water Ingestion -

a Fig. 1. Ultrasonography of normal gastrlc wall after water ingestlon , showing five different echoic layers in fundus , body, antrum on transvcerse sc없1 (a) , and in gastric antrum on longitudinal scan (b l. with we\l

visualization of perigastric anatomy

Table 1. Classification of 40 Cases of Gastric Cancer

ulcer , necrotic change or calcifications. etc J,

with or without (3) metastatic nodules in sur­

rounding or distant abdominal organs. Iymph

adenopathy. or ascites. etc.

Cancer 꺼rpe

EGC'

llc+lla

I1 c

llc+llb AGC" Borrmann type

m N n

M. propria

• early gastric cancer •• advanced gastric cancer

No. of Patients Sum

4

1

2

36

20

8

4

4

Advanced gastric cancer usually showed

heterogenous mass with loss of inner four la­

yers (cancer extended only to muscularis pro­

pria. Fig. 2) or complete loss of all five layers

of stomach wall (Fig. 3 ), or extension to ad­

jacent or distant Iymph nodes (Fig. 4) or abdo­

minal organs. The lateral extension along the

gastric wall was determined by distorted gas­

tric layers (Fig. 3) (sometimes the peripheral

portions of advanced gastric cancer showed

destruction of only inner three layers). Early

Table 2. Sites of Pathologica\ly Proven Gastric Cancer in 40 Patients

팩삶펀E Cardia Fundus High B Modidy Low

Angle Antrum Pylorus Sum

EGC

llc+ l1 a 1

llc 2 2

I1 c+ l1 b 1

AGC

m 2 3 4 6 3 6 20 44

N l 2 2 2 2 2 12

n 2 2 4

M. propria 3 1 4

TOTAL 5 4 6 8 5 12 28 68

-367-

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- 大韓放射線훌훌學會誌 : 第 26 卷 第 2 號 1990 -

Fig. 2. Transverse scan of gastric antrum at LAO position demonstrates the depth of invasion of AGC limited to muscularis propria (crosses l. leaving the serosal layer intact.

Fig. 3. Transverse scan of advanced gastric cancer in antrum involving 외llayers of gastric wall (arrow). The lateral extension of the cancer is shown as an open arrow.

Fig. 4. Longitudinal scan of gastric body and antrum in advanced stomach cancer patient on LAO position shows the encircling gastric mass (open arrows) containing echogenic calcifications with posterior acoustic shadowing (arrow) 없ld having extragastric extension with retrogastric Iymphadenopathy (curved arrow) .

gastric cancer revealed mass and distortion of

inner three layers. The cancer confined to the

mucosa showed only destruction of the inner

one or two layers (Fig. 5) while cancer ex­

tended to submucosa showed distortion of in­

ner three layers , leaving the fourth and outer­

most layers of gastric wall intact, with or

without lymphadenopathy.

Five cases of advanced cancer penetrated

into muscularis propria were mistaken for

early gastric cancer by UGIS , and a case of

advanced gastric cancer involving all gastric

layers was mistal‘en for early gastric cancer

type II c+ II a b y UGIS (Fig. 6). In those cases

the ultrasonography after water ingestion de­

picted those lesions correc t1y. A case of advan­

ced gastric cancer p enetrated into muscularis

propria was mistaken for a n a dvanced gastric

cancer involving a ll 5 layers by the u 1trasono-

Fig. 5. Longitudinal scan of an early gastric cancer confined in mucosa in gastric angle shows hypo­echoic mass with gastric wall thickening in inner two layers (white arrow l, leaving outer three layers intac t. Posterior margin of lateral extension of the tumor is indicated by curved black arrow.

- 368-

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- Jong Chul Kim: Ultrasonography 01 Gastric Cancer alter Water Ingestion

b Fig. 6. a. UGIS of AGC simulating EGC type n c+ n a in gastric angle. b. Longitudinal scan of ultrasonogra­phy of the same patient revealed AGC destroying all 5 Iayers of gastric wall , which was pathologically proven

graphy after water ingestion , because of mis­

interpretation of interrupted echogenic peri­

P없lcreatic fat plane as the gastric serosal layer.

ln one case of early gastric cancer confined

to the mucosal layer, lateral extension of the

tumor along the gastric wall could not be pre­

cisely determined , but in other cases lateral

extension was determined with a good correla­

tion with surgical specimen.

