胃癌大肠转移的影像学与胃癌原发灶的病理学特征的研究
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摘要
第一部分胃癌大肠转移的X线气钡双对比灌肠表现
目的分析胃癌大肠转移的X线气钡双对比灌肠造影表现，探讨胃癌大肠转移的X线影像学表现特征和胃癌大肠转移的发生发展规律。
对象与方法研究对象因胃癌或胃癌复发入院治疗，并在术前或治疗过程中进行结肠X线钡剂灌肠检查发现胃癌大肠转移的104例。
所有病例均满足以下标准：胃癌原发灶均经手术病理或内镜活检病理证实，均有术前胃气钡双对比造影检查图像和／或MSCT平扫和增强检查的图像以及胃内窥镜检查的资料；胃癌大肠转移均符合如下标准：①手术病理证实；②开腹探查或腹腔镜探查病理活检证实；③影像学或内镜诊断大肠转移，临床治疗观察随访确定诊断；④排除多脏器恶性肿瘤合并胃癌造成的腹膜腔转移。⑤除外原发性大肠癌和大肠恶性淋巴瘤。
分析内容：
1．病人的性别、钡灌肠初次发现大肠转移征象的年龄、发现胃癌原发病变距初次发现大肠转移的间隔时间(月)。
2．X线气钡双对比灌肠造影的表现特征：分析病变部位、肠腔狭窄程度、肠管变形情况和大肠粘膜面的改变。
(1)病变部位：在对直肠、乙状结肠、降结肠、横结肠、升结肠和盲肠进行分段观察的基础上，将各段作了进一步细化分段，以对病变进行更准确的定位，将直肠分为腹膜返折下段(Rb)、腹膜返折上段(Ra)和直肠乙状结肠交界段(Rs)；乙状结肠分为肛侧半(Sp)和口侧半(So)；降结肠也分为肛侧半(Dp)和口侧半(Do)；结肠脾区(Sf)为结肠在脾曲的外缘转折点分别向近侧和远侧3cm区域的肠段；同样，肝区(Hf)为结肠在肝曲外缘转折点分别向近侧和远侧3cm的区域；将横结肠分成三等份，分别为横结肠肝侧段(Th)、横结肠中段(Tm)和横结肠脾侧段(Ts)；升结肠分为肛侧半(Ap)和口侧半(Ao)；盲肠(Cecum)单独为一段。鉴于钡灌肠图像的放大率不确定等因素，不易测量病变的准确长度，未对病变侵犯肠管的长度进行分析，仅记录病变部位。
(2)肠腔的狭窄程度：根据肠腔狭窄程度分为5个等级：0为肠腔无明显狭窄；1为肠腔狭窄＜1／3；2为肠腔狭窄在1／3～2／3之间；3为肠腔狭窄＞2／3；4为肠腔完全闭塞。
(3)肠管变形：将肠管变形分为单侧变形和双侧变形。
(4)结肠粘膜面的改变：分为梳齿状黏膜皱襞聚集(tethered)改变、颗粒结节状(granular)改变、外压性(compression)改变和弥漫性(diffuse)改变4种。多种改变同时存在同时记录。
3．与胃癌原发灶的影像学形态、病理组织学表现相关性。
4．对接受2次以上X线气钡双对比灌肠灌肠者，观察病变的发展与变化。
结果
1．104例胃癌大肠移转病例，男67例，女37例。年龄最小者22岁，最长者89岁。发生大肠转移的高发年龄组在56岁～75岁之间，占本组病例的61.5％。
2．发现大肠转移与发现胃癌的间隔时间，胃癌术前检查发现大肠转移32例，胃癌术后3年内发生大肠转移者占91.3％。
3．胃癌肉眼形态主要为3型和4型，两者之和占本组病例的89.4％。组织学类型以低分化腺癌和印戒细胞癌以及含有这两种成份者为多，占本组病例的88.5％。
4．大肠转移病灶的分布，胃癌大肠转移灶的最常侵犯的部位为横结肠(83例)，其次为直肠(50例)。再次为降结肠(20例)、乙状结肠(17例)和升结肠(15例)。盲肠受累者少见，仅2例。
将大肠细化分段，受累频率依次为横结肠中1／3段(Tm，47处)，横结肠左1／3(Ts，44处)，横结肠右1／3(Th，39处)和直肠腹膜返折之上(Ra，39处)。
胃癌术前检查发生大肠转移同手术7个月后发生大肠转移的病变部位进行比较，显示术前检查发现的大肠转移以横结肠中段(Tm)的发生率最高，而术后7个月发生转移者则以直肠腹膜返折以上(Ra)的发生率最高，两者差别有统计学意义(P＜0.05)。
5．X线气钡双对比灌肠的表现，从狭窄程度看，病变无明显狭窄者19处，1度狭窄104处，2度狭窄110处，3度狭窄96处，完全阻塞者4处。从肠腔变形的情况看，单侧变形者227处，双侧变形者96处。
病变部位粘膜面的表现，呈梳齿状黏膜纹聚集改变者253处，呈颗粒结节状改变者23处，显示外压性改变者20处，表现为弥漫性改变者62处。梳齿状黏膜纹聚集为大肠转移的主要表现。
6．复查随访X线气钡双对比灌肠图像的发展演变，在累及直肠的病灶中，30例进行了两次以上的钡灌肠检查，随访过程中病变即无明显变化者7例。经过治疗有缓解者5例，其中1例最终恶化，形成梗阻。病变部位狭窄程度加重或病灶范围延长者18例，其中6例病灶范围延长者，均为由首次发现时为侵犯Ra或Rs的病变发展为累及Rb的病变。
除直肠之外的结肠受累的病例中，54例接受了2次以上钡灌肠检查，病变趋向加重者33例，改善者10例，无显著变化者11例。
结论
1．胃癌发生大肠转移的原发灶的大体形态多为4型和3型病变，病理组织学以低分化腺癌和印戒细胞癌居多。
2．横结肠和直肠为胃癌发生大肠转移的好发部位。胃癌转移造成的横结肠的改变，推测可能是胃癌细胞沿胃结肠韧带的直接侵犯横结肠，也可能为癌细胞经胃后壁的浆膜面脱落进入小网膜囊播种于结肠的浆膜面所致。而胃癌的直肠和乙状结肠转移极有可能是腹膜腔播种转移的结果。
3．胃癌发生大肠转移时，X线结肠气钡双对比灌肠造影表现为梳齿状粘膜纹聚集、粘膜面颗粒状改变、外压性病变和弥漫性病变，其中以梳齿状粘膜纹聚集的改变最多见，具有特征性。
4．直肠病变在随访过程中，可出现病变范围延长和狭窄程度加重，其中病变范围延长时，可表现为由首次发现的Ra或Rs病变发展延伸至Rb。
5．术前检查发现大肠转移同手术7个月后发生大肠转移的病变部位进行比较，显示手术7个月后发生转移者以直肠腹膜返折以上(Ra)的发生率最高，有统计学意义。推测可能手术改变了腹膜腔的本来结构，引起腹膜腔内液体移动的途径和方式发生了变化，使癌细胞更容易到达Douglas隐窝，有待证实。
第二部分胃癌大肠转移的MSCT表现
目的：分析胃癌大肠转移的MSCT表现，探讨胃癌大肠转移的CT影像学表现特征和胃癌大肠转移的发生发展规律。
对象与方法
研究对象为因胃癌入院手术或胃癌复发入院治疗进行结肠X线钡剂灌肠检查显示胃癌大肠转移的104病例(同第一部分研究对象)，所有病例在X线初次发现大肠转移的同期均进行了全腹CT平扫与增强检查，另有95例进行了2次以上的CT复查。
分析内容，对于X线钡剂灌肠初次发现转移同期的CT图像，分析肠壁有无增厚、增厚的部位和增厚部位的增强方式，网膜、系膜有无增厚、结节以及增厚网膜、系膜的增强方式，腹腔内淋巴结有无增大，腹腔内有无肿块，腹水的有无以及液体的分布部位，肾盂输尿管有无积水，肝脏以及其他脏器有无转移等。记录腹水的分布部位时，将腹膜腔间隙分为结肠上区，结肠下区，左右两侧结肠旁沟和盆腔5个区域。对于发现大肠转移后，进行多次CT复查者，观察分析治疗过程中CT表现的变化。
结果
1．肠壁的改变：钡灌肠发现直肠受侵改变者50例中，CT显示直肠壁增厚者42例(84.0％，42／50)，有强化者41例(82.0％，41／50)，同时显示分层状强化征象者25例(50.0％，25／50)。钡灌肠发现除直肠之外的结肠受侵者89例，CT显示肠壁增厚者73例(82.0％，73／89)，71例有强化(79.8％，71／89)，其中分层状强化者31例(34.8％，31／89)。
