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Dołączył: 21 Lut 2011
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Cardiac imaging and evaluation of imaging TNM staging
Of: Li Shunzong Licai Ying Chang Junjie Li Zhi Gang cardia cancer is a common malignant tumor, because the incidence of cardiac specific location, its early symptoms are mild or not obvious, when the tumors of patients had treatment into the middle and late, so the less effective surgical treatment, postoperative 5-year survival rate of about 20% to 30% [1], and even done a lot of unnecessary exploratory surgery, to increase the patient's suffering and economic burden,[link widoczny dla zalogowanych], so the exact technique TNM staging of gastric cardia before clinical treatment program development is crucial. Chinese papers League finishing. 1 cardiac imaging methods tumor imaging is based on the anatomical range of the correct diagnosis, can make an accurate preoperative tumor stage, to help clinicians determine the treatment plan, direct clinical treatment, improve the survival rate. Cardiac imaging, including gastroscopy (FG), upper gastrointestinal barium meal (UGI), CT and ultrasound. Which UGI, FG as the diagnosis of gastrointestinal disease in the traditional inspection methods [1], still plays an irreplaceable role, is the first choice for cardiac screening method. UGI and FG inspection is the lack of co-existence of a simple observation from the gastrointestinal mucosa and gastric cavity the situation, can not understand the internal structure of the tumor, partial gastric wall thickness and the relationship with surrounding organs, as well as whether local or distant metastasis. Ultrasonography in the diagnosis of cardiac cancer were also studied and discussed more than [2,[link widoczny dla zalogowanych],3], that ultrasound can understand the tumor location, extent, wall thickness and outside invasion, lymph node metastasis and liver blood and other organs of metastasis, the accuracy above 95% sensitivity [3], can help determine as a preoperative tumor staging and the development of treatment means. However, Ultrasound imaging is affected by many factors: (1) the small left lobe of the liver, obesity transverse shape, due to the higher position of internal organs, cardiac region structure is difficult to display. (2) mass to cardiac growth on the area, ultrasound showed limited connectivity with Minister of gastric cardia curved shaft, resulting in measured values are not allowed. (3) the location of small or deep (eg, around the splenic artery) lymph node ultrasound and so easily missed. Thus for the diagnosis of cardiac barium current and gastroscopy still prevail, ultrasonography only as FG, UGI means of a clinical application of laboratory examinations [2]. Cardiac CT scan before surgery can not only accurately and objectively the size of lesions,[link widoczny dla zalogowanych], tumor invasion outside the scope and extent of, and adjacent organs of the relationship, more importantly, CT can accurately determine the local and distant tumor swollen lymph nodes and liver, adrenal gland and other organs without distant hematogenous metastasis, etc. [4 ~ 16], CT examination is simple, non-invasive, no pain, no contraindications with other tests unparalleled advantage. Stomach transverse unenhanced CT images can show the thickness of filling the stomach, the stomach is slightly different thickness of various parts of the stomach, gastric cardia as special anatomy, CT scan cross-sectional image shows the gastric wall thickness was significantly greater than Other stomach area stomach wall thickness, Peng Weijun [15] reported that oral administration of 1000ml of water and contrast agent injected 654-2 20mg scan, cardiac region into a bell shape, thickness of the gastroesophageal junction 0.51cm, other sites were 0.16 ~ 0.23cm ; also the author [19] showed that the level of the esophagus to the stomach due to cardia, cardia form a beak-like convex, the left in front of the spine associated with abdominal esophagus, when a contrast agent filling the lumen, the wall can be displayed thickness and cardiac morphology, Ben entrance to the stomach convex part of the Department of the cross-sectional images, mild gastric wall thickening seen local uplift to the cavity, characterized by thickening of the gastric wall to the center front of Ben and bilateral symmetry. Enhanced CT scan, the gastric wall or multi-layer structure into a homogeneous enhancement, multi-layer structure of more performance for 2 to 3 layers [15,17,20], the inner layer was enhanced, the equivalent of mucous layer, the middle was a relatively low density, equivalent to submucosa, the outer mild enhancement was medium density, relative to the muscle - serosal layer. GAO Jian-bo et al reported that the stomach to strengthen the multi-layer structure when the arterial and portal venous phase show better [17], strengthen the balance of the stomach tend to uniform, multi-layer structure disappeared; stomach display multi-layer structure is conducive to accurately determine the gastric T min period, multi-layer structure shows the higher rate, T staging accuracy of the higher phase enhanced helical CT scan of the stomach is superior to an ordinary multi-layer structure of the CT. In addition Alves [12], who try to screw with artificial pneumoperitoneum method CT (SCTPP) staging of gastric cancer, and found that after artificial pneumoperitoneum appropriate position, so that the stomach and lesser sac inflated week well, increasing the stomach and the gap between adjacent organs, lymph nodes improve the detection rate, increased the sensitivity of staging. Recent years, the three-dimensional CT (3DCT) technology, especially CT virtual endoscopy (CTVE) method is extensively used in clinical studies of gastrointestinal diseases [21,22], this technique can be directly and fully show the gastric chamber shape, the Borrmann type of gastric cancer is superior to UGI,[link widoczny dla zalogowanych], and FG is similar, and the combination of CT cross-sectional images can also be the stomach cavity, stomach and adjacent organ invasion and many other diagnostic indicators of the situation This is to develop a more accurate preoperative tumor TNM stage, guiding the establishment of treatment programs have a key role, but because technology is more CTVE other 3DCT in clinical studies, not widely used clinically, and because the anatomical cardia special structure, cardia lesions 3DCT inspection techniques have no special report. 