On the basis of UG1S and gastroscopy, gas

tric cancer is classified as polypoid , elevated ,

f1at , depressed or excavated areas according to

their macroscopic appearance. On ultrasono

graphy, however, there were difficulties to cor­

relate the ulcerative areas of gastric cancer,

and macroscopic classification of early gastric

cancer was impossible.

Discussion

There have been many efforts to obtain a

basic tomographic image of the gastric wall

that allows visualization of the intemal archi­

tecture of a gastric lesion together with the

deeper layers of the gastric wall. UItrasonic

endoscopy has made a major role for this pur­

pose , but it can give discomforts to patients

as gastroscopy.

Matsue et 외" based on u Itrasonographic

study using normal parts of a resected sto­

mach4.5l, described the normal gastric wall as

having five layers , from within outward; slightly

hypoechoic layer (histologically corresponding to

foveolar gastric glands l. hypoechoic thin layer

(propria gastric glands) , hypoechoic thick layer

(submucosa J. hypoechoic thick layer (muscularis

propria J. and hypoechoic layer (serosa).

High-resolution operative ultrasonography

of normal stomach wall and gastric cancer,

filling the stomach with 300-500 ml of saline

or introducing sterile saline solution into the

abdominal cavity was also reported by Machi

et a l. 61, using a 7.5 MHz linear array transducer.

They also described five layers of the normal

gastric wall , but their histologic correlation of

inner two layers was the mucosal surface and

the mucosa , respectively.

Ultrasonographic findings of normal gastric

wall correlated with experimenta l s tudy7 1 us­

ing stomachs of pigs and clinical applica tion

-369-

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- 大韓放射線醫學會픔 : 第 26 卷 第 2 號 1990 -

using water drinking technique8J were de­

scribed by Han et a l., mainly applying 5 MHz

tranducer. They also described five layers of

the normal gastric wall , but they correlated

the inner two layers with histologic layers of

mucosa and muscularis mucosae , res­

pectively.

There were discrepancy in histologic cor­

relation of ultrasonic inner two layers of the

normal gastric wall among these studies.

Nevertheles , there is no problem in the dif­

ferential diagnosis between early gastric can­

cer and advanced gastric cancer.

The ultrasonography of the stomach after

water ingestion is more convenient to both

examiners and patients than the endoscopic

ultrasonography as the latter needs cumber­

some preparation and can cause discomforts.

It also retains the advantage of lower cost ,

shorter examination time and safety due to its

noninvasiveness , compared with the endos

copic ultrasonography.

The five layers demonstrated on ultrasono­

graphy after water ingestion correlated with

histologic structures may be a useful indicator

for detecting and staging the spread of gastric

cancers or submucosal tumors such as leio­

myo(sarco)ma or lymphoma , etc. On the basis

of the mass , wall thickening , distortion or des

truction of each layer of gastric wall , or layer

defect without definite abnormal tissue , the dif­

ferential diagnosis among early gastric cancer,

advanced gastric cancer, and the benign gas­

tric ulcer can be possible.

Early gastric cancer involves mucosa or sub­

mucosa. Therefore a loss , deformity or des­

truction of one or more of the inner three

layers of gastric wall with wall thickening or

masses will be seen in early gastric cancer,

leaving the outer two layers intact. In con­

trast , the advanced stomach cancer will show

destruction of gastric wall extending to the

muscularis propria (the fourth layer) or the

(sub) serosa (the flfth layer) , or invading the

perigastric structures. The ultrasonography

with water ingestion technique could deter­

mine whether gastric cancer was limited to

the musclaris propria, extended to the serosa,

or involved the perigastric structures. In four

cases of pathologically proven “ PM cancer"

(advanced gastric cancer involving inner four

layers of gastric wall ), three cases were diag­

nosed preoperatively. There may be inter­

pretative mistake to define the serosal layer.

In one case of “ PM cancer" 1 misinterpreted

the discontinuous peripancreatic fat lines as

the invaded serosa. The perigastric extension

cannot be accurately diagnosed by UGI5 or

gastroscopy, but the ultrasonography with wa­

ter ingestion can predict the presence or absc­

ence of perigastric extension including re­

gional lymphadenopathy or pancreatic or ab­

dominal wall invasion In thin patients of gas­

tric cancer, CT sometimes cannot detect the

P없lcreatic involvement or regional lympha­

denopathy, and conventional abdominal ultra­

sonography in obese patients frequently can­

not depict those perigastric involevement. Re­

cently there has been some reports about use

of water as an oral contrast agent rather than

gastrografin for CT study of the stomach9 . 1 이.

