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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
댔
- 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-
- 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-
- 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-
- 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-
- 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 •
- 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.
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n n t