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Utility of Multidetector CT in the Diagnosis of Gastric Bare Area

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Utility of Multidetector CT in the Diagnosis of Gastric Bare Area ª Springer Science+Business Media, LLC 2007 Abdom Imaging (2007) 32:284–289 Abdominal Published online: 12 September 2006 DOI: 10.1007/s00261-006-9058-3 Imaging Utility of multidetector CT in the diagnosis of gastric bare area invasion by proximal gastric carcinoma Bing Wu,1 Peng-qiu Min,1 Kaiqing Yang2 1Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China 2Department of Anatomy, Sichuan University, Chengdu, Sichuan, China Abstract The overall survival among patients with stomach cancer has remained stable at a low level for several decades. Purpose: To investigate the utility of multidetector CT Proximal gastric carcinoma (PGC) is a distinct clinical (MDCT) in the diagnosis of gastric bare area (GBA) entity compared with tumors located in other parts of the invasion by proximal gastric carcinoma (PGC). stomach with an increasing incidence and a poor prog- Methods: Sixty-eight consecutive patients with biopsy- nosis [1–4]. proven PGC underwent MDCT scan prior to gastrec- Regarding the surgical treatment, no difference exists tomy. We evaluated the CT images separately for the between PGC of anterior wall and those of posterior site, size, depth, lymph node, and enhancement charac- wall. Nevertheless, cancers of the posterior wall of teristic of each case. Each postsurgical stomach specimen proximal stomach are more difficult to cure than that of was axially sectioned and comparison was made to the anterior wall [5]. The cause must consist of an ana- determine the correlation between the CT findings and tomical characteristic, the fact that posterior wall of the the pathological examination of each tumor bearing fundus and subcardial portion (we call it gastric bare slice. area, GBA) is not covered by the visceral peritoneum [5, Results: The sensitivity for detecting GBA involvement 6]. in patients with PGC was 84%. MDCT correctly To our knowledge, GBA space resembles an inverted identified 32 of 38 patients with GBA invasion and 10/ triangle. The upper aspect of GBA is gastrophrenic lig- 13 (77%) tumors with metastatic lymph node greater ament. Right side of GBA is marginated by the perito- than 5 mm in GBA or subphrenic retroperitoneal space. neal reflection of upper recess of lesser sac and left side is 33/36 (92%) patients with tumor extension within the defined by the peritoneal reflection between stomach and edge of the gastric wall and 28/32 (88%) patients with diaphragm (also, we call them right gastrophrenic liga- tumor infiltration into subphrenic fat were correctly ment and left gastrophrenic ligament, respectively) identified. MDCT correctly predicted the infiltration of (Figs. 1, 2). tumor into the diaphragm in all 14 patients and identified The CT has been ascertained to have potential in the 6/11 (55%) patients with gastrophrenic ligament inva- evaluation of tumor location, stage of the disease, and sion. monitoring of therapy, but its value in the preoperative Conclusion: MDCT may be of value in assessing the evaluation has not been completely established, espe- important radiological characteristics of GBA invasion cially to PGC with GBA invasion [7, 8]. The purpose of in patients with PGC. our study is to better understand efficacy of detection with MDCT in patients with GBA invasion. Key words: Stomach neoplasm—Anatomy—CT— Retroperitoneal space—Gastric bare area Materials and methods This prospective study was conducted at our university hospital between October 2003 and December 2005. One hundred and twenty consecutive patients with gastros- Correspondence to: Bing Wu; email: [email protected] copy biopsy proven PGC underwent MDCT scanning. B. Wu et al.: Utility of MDCT in the diagnosis of GBA invasion by PGC 285 inspiratory breath hold. The MDCT imaging was started about 70 s after a bolus injection of intravenous contrast agent. MDCT parameters were the following: the colli- mation was 1.5 mm and the table feed was between 20 and 30 mm/rotation. The tube parameters were 200–240 milliampere second at 120 kV. Axial images were reconstructed with 3 mm slice width at a 2 mm recon- struction interval. The reconstructed image data was networked to an interactive workstation (Leonardo, Siemens). Images viewed at different window settings and multiplanar reformation were performed, if neces- sary. Data analysis was included as follows: MDCT Fig. 1. Photograph of an axial cadaveric section shows depiction of tumors at specific sites, especially in relation peritoneal reflection of upper recess of lesser sac (white ar- to the GBA and the peritoneal reflection; the maximum row). Red latex was injected into GBA to show its location. depth of tumor extraluminal extension; the presence of gastrophrenic ligament invasion; and lymph nodes in the GBA or along the subphrenic retroperitoneal space. The MDCT findings to be analyzed were agreed on before surgery. The results of physical examination, primary tumor stage, or laboratory data were not known at the MDCT scanning interpretation. Prospective MDCT readings were used for data analysis, both overall and site specific, MDCT official reports were generated during clinical readings overseen by two abdominal sec- tion professors (P. M., K.Y). All patients underwent surgical resection and each surgical specimen was axially dissected. MDCT findings were compared with the pathology examination of each tumor bearing slice, respectively. Findings from the surgical and histologic reports were used as the standard Fig. 2. Photograph of an axial cadaveric section shows of reference and were correlated with the MDCT find- peritoneal reflection of left gastrophrenic ligament (black ar- ings. MDCT findings–pathologic correlation was per- row). Red latex was injected into GBA to show its location. formed. A true-positive lesion was one found at surgery and on MDCT scannings. A false-negative lesion was one missed on MDCT scannings, but found at surgery. A Fifty-two patients underwent chemotherapy after false-positive finding was one demonstrated on MDCT MDCT scan and were therefore excluded. The other 68 scannings but not found at surgery or histopathologic patients (45 men, 23 women; mean age 58 years, range examination. 