2．腹膜腔的改变：CT显示55例有腹膜腔积液。其中，腹水位于结肠上间隙者18例，分布于结肠下间隙者4例，分布在双侧结肠旁沟者15例，位于盆腔者45例。另外有6例病人可见明显的胸腔积液。CT显示网膜或系膜明显增厚者3例，显示网膜或系膜内结节影者14例，增强扫描均有中等程度强化。
3．尿路积水及其他改变27例病人有肾盂输尿管积水，其中表现为左侧肾盂输尿管积水者4例，右侧肾盂输尿管积水者12例，双侧肾盂输尿管积水者11例。均为轻度的肾盂输尿管扩张。2例有腹腔肿块，1例有肝脏转移，1例肺内有结节状病灶。
4．病变的发展与变化的观察：累及直肠的病例中，45例进行了2次以上的CT检查，31例的直肠肠壁由正常的厚度发展为增厚，或由原来已经增厚的肠壁变得更厚，并有明显的内层强化。10例原有直肠壁增厚的病例在复查过程中肠壁无明显的变化。4例在随访过程中由增厚恢复正常厚度。除直肠外的结肠受累病例中，78例接受了2次以上的CT检查，病变趋向加重者50例，趋向减轻者2例，病变平稳无显著变化者26例。在肾盂输尿管积水的病例中，8例是在发现大肠转移的同期CT显示肾盂输尿管积水，其余均为在CT复查时显示肾盂输尿管积水。
结论
1．胃癌大肠转移的CT扫描肠壁的改变表现为肠壁增厚和肠壁环形增强。推测是由于发生大肠转移的胃癌多数为弥漫浸润型胃癌，癌细胞趋向于弥散分布于间质中，受累的肠段由于大量的胶原纤维组织形成而引起管壁异常增厚，还可保留肠壁的分层结构。且动脉期在增厚的内层呈明显的强化。本组病例还发现，直肠肠壁的增厚除可表现为弥漫性肠壁增厚和靶征外，还可表现为不对称性增厚和强化，这种增厚和强化的部位多在前壁和侧壁。这种表现表明直肠壁的病变是由腹膜腔播种转移所造成。
2．CT可以显示腹膜腔积液、腹膜增厚的位置与分布。腹膜腔积液是胃癌腹膜腔转移的重要征象，少量腹腔积液最早可在盆腔内显示。腹膜增厚、网膜结节和腹腔肿块的在本组病例中发生率较低。
3．部分病例CT显示轻度肾盂输尿管积水征象。弥漫浸润型胃癌的癌细胞沿腹膜后组织间质中扩散可能是肾盂输尿管的不完全梗阻的原因。
4．复查随访病灶的变化过程发现：X线气钡双对比灌肠表现轻微者CT图像上可能阴性，部分病例的CT改变可能要早于钡灌肠。多数病例在随访过程中病变特征逐渐典型，侵犯直肠的病变在随访过程中病变范围可向下扩展延伸。
第三部分发生结肠转移的胃癌原发灶的影像学与病理学对比研究
目的：分析发生大肠转移的胃癌原发灶的影像学表现，并与病理组织学表现相对照，研究胃癌原发灶的影像形态学与病理学的相关性。
对象与方法
研究对象为因胃癌入院手术或胃癌复发入院治疗进行结肠X线钡剂灌肠检查显示胃癌大肠转移的104病例(同第一部分)中，有完整的手术和病理学记录的56例，作为本部分的研究对象。
1．分析胃癌原发灶的影像学资料：包括X线钡剂造影图像上病变部位、大体形态，并判断病灶的浸润深度。由3位医师讨论并作出诊断，X线影像上的大体形态的基本分型为：0型(表浅型)，1型(隆起型)，2型(局限溃疡型)，3型(浸润溃疡型)、4型(弥漫浸润型)和5型(分类不能)。
2．病理学资料包括手术切除标本测量的粘膜面病灶大小、镜下病变的粘膜下浸润大小、组织学类型、间质量、癌浸润增殖方式、癌侵犯深度、淋巴管浸润、静脉浸润、局部淋巴结转移与肿瘤的综合分期等。胃癌病理组织学分类：分为常见型和特殊型，本组病例中均为常见型。包括乳头状腺癌，高分化管状腺癌，中分化管状腺癌，低分化腺癌，印戒细胞癌和粘液癌。同时对照了病理记录中癌的间质量(髓样癌、中间型和硬癌)、癌浸润增殖方式(INFα：膨胀性生长，INFγ：浸润性增殖和INFβ：浸润增殖方式介于α与γ之间)。
3．采用Spearman秩相关分析，检验肉眼形态与病理组织学表现的相关性。
结果
1．年龄56例胃癌的手术切除时年龄自31岁至77岁，多为51岁至75岁年龄段43例，占76.8％。
2．胃癌X线大体形态表浅型2例，1型1例，2型6例，3型22例，4型25例。3型与4型占83.9％。
3．病理组织学56例胃癌中，乳头状腺癌1例，高分化腺癌4例，中分化腺癌6例，低分化腺癌37例，印戒细胞癌6例，粘液癌2例。以低分化癌居多(66.1％)。关于癌的间质量与浸润增殖方式，56例胃癌中，无髓样型，40例硬癌，占71.4％；16例为中间型，占28.6％。40例硬癌中，24例大体肉眼类型为4型，12例为3型，两者占硬癌的90％。43例显示为病灶呈浸润性增殖、与周围组织界限不清的γ型，占76.8％；未见病灶呈膨胀性生长、与周围组织间有清楚分界的α型者；病灶的浸润增殖方式介于α型与γ型之间者13例，占23.2％。其中γ型43例中，25例的大体肉眼类型为4型，14例为3型，两者占γ型的90.1％。
(3)脉管浸润无淋巴管浸润者18例，轻度浸润者19例，中度浸润者11例，重度浸润者8例Ly3。无静脉浸润者40例，轻度静脉浸润者14例，中度静脉浸润者2例。
(4)淋巴结转移无淋巴结转移者15例，转移少于5个者淋巴结者14例，转移淋巴结在6～10个之间者8例，转移淋巴结多于11个者19例。
4．Spearman秩相关检验对56胃癌原发灶的X线大体形态，粘膜下浸润大小、组织学类型、间质量、间质浸润方式、淋巴管浸润、静脉浸润和淋巴结转移等指标进行spearman秩相关检验。结果显示：X线大体形态与粘膜下浸润大小相关性有统计学意义(p＜0.01)，呈中度正相关(r=0.629)。X线大体形态与间质量的相关性有统计学意义(p＜0.01)，呈中度正相关(r=0.473)，X线大体形态与浸润增殖方式的相关性有统计学意义(p＜0.01)，呈中度正相关(r=0.495)。X线大体形态与淋巴管浸润的相关性有统计学意义(p＜0.01)，呈中度负相关(r=-0.441)。
另外，间质量与癌浸润增殖方式之间的相关性有统计学意义(p＜0.01)，呈高度相关(r=0.868)。淋巴管浸润与静脉浸润之间的相关性有统计学意义(p＜0.01)，呈中度相关(r=0.480)。
结论
1．胃癌的X线大体形态与胃癌粘膜下浸润大小、间质量以及浸润增殖模式有相关性，可以根据X线的大体类型推测病理组织学特征。本组发生大肠转移的胃癌，X线影像上多表现为4型或3型病变，组织学显示癌细胞的粘膜下浸润范围较大，多显示间质量丰富的硬癌，癌浸润增殖方式多呈弥漫性增殖浸润，与周围分界不清。这就提示如在影像学上胃癌显示4型病变(皮革胃)，应考虑有大肠转移的可能性，需行进一步检查。
2．X线大体形态与淋巴管浸润呈明显负相关，即在本组3型和4型病变中，淋巴管浸润程度较1型和2型病变轻，其临床意义尚需深入探讨。
3．胃癌的组织学类型、癌的间质量与浸润增殖方式有相关性，本组病例中，以低分化腺癌和印戒细胞癌，或两种组织类型混合存在者占多数，这种组织学类型的癌肿多表现为间质量丰富的硬癌，癌的浸润增殖方式多呈弥漫浸润，与周围分界不清。
Part One The radiological features of colorectai metastases from gastriccancer on double-contrast barium enema
Purpose: to analyze X-ray barium enema manifestations of colorectal metastasisfrom gastric cancer, and investigate the clinical and pathological characteristics andmechanism of occurrence and development of metastasis.
