Computed Tomography Signs

Computed tomography is commonly used to study those anatomical structures characterized by a relative homogeneity of structure and by the absence of permanent peristaltic contractions. Modern CT made it possible to study internal organs regardless of the presence of peristalsis. This stimulated the

▲ Fig. 80 c. ▲ Fig. 80 d.

□ Fig. 80a-e. Patient M., age 55. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): organic changes are not visible. b Stomach roentgenogram (double contrast, horizontal position, left half-oblique projection): the anterior wall of the stomach body is thickened due to intramural infiltration (arrow). Conclusion: Infiltrative cancer of the stomach. Histological examination of bioptates taken during endoscopy verified signet-ring cell carcinoma. c, d, e Tomograms of the stomach (stomach inflated with air, supine patient): thickening of the wall due to intramural infiltration, which remains stable on repeated inflation of the stomach. Depending on the amount of insufflated air, thickness of the infiltrated stomach wall varies from 13 to 9 mm; the wall remains thick with the stomach inflated to the maximum (arrows).

□ Fig. 81a-j. Patient G., age 72. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): uneven contours of the lesser curvature of the stomach body; the lesser curvature is depressed (arrow). b, c, d Target stomach roentgenograms (tight filling, vertical position, anterior projection) as the stomach is filled with barium sulfate suspension: uneven contours of the lesser curvature (arrows). e Stomach roentgenogram (double contrast, horizontal position, anterior projection): wall of the lesser curvature is rigid and thickened due to intramural infiltration (arrows). Conclusion: Infiltrative cancer of the stomach body. Histological examination of bioptates taken during endoscopy failed to detect tumor cells. The patient was examined by computed tomography. f Computed tomogram of the stomach (tight filling with E-Z-CAT DRY, supine patient): visualized are the walls of the lesser curvature, thickened due to intramural infiltration. g, h, i, j Computed tomograms (dosed inflation of the stomach with air, supine position): wall is thickened unevenly, inner contour is uneven, sometimes tuberous due to intramural infiltration (arrows). The patient underwent surgery. Histologically; adenocarcinoma with signet-ring cell component.

The two methods of computed tomography proposed by us and our colleagues and described in the previous chapter are based on determination of thickness of the stomach wall (D Fig. 81). The methods can give a significant amount of information on the condition of the stomach wall (D Fig. 82). One of the proposed methods (pneumotomography) helps avoid mistakes connected with pseudo-thickening and distorted information on wall thickness during CT using water as the contrast medium. Thus, pneu-motomography markedly broadens the diagnostic potentials of the method. Moreover, data obtained

with this method can completely change our understanding of the character of tumor infiltration based on the results of the traditional X-ray and endoscop -ic examinations, especially in patients with cardio-esophageal cancer. Data obtained using pneumoto-

mography confirm our main concept: that intramurally spreading carcinomas predominate among the malignant tumors of the stomach (D Fig. 83) [44].

O Fig. 82a-d. Female patient K., age 63. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, left lateral projection) at the moment of contrast medium passage through the gastroesophageal junction: a limited portion of the infiltrated wall of the stomach with possible involvement in the process of the abdominal segment of the esophagus can be seen in projection of the cardiac rosette (black arrows). No changes are detected in the underlying parts of the stomach; the wall thickness is normal (white arrow). In order to verify the spread of infiltration onto the abdominal segment of the esophagus, the patient's stomach was examined by CT. b Computed tomography of the stomach (dosed inflation of the stomach with air, the level of the cardiac rosette, supine position): the cardiac wall is thickened due to intramural infiltration invading the abdominal segment of the esophagus (arrows). c Computed tomography of the stomach (dosed inflation of the stomach with air, the level of the cardiac rosette, supine position): following insufflation of additional air, thickening of the walls of the abdominal segment of the esophagus persists (arrows). d Computed tomogram of the stomach (dosed inflation of the stomach with air, the level of the stomach body, supine position): a group of enlarged lymph nodes with uneven contours and maximum diameter of 1517 mm is seen in the projection of the lesser omentum (arrows). Conclusion: Infiltrative cancer of the upper part of the stomach with invasion of the esophagus; metastases to the lymph nodes of the lesser omentum. The patient was operated. Histologically; signet-ring cell carcinoma.

D Fig. 83a-l. Female patient Z., age 73. Diagnosis: gastric cancer. a Stomach roentgenogram (tight filling, vertical position, anterior projection): no organic changes are observed. b Stomach roentgenogram (double contrast, horizontal position, left lateral projection) at the moment of contrast medium passage through the gastroesophageal junction at the inspiration phase: normal function of the gastroesophageal junction; formed esophageal ampulla (arrow). c, d, e, f, g Stomach roentgenograms (double contrast, horizontal position, left lateral projection): atypical relief of the cardiac rosette (cardioesoph-ageal junction) with termination of the folds by the periphery (arrows). h Stomach roentgenogram (double contrast, vertical position, left lateral projection): atypical relief of the cardiac rosette (arrows); the specific radiating pattern is absent. Conclusion: Minor infiltrative cancer of the cardiac part of the stomach. Endoscopy with subsequent histological examination of bioptates failed to find organic changes. The patient's stomach was examined by computed tomography. i, j Computed tomograms of the stomach (double contrast, the level of the upper part of the stomach, supine position): the wall of the cardiac part of the stomach is thickened over a small length due to intramural infiltration as seen in projection of the cardiac rosette (arrow); k,l Computed tomograms of the stomach (double contrast, at the level of the upper part of the stomach, position on the right side): the wall of the cardiac part of the stomach is thickened over a short length due to intramural infiltration as seen in projection of the cardiac rosette (arrow); Conclusion: Minor infiltrative cancer of the cardiac part of the stomach. Repeated endoscopic examinations conducted later did not reveal organic changes. Tumor cells were not detected by histological examination of the bioptates either. In the absence of histological verification of gastric cancer, the patient was not operated despite the convincing evidence obtained by radiological examination. A year later, histological examination of the material taken during another endoscopy revealed the presence of signet-ring cells.

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