21–78 years) who underwent radical gastric cancer sur- gery with extensive lymph node dissection were included Results in the study. The interval between MDCT examination and surgery was l day to 2 weeks (mean 7.8 days). Thirty-eight (56%) of 68 cases had GBA involvement at The MDCT scanning was performed using a MDCT surgery and proved by pathology. Gastroscopy and system (Sensation 16, Siemens, Erlangen, Germany). gastrointestinal barium examination did not offer help in Bowel relaxant medication was not administered. Before detecting GBA involvement. MDCT correctly depicted MDCT, patients were asked to ingest at least 500 mL of the presence of GBA involvement in 32 of 38 cases. pure water with contrast medium to distend the stomach. Tumor intrusion was not detected in six cases, and the Each patient received 80–120 mL of ionic contrast MDCT findings were mistaken for GBA invasion in ten material (Iopamiro 300, Bracco, Milano, Italy or Ultra- patients. This was expressed in a MDCT overall sensi- vist, Sherling, Berlin, Germany), which was injected in a tivity of 84%, specificity of 67%, positive predictive value forearm vein at a rate of 2 mL/s by using an automatic (PPV) of 76%, negative predictive value (NPV) of 77%, injector and 17-gauge angiography catheter. and overall accuracy of 76% (Table 1). Based on an initial scout image, the scanning range Among the 30 cases without GBA invasion, the ab- was planned from the diaphragmatic domes to inferior sence of involvement was correctly diagnosed with pole of the kidneys. All imaging was performed with an MDCT scanning in 20 cases. In eight cases, muscles of 286 B. Wu et al.: Utility of MDCT in the diagnosis of GBA invasion by PGC Table 1. MDCT-surgical correlation: overall results Group Number of cases TP TN FP FN Accuracy (%) Sensitivity (%) Specificity (%) PPV (%) NPV (%) No invasion 30 0 20 10 0 67 – 67 – 100 GBA invasion 38 32 0 0 6 84 84 – 100 – All 68 32 20 10 6 88 84 67 76 77 FN, false negative; FP, false positive; TN, true negative; TP, true positive Table 2. Sensitivity of MDCT sign for detection of GBA involvement Signs Histologic findings MDCT findings FP/FNa Sensitivity (%) Extraluminal extension 36 33 6/3 92 Subphrenic fat involvement 32 28 4/4 88 Gastrophrenic ligament involvement 11 6 6/5 55 Diaphragm involvement 14 14 0/0 100 Lymph nodes (>5 mm) in GBA 13 10 1/3 77 aFP/FN = number of false-positive diagnoses/number of false-negative diagnoses Fig. 3. Axial MDCT shows transmural involvement and ex- Fig. 4. Axial MDCT shows a transmural PGC with blurring traluminal extension with linear stranding in perigastric fat of and obliteration of the fat plane between the gastric wall and GBA (black arrow). the left diaphragm (white arrow) and additional invasion of the later. The fat plane between the liver and the right diaphragm gastric wall or left diaphragm were misdiagnosed as tu- is clear (black arrow). mor extramural intrusion because the subphrenic fat is too thin to be identified on CT imaging. In two cases, irregular soft-tissue density edema adjacent to the stomach was misinterpreted for tumors. Among the 38 cases with tumors involved in the GBA, a correct diagnosis was made with MDCT scan- ning in 32 patients (sensitivity 84%). In five patients, GBA invasion by PGC was found at surgery but not detected with MDCT scanning, and in the other one, a 2.2 cm tumor nodule adherent to the cardia was sus- pected to metastatic lesion. Sensitivity of MDCT signs for detection of GBA involvement is reported in Table 2. MDCT correctly identified 32/38 patients with GBA invasion and cor- rectly predicted 5/8 patients with tumor extension within 2.0 cm of the edge of the gastric wall (Fig.
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  • The Peritoneum General Features • General Features • the Peritoneum Is a Thin Serous Membrane Consisting Of: • 1- Parietal Peritoneum －Lines the Ant
    The Peritoneum General features • General features • The peritoneum is a thin serous membrane Consisting of: • 1- Parietal peritoneum －lines the ant. Abdominal wall. • 2- Visceral peritoneum - covers the viscera - Peritoneum is continuous below with parietal peritoneum lining the pelvis. • 3- Peritoneal cavity - the potential space between the parietal and visceral layer of peritoneum - in male, is a closed sac - but in the female, there is a communication with the exterior through the uterine tubes, the uterus, and the vagina Peritoneum cavity divided into Greater sac Lesser sac Communication between them by the epiploic foramen Deep to lesser omentum Behind the stomach Between two layers of greater omentum Under the diaphragm and liver Deep to lesser opening (Epiploic opening) Walls： Superior－peritoneum which covers the caudate lobe of liver and diaphragm Anterior－lesser omentum, peritoneum of posterior wall of stomach, and anterior two layers of greater omentum Inferior－conjunctive area of anterior and posterior two layers of greater omentum Posterior－posterior two layers of greater omentum, transverse colon and transverse mesocolon, peritoneum covering posterior abdominal wall. Omental bursa……cont Left－ spleen, gastrosplenic ligament splenorenal ligament Right－omental foramen Deep to ant. Abdominal wall Below the diaphragm Above pelvic viscera Out to: Liver surround all the liver except bare area Stomach completely surrounded by peritoneum Transverscolon Greater omentum two layers of peritoneum from greater curvature
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