Subject and methods: The history of one hundred and four patients who receivepreoperative routine radiological examination as suffering from gastric cancer or whobe examined because of being diagnosed recurrences or metastases of gastric cancerpostoperatively was reviewed, and the imaging findings of barium enema wereanalyzed.
The primary gastric cancer were conformed by operation pathology or endoscopebiology, with imaging of gastric barium examination, plane and contrast enhancedMSCT as well as pictures of gastric endoscope. The diagnostic criteria of colorectalmetastasis from gastric cancer are: surgical pathology, exploratory abdominal operationbiopsy, ascetic cytology, concomitant clinical and radiological signs of the disease,with clinical exclusion of metastasis from the organs other then stomach, as well as thepathological conditions other then metastasis.
The imaging findings were evaluated the following: Sex, the age of colorectalmetastasis initially is found, and the duration between the time which gastric cancer was found and the time which colorectal metastasis was revealed. Findings of gastricbarium examination, surgical pathology or endoscope biology. Imaging findings wereevaluated with an emphasis on morphology, histology, lymph node invasion, peritonealimplant, ascites cytology and metastasis to liver and spleen. In evaluating the findingsof barium enema, the large bowel was divided into rectum, sigmoid, descending,transverse, ascending and cecum. And further detailed segmentation of large bowelwere divided into rectum as Rb, Ra and Rs, sigmoid to Sp and So (p: pectoral half, o:oral half), descending colon to Dp and Do, spleen flexure, hepatic flexure, Th (onethird of hepatic side of transverse colon), Tm (middle one third of transverse colon),Ts(one third of spleen side of transverse colon), ascending colon to Ap and Ao, andcecum.
The constriction of bowel lumen was graded as five following degrees: grade 0:no observable constriction, grade 1: constriction＜1/3, grade 2 constriction between1/3 and 2/3, grade 3: constriction＞2/3, and grade 4: obstructed. The deformation ofbowel lumen was designed as single side and bilateral. The changes of mucosa reliefwere designed as parallel tethered folds, granular changes, compression and diffusedchange.
Results: There are 67 males and 37 females in 104 patients suffering from thecolorectal metastasis from gastric cancer, with the youngest 22 years old and oldest 89years old, and there are 63 patients whose age between 56 and 75 years old. Theinterval between the detection of the primary gastric cancer and colorectal metastasisrange from 0 to 128 months, with most (91.3%) in 36 months, including 32 cases inwhich colorectal metastasis found in the routine examination before gastric operation.
The morphology of the primary gastric carcinoma was Borrmann 4 (n=65),Borrmann 3 (n=28), Borrmann 2 (n=9) and early cancer (n=2). The histology waspoorly differentiated adenocarcinoma (n=44), poorly differentiated adenocarcinomawith signet-ring cell carcinoma (n=27), signet-ring cell carcinoma (n=10), poorlydifferentiated adenocarcinoma with moderately differentiated adenocarcinoma (n=11),moderately differentiated adenocarcinoma (n=7), well differentiated adenocarcinoma(n=3), papillary adenocarcinoma (n=1) and undifferentiated carcinoma (n=1).
The involved sites of colorectal metastasis were transverse colon (83), rectum (50),descending colon (20), sigmoid colon (17), ascending colon (15) and cecum (1). Withdetailed segmentation, the occurrence of involvement was Tm (47), Ts (44), Th (39)and Ra (39).
The constriction of bowel lumen was evaluated on the barium enema. There were19 lesions with no observable constriction, 104 lesions with constriction＜1/3, 110lesions with constriction between 1/3 and 2/3, 96 lesions with constriction＞2/3, andfour lesions completely obstructed. The deformation of bowel lumen on single side wasseen in 227 lesions and bilateral in 96 lesions. Mucosal changes showed as paralleltethered relief in 253 lesions, granular in 23 lesions, compression in 20 lesions anddiffused change in 62 lesions.
In 48 cases rectum metastasis found on barium enema, 42 cases of rectum wallthickening were revealed on MSCT, in which 41 cases enhanced and 25 cases revealedas layering pattern. In 89 cases colon metastasis found on barium enema, 73 werefound with colon wall thickened, and in which 71 cases were enhanced and 31 caseshad layering pattern.
Conclusion: The preferable sites of colorectal metastasis from gastric cancer aretransverse colon and rectum. Barium enema shows parallel tethered mucosal folds,granular appearances, compression and diffused invasion, and several changes maymixed, with the parallel tethered mucosal folds typical and the most common findings.Most lesions were progressed to typical change in the following examination, and partsof involved segments are elongated and especially the lesion of upper and middlerectum extended to lower part of rectum. From this study we considered that thoughthe pattern of colorectal metastasis from gastric cancer are always known as directinvasion and peritoneal seeding from primary tumor, we think the main route ofmalignant spread may be subperitoneal spread, and metastasis to the transverse colonfrom gastric tumor by the gastrocolic ligament may be one type of subperitonealspread.
We studied the colorectal metastasis from gastric cancer mainly on the base ofthe imaging of barium enema. Although we studied the primary gastric lesions with pathological correlation, the limitation was lack of comprehensive pathologicalcorrelation in many metastasis lesions. So there are much unclear knowledge to beresearched about pathological features and mechanism of metastasis.
Part twoThe radiological features of colorectal metastases from gastriccancer on MSCT
Purpose: to analyze CT manifestations of colorectal metastasis from gastriccancer, and investigate the clinical and pathological characteristics and mechanism ofoccurrence and development of metastasis.
Subject and methods: The history of one hundred and four patients who receivepreoperative routine radiological examination as suffering from gastric cancer or whobe examined because of being diagnosed recurrences or metastases of gastric cancerpostoperatively were analyzed. The imaging of MSCT were reviewed
CT findings scanned at the same time when barium enema examined werereviewed by the consensus of two experienced radiologists. The findings wereevaluated on the following: the presence or absence of thickening at the site ofinvolvement, the pattern of enhancement, the thickening and nodule of omentum andperitoneum as well as ligament, and enhancement, the presence or absence of lymphnode swelling and mass in the abdominal cavity, ascites and distribution,hydronephrosis or hydroureter, liver or spleen metastasis, etc. For the cases whichreceived barium enema and CT more then one time, evaluate the progress of abovechanges.
Results: In 48 cases rectum metastasis found on barium enema, 42 cases ofrectum wall thickening were revealed on MSCT, in which 41 cases enhanced and 25cases revealed as layering pattern. In 89 cases colon metastasis found on barium enema,73 were found with colon wall thickened, and in which 71 cases were enhanced and 31 cases had layering pattern.
CT revealed ascites in 55 patients, with fluid in supramesocolic compartments in18 cases, inframesocolic in 4 cases, right and left paracolic gutters in 15 cases andpelvis in 45 cases. Pleural effusion was found in six patients. Omenta or mensentarywere remarkably thickened in three cases and nodule in 14 cases, hydronephrosis andhydroureter were found on CT in 27 patients, all of which were slightly dilated. Tumormass were found in two cases and hepatic metastasis in one patient.
Forty-five patients were received MSCT scan in those patients, and 31 cases werefound the wall of involved bowel segment thicker then prior examination, and most oflesions developed as layered enhancement.