Ultrasonographic localization and demar­

cation of lateral extension of the early or adv­

anced gastric cancer is possible by identifying

adjacent mucosal layer distortion which is dif­

ficult by other examinations including the U­

GIS , gastroscopy, or palpation or inspection of

gastric wall in operation fields. 50 it will pro­

vide the surgeons with useful information to

determine the safe resection margins. 50me­

times the lateral extension cannot be depicted

cleary especially when an early gastric cancer

is small in size (as in one case of my study) or

when the lesion is in week points of ultra-m •

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- Jong Chul Kim: Ultrasonography of Gastric Cancer after Water Ingestion -

sonography such as gastric angle , posterior or

lateral wall of fundus.

The UGIS and gastroscopy sometimes

underestimate or overestimate the depth of in­

vasion or lateral extension of gastric cancer as

in five cases of my study. In one case of a

pathologically proven advanced stomach can­

cer , UGIS and gastroscopy misdiagnosed that

lesion in gastric angle as an early gastric can­

cer, but the ultrasonography after water ing­

estion could diagnose correctly (Fig. 6) .

Ultrasonography could not always detect

and correlate the ulcerative portions in gastric

cancer that were usually described by UGIS or

gastroscopy. It was difficult to classify early

gastric cancer macroscopically. In the com­

puted tomography study of the stomach with

water as an oral contrast agent , Baert et al9l ,

could dfagnose the tumoral ulceration only in

two of thirteen proven ulcerated tumors. So

further study correlated with ultrasonography

of surgical specimen will be required.

Because my experience is still limited to a

small number of cases especially in early gas­

tric cancer and advanced gastric cancer lim­

ited to the muscularis propria, 1 cannot quan­

titate the accuracy of this ultrasonography af­

ter water ingestion in tumor detection and

staging. Nevertheless , this preliminary experi­

ence is sufficiently encouraging to justify this

approach for the gastric cancer diagnosis , dif­

ferential diagnosis , assessment of tumor

spread through the gastric wall , and tumor

staging.

Ultrasonography following water ingestion is

considered to be valuable to obtain further

information about gastric lesions detected by

UGIS and/ or gastroscopy rather than as the

primary screening modality for detection of

gastric pathlogy.

The use of some combinations of these

modalities (UGIS , gastroscopy, CT , ultra-

sonography with water intestion or ultrasonic

endoscopy) is considered to be warranted

when surgical intervention is planned.

Inspite of some limitations , ultrasonography

with water ingestion will give information ab­

out anatomy and pathology of the stomach

and surrounding structures , providing clini­

cians with useful idea in the treatment or fol­

low-up plan.

REFERENCES

1. Derchi LE , Biggi E, Neumaier CE et 외: Ultraso­

nographic appearances of gastric cancer. Br J

Radiol 56: 365-370 , 1983

2. Myllyla Y, Paivansalo M, Suramo 1: Ultrasonogra­

phy of gastric tumors. Ann Clin Res 16: 65 , 1984

3. Yeh HC , Rabinowitz JG: Ultrasonography and

computed tomography of gastrlc wall lesions.

Radiology 141: 147-155 , 1981

4. Matsue H: Ultrasonographic examlnatlon and

diagnosis of stomach diseases. In Maruyama M,

and Klmura K, editors: Review of cllnical re­

search in gastroenterology, Igaku-Shoin , To셔0,

1988

5. Matsue H et 외 UItrasonographic study on dl­

agnosis for depth invastion of the stomach can­

cer, Jpn J Med Ultrason 41: 47, 1982

6. Machi J , Takeda J , Sigel B et 허 Normal sto­

mach wall and gastric cancer; Evaluation with

high-resolution operative ultrasonography.

Radiology 159: 85-87 , 1986

7 한상석 , 장재용, 차성숙 퉁 : 상복부 초음파검사시

물마시기 효과의 중요성에 관하여. 대한초음파의학

회 지 3 : 139-146, 1984 8 한상석, 차성숙, 김종덕 동 : 정상 위벽의 초음파 소

견 -실험연구 및 엄상적 웅용 대한초음파의학회

지 5 : 68 -75, 1986 9. Baert AL, Roex L, Marchal G et 외 Computed

tomography of the stomach with water as an

or외 contrast agent: Technique and preliminary

results. J Comput Assist Tomogr 13(4):

633-636 , 1989

10. Angelelli G, Macarini L, Fratello A: Use of water

as an oral contrast agent for CT study of the

stomach. AJR 149: 1084, 1987

n n t