2 preoperative TNM staging of cardiac imaging assessment the UGI and FG on the cavity relationship with the surrounding organs, lymph node and hematogenous metastasis the inspection are blind, to assess the possibility of surgical resection are indirect signs are inferred role. With the clinical application of ultrasound, B-the cardiac preoperative evaluation must have been more than studies [2], can be used as preoperative tumor staging, according to one of the designated treatment programs, but due to the existence of the aforementioned B-ultrasound factors, cardiac examination of its obvious limitations. CT examination in the preoperative cardiac assessment is based on the TNM staging cross-sectional CT images of the gastric cardia partial thickness, lymph nodes and other organs of the blood line of the display of the transfer. Because CT equipment and inspection methods and many other factors, CT staging accuracy of gastric difference of opinion [5,7,18,21,22] a great, common CT TNM staging of gastric cancer less accurate [ ],[Use at home and abroad in recent years, more than three helical CT scanning and other techniques to increase the enhanced layered display rate of the stomach (as aforesaid), in order to improve the accuracy of gastric T staging, the CT for T staging of gastric cancer depends on the accuracy of clearly show whether the stomach wall layers, serosa invasion and adjacent organ involvement outside the [11]. GAO Jian-bo [17] studies have shown that early gastric cancer (T1) showed marked enhancement of local thickening of the stomach lining, middle and outer structure of normal gastric wall in the middle if the structure is considered to be lost interrupt advanced gastric cancer, so multi-layer structure of the stomach display for early gastric cancer and advanced cancer premise identification, if the CT scan showed the stomach as the distinction between T1 and T2 layer is difficult; GAO Jian-bo et al Phase III statistical spiral CT scan showed the stomach to strengthen multi-layer structure was 60.9% chance of , and its gastric T staging accuracy was 82.0%, Takao [4] that the performance of advanced gastric mucous layer from the outer serosal layer to gradually strengthen the balance of the tumor was finally complete enhancement of the thickened gastric wall if the balance no significant enhancement of the serosal layer, even if the stomach wall and the surrounding layer of fat between the organs do not see, can not think outside the tumor invasion to the wall, so a balance in favor of scanning the identification of T3 and T4 [14], another intermediate TLC of the MPR technology lesions observed multi-faceted relationship with the surrounding organs, correcting for body fat, lean due to the volume effect of the gap caused by lost or been estimated [5]. Advanced gastric cancer reported in the literature spiral CT-T staging accuracy of three to 82% [4], the middle layer and the MPR of 77% [5], portal venous phase was 55% to 73% [6,7 ]. CT scan in preoperative staging assessment of cardiac Another advantage is the more accurate N staging. Cardiac lymph node metastasis is the main transfer channels, as ordinary CT showed poor internal structure of the lymph nodes, mainly in the lymph nodes the size of the previous CT assessment of lymph node metastasis as the standard, so do conventional CT staging accuracy of the low N (70% ) [14], and three conventional SCT scanning accuracy of N staging was 85% [20]. Most researchers support 5mm significance of lymph node metastasis as determined threshold, Fukuya [9] that the following helical CT of 5mm very low detection rate of lymph node (1.1%), and not less than 80% of lymph node metastasis 5mm [ ],[because the lymph nodes above the threshold may be caused by inflammation rather than the transfer of proliferation. Fukuya, Kudo subtlety and other studies have shown that metastatic lymph nodes mostly relatively high density, high-density center and peripheral low-density, or pressure vessels and have a greater short / long axis ratio (ratio ≥ 0.7); not only the detection of metastatic lymph nodes lymph node size, shape, density, while the location of lymph node, stomach and adipose layer thickness scan of the conditions of SCT, such as blood vessels next to the CT detection rate of lymph node high, because it is easy with the adjacent lymph nodes was significantly enhanced separate the blood vessels, particularly the most obvious portal of contrast [20]; while on cardiac CT, especially near the tumor and peritumoral lymph nodes together,[link widoczny dla zalogowanych], difficult to distinguish, the lymph node detection rate was significantly lower, Alves made artificial gas perigastric abdominal method to increase the gap with the adjacent organs, improve the detection rate of gastric lymph node (93%) [12].
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