Conclusion. CT findings at the time when lesions were found at barium enemamanifested as thickened bowel wall with typically concentric layering bowel wallthickening, as called it as target sign. Ascites, thickening of and nodule in omentum ormesentery, hydronephrosis and hydroureter were also features on CT images. Mass andhepatic metastasis are relatively rare. In the following up examination with bariumenema and CT, we found part of lesions may not be revealed out on MSCT at the slightchange on barium enema, but part of lesion may be more remarkable on CT thenbarium enema. Most lesions were progressed to typical change in the followingexamination, and parts of involved segments are elongated and especially the lesion ofupper and middle rectum extended to lower part of rectum. From this study weconsidered that though the pattem of colorectal metastasis from gastric cancer arealways known as direct invasion and peritoneal seeding from primary tumor, we thinkthe main route of malignant spread may be subperitoneal spread, and metastasis to thetransverse colon from gastric tumor by the gastrocolic ligament may be one type ofsubperitoneal spread.
Part threeThe comparative study between radiological findings andpathology of primary gastric carcinoma in colorectal metastasis cases
Purpose: to investigate the imaging characteriatics of primary gastric carcinomain colorectal cases compared with pathological findings, and study the correlationsbetween imaging features and histology of primary gastric carcinoma.
Subject and methods: The radiological and pathological data of fifty six cases ofgastric cancinoma with complete records of operation pathology in one hundred andfour patients (same as part one) were collected. Radiological findings including the sizeand morphology of tumor were reviewed by the consensus of three experiencedradiologists. Morphology of tumor divided into six types as following: type 0(superficial type), type 1 (protruded type), type 2 (localized ulcerated type), type 3(invasive ulcerated type), type 4 (massive invasive type) and type 5 (unclassified).
The histology of gastric cancer firstly divided into common type and special type,all cases in this study were common type, which further divided into papillaryadenocarcinoma (pap), well differentiated tubular adenocarcinoma (tub1), moderatelydifferentiated tubular adenocarcinoma (tub2), poorly differentiated adenocarcinoma (por),signet-ring cell carcinoma (sig) and mucinous adenocarcinoma (muc). The histologicalrecords such as the pattern of tumor infiltration, lymphatic infiltration, venousinfiltration and lymph nodes metastasis were reviewed. The correlation between theradiology and histology were statistically analyzed using spearman method.
Results: the age of this 56 patients group range from 31 years old to 77 years old,among them, 43 cases in the range from 51 years old to 75 years old, accounting for76.8 percents. Radiologically, there were 2 cases of type 0, 1 case of type 1, 6 cases oftype 2, 22 cases of type 3 and 25 cases of type 4, with type 3 and type 4 accounting for83.9 percents. Histologically, there were 1 case of pap, 4 cases of tub1, 6 cases of tub237 cases of por, 6 cases of sig, and 2 cases of muc, with por for 66.1 percents. Therewere 40 cases of scirrhous type and 16 cases of intermediate type, without any case ofmedullary type in this 56 cases group. In the pattern of tumor infiltration, 43 cases manifested as typeγ, and 13 cases as typeβ, without any case of typeα. In thelymphatic and venous infiltration, 18 cases with no lymphatic Infiltration, 19 caseswith slight lymphatic infiltration, 11 cases with moderate and 8 cases with severeinfiltration were revealed, no venous infiltration were revealed in 40 cases, slightvenous infiltration in 14 cases and moderate venous infiltration in 2 cases, with nosevere venous infiltration case. Lymphatic nodes metastasis were not revealed in 15cases, the number of metastasis lymphatic nodes less than 5 were revealed in 14 cases,the number of metastasis lymphatic nodes between 6 and 10 were revealed in 8 cases,the number of metastasis lymphatic nodes more than 5 were revealed in 19 cases.
Statistical analysis results shows that there were statistical significance incorrelation between the radiological morphology and the size of sub mucosa invasion,radiological morphology and the pattern of tumor infiltration, and minus correlationbetween radiological morphology and the lymphatic infiltration.
Conclusion: The strong correlation is existed between radiological morphologyand histological features as the size of submucosal invasion and pattern of tumorinfiltration. In these cases of gastric carcinoma with colorectal metastasis, the tumorsmostly were type 4 and type 3, with massive submucosal invasion and massive tumorinfiltration.
目的分析胃癌大肠转移的X线气钡双对比灌肠造影表现，探讨胃癌大肠转移的X线影像学表现特征和胃癌大肠转移的发生发展规律。
对象与方法研究对象因胃癌或胃癌复发入院治疗，并在术前或治疗过程中进行结肠X线钡剂灌肠检查发现胃癌大肠转移的104例。
所有病例均满足以下标准：胃癌原发灶均经手术病理或内镜活检病理证实，均有术前胃气钡双对比造影检查图像和／或MSCT平扫和增强检查的图像以及胃内窥镜检查的资料；胃癌大肠转移均符合如下标准：①手术病理证实；②开腹探查或腹腔镜探查病理活检证实；③影像学或内镜诊断大肠转移，临床治疗观察随访确定诊断；④排除多脏器恶性肿瘤合并胃癌造成的腹膜腔转移。⑤除外原发性大肠癌和大肠恶性淋巴瘤。
分析内容：
1．病人的性别、钡灌肠初次发现大肠转移征象的年龄、发现胃癌原发病变距初次发现大肠转移的间隔时间(月)。
2．X线气钡双对比灌肠造影的表现特征：分析病变部位、肠腔狭窄程度、肠管变形情况和大肠粘膜面的改变。
(1)病变部位：在对直肠、乙状结肠、降结肠、横结肠、升结肠和盲肠进行分段观察的基础上，将各段作了进一步细化分段，以对病变进行更准确的定位，将直肠分为腹膜返折下段(Rb)、腹膜返折上段(Ra)和直肠乙状结肠交界段(Rs)；乙状结肠分为肛侧半(Sp)和口侧半(So)；降结肠也分为肛侧半(Dp)和口侧半(Do)；结肠脾区(Sf)为结肠在脾曲的外缘转折点分别向近侧和远侧3cm区域的肠段；同样，肝区(Hf)为结肠在肝曲外缘转折点分别向近侧和远侧3cm的区域；将横结肠分成三等份，分别为横结肠肝侧段(Th)、横结肠中段(Tm)和横结肠脾侧段(Ts)；升结肠分为肛侧半(Ap)和口侧半(Ao)；盲肠(Cecum)单独为一段。鉴于钡灌肠图像的放大率不确定等因素，不易测量病变的准确长度，未对病变侵犯肠管的长度进行分析，仅记录病变部位。
(2)肠腔的狭窄程度：根据肠腔狭窄程度分为5个等级：0为肠腔无明显狭窄；1为肠腔狭窄＜1／3；2为肠腔狭窄在1／3～2／3之间；3为肠腔狭窄＞2／3；4为肠腔完全闭塞。
(3)肠管变形：将肠管变形分为单侧变形和双侧变形。
(4)结肠粘膜面的改变：分为梳齿状黏膜皱襞聚集(tethered)改变、颗粒结节状(granular)改变、外压性(compression)改变和弥漫性(diffuse)改变4种。多种改变同时存在同时记录。
3．与胃癌原发灶的影像学形态、病理组织学表现相关性。
4．对接受2次以上X线气钡双对比灌肠灌肠者，观察病变的发展与变化。
结果
1．104例胃癌大肠移转病例，男67例，女37例。年龄最小者22岁，最长者89岁。发生大肠转移的高发年龄组在56岁～75岁之间，占本组病例的61.5％。
2．发现大肠转移与发现胃癌的间隔时间，胃癌术前检查发现大肠转移32例，胃癌术后3年内发生大肠转移者占91.3％。
3．胃癌肉眼形态主要为3型和4型，两者之和占本组病例的89.4％。组织学类型以低分化腺癌和印戒细胞癌以及含有这两种成份者为多，占本组病例的88.5％。
4．大肠转移病灶的分布，胃癌大肠转移灶的最常侵犯的部位为横结肠(83例)，其次为直肠(50例)。再次为降结肠(20例)、乙状结肠(17例)和升结肠(15例)。盲肠受累者少见，仅2例。
将大肠细化分段，受累频率依次为横结肠中1／3段(Tm，47处)，横结肠左1／3(Ts，44处)，横结肠右1／3(Th，39处)和直肠腹膜返折之上(Ra，39处)。
胃癌术前检查发生大肠转移同手术7个月后发生大肠转移的病变部位进行比较，显示术前检查发现的大肠转移以横结肠中段(Tm)的发生率最高，而术后7个月发生转移者则以直肠腹膜返折以上(Ra)的发生率最高，两者差别有统计学意义(P＜0.05)。
5．X线气钡双对比灌肠的表现，从狭窄程度看，病变无明显狭窄者19处，1度狭窄104处，2度狭窄110处，3度狭窄96处，完全阻塞者4处。从肠腔变形的情况看，单侧变形者227处，双侧变形者96处。
病变部位粘膜面的表现，呈梳齿状黏膜纹聚集改变者253处，呈颗粒结节状改变者23处，显示外压性改变者20处，表现为弥漫性改变者62处。梳齿状黏膜纹聚集为大肠转移的主要表现。
6．复查随访X线气钡双对比灌肠图像的发展演变，在累及直肠的病灶中，30例进行了两次以上的钡灌肠检查，随访过程中病变即无明显变化者7例。经过治疗有缓解者5例，其中1例最终恶化，形成梗阻。病变部位狭窄程度加重或病灶范围延长者18例，其中6例病灶范围延长者，均为由首次发现时为侵犯Ra或Rs的病变发展为累及Rb的病变。
除直肠之外的结肠受累的病例中，54例接受了2次以上钡灌肠检查，病变趋向加重者33例，改善者10例，无显著变化者11例。
结论
1．胃癌发生大肠转移的原发灶的大体形态多为4型和3型病变，病理组织学以低分化腺癌和印戒细胞癌居多。
2．横结肠和直肠为胃癌发生大肠转移的好发部位。胃癌转移造成的横结肠的改变，推测可能是胃癌细胞沿胃结肠韧带的直接侵犯横结肠，也可能为癌细胞经胃后壁的浆膜面脱落进入小网膜囊播种于结肠的浆膜面所致。而胃癌的直肠和乙状结肠转移极有可能是腹膜腔播种转移的结果。
3．胃癌发生大肠转移时，X线结肠气钡双对比灌肠造影表现为梳齿状粘膜纹聚集、粘膜面颗粒状改变、外压性病变和弥漫性病变，其中以梳齿状粘膜纹聚集的改变最多见，具有特征性。
4．直肠病变在随访过程中，可出现病变范围延长和狭窄程度加重，其中病变范围延长时，可表现为由首次发现的Ra或Rs病变发展延伸至Rb。
5．术前检查发现大肠转移同手术7个月后发生大肠转移的病变部位进行比较，显示手术7个月后发生转移者以直肠腹膜返折以上(Ra)的发生率最高，有统计学意义。推测可能手术改变了腹膜腔的本来结构，引起腹膜腔内液体移动的途径和方式发生了变化，使癌细胞更容易到达Douglas隐窝，有待证实。
第二部分胃癌大肠转移的MSCT表现
目的：分析胃癌大肠转移的MSCT表现，探讨胃癌大肠转移的CT影像学表现特征和胃癌大肠转移的发生发展规律。
对象与方法
研究对象为因胃癌入院手术或胃癌复发入院治疗进行结肠X线钡剂灌肠检查显示胃癌大肠转移的104病例(同第一部分研究对象)，所有病例在X线初次发现大肠转移的同期均进行了全腹CT平扫与增强检查，另有95例进行了2次以上的CT复查。
分析内容，对于X线钡剂灌肠初次发现转移同期的CT图像，分析肠壁有无增厚、增厚的部位和增厚部位的增强方式，网膜、系膜有无增厚、结节以及增厚网膜、系膜的增强方式，腹腔内淋巴结有无增大，腹腔内有无肿块，腹水的有无以及液体的分布部位，肾盂输尿管有无积水，肝脏以及其他脏器有无转移等。记录腹水的分布部位时，将腹膜腔间隙分为结肠上区，结肠下区，左右两侧结肠旁沟和盆腔5个区域。对于发现大肠转移后，进行多次CT复查者，观察分析治疗过程中CT表现的变化。
结果
1．肠壁的改变：钡灌肠发现直肠受侵改变者50例中，CT显示直肠壁增厚者42例(84.0％，42／50)，有强化者41例(82.0％，41／50)，同时显示分层状强化征象者25例(50.0％，25／50)。钡灌肠发现除直肠之外的结肠受侵者89例，CT显示肠壁增厚者73例(82.0％，73／89)，71例有强化(79.8％，71／89)，其中分层状强化者31例(34.8％，31／89)。
2．腹膜腔的改变：CT显示55例有腹膜腔积液。其中，腹水位于结肠上间隙者18例，分布于结肠下间隙者4例，分布在双侧结肠旁沟者15例，位于盆腔者45例。另外有6例病人可见明显的胸腔积液。CT显示网膜或系膜明显增厚者3例，显示网膜或系膜内结节影者14例，增强扫描均有中等程度强化。
3．尿路积水及其他改变27例病人有肾盂输尿管积水，其中表现为左侧肾盂输尿管积水者4例，右侧肾盂输尿管积水者12例，双侧肾盂输尿管积水者11例。均为轻度的肾盂输尿管扩张。2例有腹腔肿块，1例有肝脏转移，1例肺内有结节状病灶。
4．病变的发展与变化的观察：累及直肠的病例中，45例进行了2次以上的CT检查，31例的直肠肠壁由正常的厚度发展为增厚，或由原来已经增厚的肠壁变得更厚，并有明显的内层强化。10例原有直肠壁增厚的病例在复查过程中肠壁无明显的变化。4例在随访过程中由增厚恢复正常厚度。除直肠外的结肠受累病例中，78例接受了2次以上的CT检查，病变趋向加重者50例，趋向减轻者2例，病变平稳无显著变化者26例。在肾盂输尿管积水的病例中，8例是在发现大肠转移的同期CT显示肾盂输尿管积水，其余均为在CT复查时显示肾盂输尿管积水。
结论
1．胃癌大肠转移的CT扫描肠壁的改变表现为肠壁增厚和肠壁环形增强。推测是由于发生大肠转移的胃癌多数为弥漫浸润型胃癌，癌细胞趋向于弥散分布于间质中，受累的肠段由于大量的胶原纤维组织形成而引起管壁异常增厚，还可保留肠壁的分层结构。且动脉期在增厚的内层呈明显的强化。本组病例还发现，直肠肠壁的增厚除可表现为弥漫性肠壁增厚和靶征外，还可表现为不对称性增厚和强化，这种增厚和强化的部位多在前壁和侧壁。这种表现表明直肠壁的病变是由腹膜腔播种转移所造成。
2．CT可以显示腹膜腔积液、腹膜增厚的位置与分布。腹膜腔积液是胃癌腹膜腔转移的重要征象，少量腹腔积液最早可在盆腔内显示。腹膜增厚、网膜结节和腹腔肿块的在本组病例中发生率较低。
3．部分病例CT显示轻度肾盂输尿管积水征象。弥漫浸润型胃癌的癌细胞沿腹膜后组织间质中扩散可能是肾盂输尿管的不完全梗阻的原因。
4．复查随访病灶的变化过程发现：X线气钡双对比灌肠表现轻微者CT图像上可能阴性，部分病例的CT改变可能要早于钡灌肠。多数病例在随访过程中病变特征逐渐典型，侵犯直肠的病变在随访过程中病变范围可向下扩展延伸。
第三部分发生结肠转移的胃癌原发灶的影像学与病理学对比研究
目的：分析发生大肠转移的胃癌原发灶的影像学表现，并与病理组织学表现相对照，研究胃癌原发灶的影像形态学与病理学的相关性。
对象与方法
研究对象为因胃癌入院手术或胃癌复发入院治疗进行结肠X线钡剂灌肠检查显示胃癌大肠转移的104病例(同第一部分)中，有完整的手术和病理学记录的56例，作为本部分的研究对象。
1．分析胃癌原发灶的影像学资料：包括X线钡剂造影图像上病变部位、大体形态，并判断病灶的浸润深度。由3位医师讨论并作出诊断，X线影像上的大体形态的基本分型为：0型(表浅型)，1型(隆起型)，2型(局限溃疡型)，3型(浸润溃疡型)、4型(弥漫浸润型)和5型(分类不能)。
2．病理学资料包括手术切除标本测量的粘膜面病灶大小、镜下病变的粘膜下浸润大小、组织学类型、间质量、癌浸润增殖方式、癌侵犯深度、淋巴管浸润、静脉浸润、局部淋巴结转移与肿瘤的综合分期等。胃癌病理组织学分类：分为常见型和特殊型，本组病例中均为常见型。包括乳头状腺癌，高分化管状腺癌，中分化管状腺癌，低分化腺癌，印戒细胞癌和粘液癌。同时对照了病理记录中癌的间质量(髓样癌、中间型和硬癌)、癌浸润增殖方式(INFα：膨胀性生长，INFγ：浸润性增殖和INFβ：浸润增殖方式介于α与γ之间)。
3．采用Spearman秩相关分析，检验肉眼形态与病理组织学表现的相关性。
结果
1．年龄56例胃癌的手术切除时年龄自31岁至77岁，多为51岁至75岁年龄段43例，占76.8％。
2．胃癌X线大体形态表浅型2例，1型1例，2型6例，3型22例，4型25例。3型与4型占83.9％。
3．病理组织学56例胃癌中，乳头状腺癌1例，高分化腺癌4例，中分化腺癌6例，低分化腺癌37例，印戒细胞癌6例，粘液癌2例。以低分化癌居多(66.1％)。关于癌的间质量与浸润增殖方式，56例胃癌中，无髓样型，40例硬癌，占71.4％；16例为中间型，占28.6％。40例硬癌中，24例大体肉眼类型为4型，12例为3型，两者占硬癌的90％。43例显示为病灶呈浸润性增殖、与周围组织界限不清的γ型，占76.8％；未见病灶呈膨胀性生长、与周围组织间有清楚分界的α型者；病灶的浸润增殖方式介于α型与γ型之间者13例，占23.2％。其中γ型43例中，25例的大体肉眼类型为4型，14例为3型，两者占γ型的90.1％。
(3)脉管浸润无淋巴管浸润者18例，轻度浸润者19例，中度浸润者11例，重度浸润者8例Ly3。无静脉浸润者40例，轻度静脉浸润者14例，中度静脉浸润者2例。
(4)淋巴结转移无淋巴结转移者15例，转移少于5个者淋巴结者14例，转移淋巴结在6～10个之间者8例，转移淋巴结多于11个者19例。
4．Spearman秩相关检验对56胃癌原发灶的X线大体形态，粘膜下浸润大小、组织学类型、间质量、间质浸润方式、淋巴管浸润、静脉浸润和淋巴结转移等指标进行spearman秩相关检验。结果显示：X线大体形态与粘膜下浸润大小相关性有统计学意义(p＜0.01)，呈中度正相关(r=0.629)。X线大体形态与间质量的相关性有统计学意义(p＜0.01)，呈中度正相关(r=0.473)，X线大体形态与浸润增殖方式的相关性有统计学意义(p＜0.01)，呈中度正相关(r=0.495)。X线大体形态与淋巴管浸润的相关性有统计学意义(p＜0.01)，呈中度负相关(r=-0.441)。
另外，间质量与癌浸润增殖方式之间的相关性有统计学意义(p＜0.01)，呈高度相关(r=0.868)。淋巴管浸润与静脉浸润之间的相关性有统计学意义(p＜0.01)，呈中度相关(r=0.480)。
结论
1．胃癌的X线大体形态与胃癌粘膜下浸润大小、间质量以及浸润增殖模式有相关性，可以根据X线的大体类型推测病理组织学特征。本组发生大肠转移的胃癌，X线影像上多表现为4型或3型病变，组织学显示癌细胞的粘膜下浸润范围较大，多显示间质量丰富的硬癌，癌浸润增殖方式多呈弥漫性增殖浸润，与周围分界不清。这就提示如在影像学上胃癌显示4型病变(皮革胃)，应考虑有大肠转移的可能性，需行进一步检查。
2．X线大体形态与淋巴管浸润呈明显负相关，即在本组3型和4型病变中，淋巴管浸润程度较1型和2型病变轻，其临床意义尚需深入探讨。
3．胃癌的组织学类型、癌的间质量与浸润增殖方式有相关性，本组病例中，以低分化腺癌和印戒细胞癌，或两种组织类型混合存在者占多数，这种组织学类型的癌肿多表现为间质量丰富的硬癌，癌的浸润增殖方式多呈弥漫浸润，与周围分界不清。
Part One The radiological features of colorectai metastases from gastriccancer on double-contrast barium enema
Purpose: to analyze X-ray barium enema manifestations of colorectal metastasisfrom gastric cancer, and investigate the clinical and pathological characteristics andmechanism of occurrence and development of metastasis.
Subject and methods: The history of one hundred and four patients who receivepreoperative routine radiological examination as suffering from gastric cancer or whobe examined because of being diagnosed recurrences or metastases of gastric cancerpostoperatively was reviewed, and the imaging findings of barium enema wereanalyzed.
The primary gastric cancer were conformed by operation pathology or endoscopebiology, with imaging of gastric barium examination, plane and contrast enhancedMSCT as well as pictures of gastric endoscope. The diagnostic criteria of colorectalmetastasis from gastric cancer are: surgical pathology, exploratory abdominal operationbiopsy, ascetic cytology, concomitant clinical and radiological signs of the disease,with clinical exclusion of metastasis from the organs other then stomach, as well as thepathological conditions other then metastasis.
The imaging findings were evaluated the following: Sex, the age of colorectalmetastasis initially is found, and the duration between the time which gastric cancer was found and the time which colorectal metastasis was revealed. Findings of gastricbarium examination, surgical pathology or endoscope biology. Imaging findings wereevaluated with an emphasis on morphology, histology, lymph node invasion, peritonealimplant, ascites cytology and metastasis to liver and spleen. In evaluating the findingsof barium enema, the large bowel was divided into rectum, sigmoid, descending,transverse, ascending and cecum. And further detailed segmentation of large bowelwere divided into rectum as Rb, Ra and Rs, sigmoid to Sp and So (p: pectoral half, o:oral half), descending colon to Dp and Do, spleen flexure, hepatic flexure, Th (onethird of hepatic side of transverse colon), Tm (middle one third of transverse colon),Ts(one third of spleen side of transverse colon), ascending colon to Ap and Ao, andcecum.
The constriction of bowel lumen was graded as five following degrees: grade 0:no observable constriction, grade 1: constriction＜1/3, grade 2 constriction between1/3 and 2/3, grade 3: constriction＞2/3, and grade 4: obstructed. The deformation ofbowel lumen was designed as single side and bilateral. The changes of mucosa reliefwere designed as parallel tethered folds, granular changes, compression and diffusedchange.
Results: There are 67 males and 37 females in 104 patients suffering from thecolorectal metastasis from gastric cancer, with the youngest 22 years old and oldest 89years old, and there are 63 patients whose age between 56 and 75 years old. Theinterval between the detection of the primary gastric cancer and colorectal metastasisrange from 0 to 128 months, with most (91.3%) in 36 months, including 32 cases inwhich colorectal metastasis found in the routine examination before gastric operation.
The morphology of the primary gastric carcinoma was Borrmann 4 (n=65),Borrmann 3 (n=28), Borrmann 2 (n=9) and early cancer (n=2). The histology waspoorly differentiated adenocarcinoma (n=44), poorly differentiated adenocarcinomawith signet-ring cell carcinoma (n=27), signet-ring cell carcinoma (n=10), poorlydifferentiated adenocarcinoma with moderately differentiated adenocarcinoma (n=11),moderately differentiated adenocarcinoma (n=7), well differentiated adenocarcinoma(n=3), papillary adenocarcinoma (n=1) and undifferentiated carcinoma (n=1).
The involved sites of colorectal metastasis were transverse colon (83), rectum (50),descending colon (20), sigmoid colon (17), ascending colon (15) and cecum (1). Withdetailed segmentation, the occurrence of involvement was Tm (47), Ts (44), Th (39)and Ra (39).
The constriction of bowel lumen was evaluated on the barium enema. There were19 lesions with no observable constriction, 104 lesions with constriction＜1/3, 110lesions with constriction between 1/3 and 2/3, 96 lesions with constriction＞2/3, andfour lesions completely obstructed. The deformation of bowel lumen on single side wasseen in 227 lesions and bilateral in 96 lesions. Mucosal changes showed as paralleltethered relief in 253 lesions, granular in 23 lesions, compression in 20 lesions anddiffused change in 62 lesions.
In 48 cases rectum metastasis found on barium enema, 42 cases of rectum wallthickening were revealed on MSCT, in which 41 cases enhanced and 25 cases revealedas layering pattern. In 89 cases colon metastasis found on barium enema, 73 werefound with colon wall thickened, and in which 71 cases were enhanced and 31 caseshad layering pattern.
Conclusion: The preferable sites of colorectal metastasis from gastric cancer aretransverse colon and rectum. Barium enema shows parallel tethered mucosal folds,granular appearances, compression and diffused invasion, and several changes maymixed, with the parallel tethered mucosal folds typical and the most common findings.Most lesions were progressed to typical change in the following examination, and partsof involved segments are elongated and especially the lesion of upper and middlerectum extended to lower part of rectum. From this study we considered that thoughthe pattern of colorectal metastasis from gastric cancer are always known as directinvasion and peritoneal seeding from primary tumor, we think the main route ofmalignant spread may be subperitoneal spread, and metastasis to the transverse colonfrom gastric tumor by the gastrocolic ligament may be one type of subperitonealspread.
We studied the colorectal metastasis from gastric cancer mainly on the base ofthe imaging of barium enema. Although we studied the primary gastric lesions with pathological correlation, the limitation was lack of comprehensive pathologicalcorrelation in many metastasis lesions. So there are much unclear knowledge to beresearched about pathological features and mechanism of metastasis.
Part twoThe radiological features of colorectal metastases from gastriccancer on MSCT
Purpose: to analyze CT manifestations of colorectal metastasis from gastriccancer, and investigate the clinical and pathological characteristics and mechanism ofoccurrence and development of metastasis.
Subject and methods: The history of one hundred and four patients who receivepreoperative routine radiological examination as suffering from gastric cancer or whobe examined because of being diagnosed recurrences or metastases of gastric cancerpostoperatively were analyzed. The imaging of MSCT were reviewed
CT findings scanned at the same time when barium enema examined werereviewed by the consensus of two experienced radiologists. The findings wereevaluated on the following: the presence or absence of thickening at the site ofinvolvement, the pattern of enhancement, the thickening and nodule of omentum andperitoneum as well as ligament, and enhancement, the presence or absence of lymphnode swelling and mass in the abdominal cavity, ascites and distribution,hydronephrosis or hydroureter, liver or spleen metastasis, etc. For the cases whichreceived barium enema and CT more then one time, evaluate the progress of abovechanges.
Results: In 48 cases rectum metastasis found on barium enema, 42 cases ofrectum wall thickening were revealed on MSCT, in which 41 cases enhanced and 25cases revealed as layering pattern. In 89 cases colon metastasis found on barium enema,73 were found with colon wall thickened, and in which 71 cases were enhanced and 31 cases had layering pattern.
CT revealed ascites in 55 patients, with fluid in supramesocolic compartments in18 cases, inframesocolic in 4 cases, right and left paracolic gutters in 15 cases andpelvis in 45 cases. Pleural effusion was found in six patients. Omenta or mensentarywere remarkably thickened in three cases and nodule in 14 cases, hydronephrosis andhydroureter were found on CT in 27 patients, all of which were slightly dilated. Tumormass were found in two cases and hepatic metastasis in one patient.
Forty-five patients were received MSCT scan in those patients, and 31 cases werefound the wall of involved bowel segment thicker then prior examination, and most oflesions developed as layered enhancement.
Conclusion. CT findings at the time when lesions were found at barium enemamanifested as thickened bowel wall with typically concentric layering bowel wallthickening, as called it as target sign. Ascites, thickening of and nodule in omentum ormesentery, hydronephrosis and hydroureter were also features on CT images. Mass andhepatic metastasis are relatively rare. In the following up examination with bariumenema and CT, we found part of lesions may not be revealed out on MSCT at the slightchange on barium enema, but part of lesion may be more remarkable on CT thenbarium enema. Most lesions were progressed to typical change in the followingexamination, and parts of involved segments are elongated and especially the lesion ofupper and middle rectum extended to lower part of rectum. From this study weconsidered that though the pattem of colorectal metastasis from gastric cancer arealways known as direct invasion and peritoneal seeding from primary tumor, we thinkthe main route of malignant spread may be subperitoneal spread, and metastasis to thetransverse colon from gastric tumor by the gastrocolic ligament may be one type ofsubperitoneal spread.
Part threeThe comparative study between radiological findings andpathology of primary gastric carcinoma in colorectal metastasis cases
Purpose: to investigate the imaging characteriatics of primary gastric carcinomain colorectal cases compared with pathological findings, and study the correlationsbetween imaging features and histology of primary gastric carcinoma.
Subject and methods: The radiological and pathological data of fifty six cases ofgastric cancinoma with complete records of operation pathology in one hundred andfour patients (same as part one) were collected. Radiological findings including the sizeand morphology of tumor were reviewed by the consensus of three experiencedradiologists. Morphology of tumor divided into six types as following: type 0(superficial type), type 1 (protruded type), type 2 (localized ulcerated type), type 3(invasive ulcerated type), type 4 (massive invasive type) and type 5 (unclassified).
The histology of gastric cancer firstly divided into common type and special type,all cases in this study were common type, which further divided into papillaryadenocarcinoma (pap), well differentiated tubular adenocarcinoma (tub1), moderatelydifferentiated tubular adenocarcinoma (tub2), poorly differentiated adenocarcinoma (por),signet-ring cell carcinoma (sig) and mucinous adenocarcinoma (muc). The histologicalrecords such as the pattern of tumor infiltration, lymphatic infiltration, venousinfiltration and lymph nodes metastasis were reviewed. The correlation between theradiology and histology were statistically analyzed using spearman method.
Results: the age of this 56 patients group range from 31 years old to 77 years old,among them, 43 cases in the range from 51 years old to 75 years old, accounting for76.8 percents. Radiologically, there were 2 cases of type 0, 1 case of type 1, 6 cases oftype 2, 22 cases of type 3 and 25 cases of type 4, with type 3 and type 4 accounting for83.9 percents. Histologically, there were 1 case of pap, 4 cases of tub1, 6 cases of tub237 cases of por, 6 cases of sig, and 2 cases of muc, with por for 66.1 percents. Therewere 40 cases of scirrhous type and 16 cases of intermediate type, without any case ofmedullary type in this 56 cases group. In the pattern of tumor infiltration, 43 cases manifested as typeγ, and 13 cases as typeβ, without any case of typeα. In thelymphatic and venous infiltration, 18 cases with no lymphatic Infiltration, 19 caseswith slight lymphatic infiltration, 11 cases with moderate and 8 cases with severeinfiltration were revealed, no venous infiltration were revealed in 40 cases, slightvenous infiltration in 14 cases and moderate venous infiltration in 2 cases, with nosevere venous infiltration case. Lymphatic nodes metastasis were not revealed in 15cases, the number of metastasis lymphatic nodes less than 5 were revealed in 14 cases,the number of metastasis lymphatic nodes between 6 and 10 were revealed in 8 cases,the number of metastasis lymphatic nodes more than 5 were revealed in 19 cases.
Statistical analysis results shows that there were statistical significance incorrelation between the radiological morphology and the size of sub mucosa invasion,radiological morphology and the pattern of tumor infiltration, and minus correlationbetween radiological morphology and the lymphatic infiltration.
Conclusion: The strong correlation is existed between radiological morphologyand histological features as the size of submucosal invasion and pattern of tumorinfiltration. In these cases of gastric carcinoma with colorectal metastasis, the tumorsmostly were type 4 and type 3, with massive submucosal invasion and massive tumorinfiltration.
引文
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27．郭华，高剑波，杨学华，等．螺旋CT三期增强扫描对胃癌TNM分期的研究[J]．实用放射学杂志，2003，19(1)：37-40．
28．任刚，陈克敏。胃癌螺旋CT术前评估及与手术病理对照研究[J]．放射 学实践，2006，21，684-686
29. Healy JC, Reznek RH. The peritoneum, mesenteries and omenta: normal anatomy and pathological processes[J]. Eur. Radiol, 1998; 8, 886-900
30. Meyers MA, McSweeney J. Secondary neoplasm of the bowel[J]. Radiology,1972; 105, 1-11
31. Meyers MA, Oliphant M, Berne AS, Feldberg MAM. The peritoneal ligaments and mesenteries: pathways of intraabdominal spread of disease[J]. Radiology, 1987;163:593-604
32. Jang HJ, Lira HK, Kim HS, et al. intestinal metastases from gastric adenocarcinoma: helical CT findings[J]. J comput assist tomogr, 2001; 25(1):61-67
33. Kim KA, Park CM, Park SW, et al. CT findings in the abdomen and pelvis after gastric carcinoma resection[J]. A JR, 2002; 179: 1037-1041
34. Ha HK, Jee KR, Yu E, et al. CT features of metastatic linitis plastica to the rectum in patients with peritoneal carcinomatosis[J]. AJR, 2000; 174:463-466
35. Meyers MA, Volberg F, Katzen B, Abbott G. haustral anatomy and pathology: a new look.—roentgen identification of normal patterns and relationship[J]. Radiology,1973; 108: 497-504
36. Meyers MA, Volberg F, Katzen B, Abbott G. haustral anatomy and pathology: a new look.—roentgen interpretation of pathological alterations[J]. Radiology, 1973; 108: 505-512
37．渡 二郎、水上裕輔、田边裕貴 転移性大腸癌診断注腸X線検查再評価——CT檢查内視鏡検查診断能比較[J]．Japanese journal of clinical radiology, 1996; 41: 211-216
38．宫川国久 胃癌大腸転移画像診断[J]．千葉医学，1994；70：245-250
39．小林 店幸，渕上 忠彦，堺 勇二，他。転移性大腸癌形態学的特徵——X線像中心[J]．胃腸，2003；38：1815-1830
40．石川 勉，縄野 繁，水口安則，他。転移性大腸癌形態診断[J]．胃腸，1988；23：617-630
41．大田博俊，畦倉 薫，関 誠，他 転移性大腸癌臨床病理[J]．胃 肠，1988；32：633-643
42．牛尾恭輔，石川 勉，宫川国久，他．転移性小肠腫疡X線诊断[J]．胃肠，1992；27：793-804
43. Ginaldi S, Lindell MMjr, Zornoza J. the striped colon -radiologic observation in metastatic serosal implants[J]. AJR, 1980; 134:453-455
44. Oliphant M, Berne AS. Computed tomography of the subperitoneal space: demonstration of direct spread of intraabdominal disease[J]. J comput assist tomogr, 1982; 6(6):1127-1137
45. Nelson RC, Chezmar JL, Hoel MJ, et al. peritoneal carcinomatosis: preoperative CT with intraperitoneal contrast material[J]. Radiology, 1992; 182: 133-138
46. Rha SE, Ha HK, Kim JG, et al. CT features of intraperitoneal manifestations of parasitic infestation[J]. AJR, 1999; 172:1289-1292
47. Ha HK, Jung JI, Lee MS, et al. CT differentiation of tuberculous peritonitis and peritoneal carcinomatosis[J]. AJR, 1996; 167: 743-748
48. DeMeo JH, Fulcber AS, Austin R. anatomic CT demonstration of the peritoneal spaces, ligaments, and mesenteries: normal and pathologic processes[J]. Radiographics, 1995; 15:755-770
49. Coakley FV, Choi PH, Gougoutas CA, et al. peritoneal metastases: detection with spiral CT in patients with ovarian cancer[J]. Radiology 2002; 223:295-499
50. Davies J, Chalmers AG, Sue-Ling HM, et al. Spiral computed tomography and operative staging of gastric cancer: a comparison with histopathological staging[J].Gut, 1997; 41:314-319
51. Raptopoulos V, Gourtsoyiannis N. peritoneal carcinomatosis[J]. Eur. Radiol, 2001; 11:2195-2206
52. Oliphant M, Berne AS, Meyers MA. Spread of disease via the subperitoneal space: the small bowel mesentery[J]. Abdom Imaging, 1993; 18:109-116
53. Oliphant M, Berne AS, Meyers MA. Imaging the direct bidirectional spread of disease between the abdomen and the female pelvis via the subperitoneal space[J]. Gastrointest Radiol, 1988; 13:285-298
54. Dodds Wj, Foley WD, Lawson TL, et al. Anatomy and imaging of the lesser peritoneal sac[J]. AJR, 1985; 144: 567-575
55. Kim KW, Choi BI, Han JK, et al. postoperative anatomy and pathologic finding at CT following gastrectomy[J]. RadioGraphics, 2002; 22: 323-336
56. Min PQ, Yang ZG, Lei QF et al. peritoneal reflections of left perihepatic region: radiologic-anatomic study[J]. Radiology, 1992; 182: 553-557
57. Stafford-Johnson DB, Bree RL, Francis IR, Korobkin M. CT appearance of primary papillary serous carcinoma of the peritoneum[J]. AJR, 1998; 171:687-689
58．岡部 聡，金子慶虎，竹村克二 他 術後5年目発症回盲部限局胃癌結腸転移1例[J]．胃腸，1988；23(6)：663-676
59．力武 浩 納富昌德 平木幹久 他 胃癌治癒切除後転移性大腸癌2手術例[J]．日本臨床外科医学会雜誌，1992；53(2)：405-410
60．井上育夫 更科広実 斎藤典男他 転移性大腸癌臨床病理学的検討[J]．日本大腸肛門誌，1987，40：186-191
61. Balthazar EJ. CT gastroimestinal tract: principles and interpretation[J]. AJR, 1991; 156:23-32
62. Chang DK, Kim JW, Kim BK, et al. Clinical significance of CT-defined minimal ascites in patients with gastric cancer[J]. World J Gastroenterol. 2005; 11(42): 6587-6592
63．日本胃癌学会，胃癌取扱規約(第13版)[M]．東京，金原出版社，1999．6
64．大腸癌研究会，大腸癌取扱規約(第6版) [M]．東京，金原出版社，1998．11
2．王金万．胃癌[J]．癌症进展杂志，2004，3，87
3．张思维，陈万青，孔灵芝，等．中国部分市县1998～2002年恶性肿瘤的发病与死亡[J]．中国肿瘤，2006，15，430-448
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12．于韬，罗娅红，邱岩。螺旋CT增强扫描对进展期胃癌的局部浸润和淋巴结转移的研究[J]．中国临床医学影像杂志，2004，15(10)：573-577
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14．颜有霞，徐香玖，任晓苏，等。多层螺旋CT多期增强的胃癌分期与手术病理对照研究[J]．实用放射学杂志，2005，21(4)，401-403
15．朱艳清，童林军，刘林祥。多排螺旋CT在胃癌术前分期中价值的研究[J]．诊断学理论与实践，2004，3(6)：444-446
16．毛淑华，赵素岗，张丽蓉．螺旋CT仿真内窥镜对胃癌分期的临床价值[J]．中国医学影像学杂志，2002，10(4)：299-300．
17．彭卫军，周康荣，秦新裕．SCT多期扫描在进展期胃癌术前分期的价值[J]．中国医学计算机成像杂志，2001，7(3)：179-181．
18．李健丁，孙华平．胃癌的SCT诊断及分期[J]．放射学实践，2002，17(1)：1-2．
19．高剑波，郭华，周志刚．胃癌SCT三期、双期和单期增强的比较研究[J]．实用放射学杂志，2002，18(9)：763-764．
20．王锡明，武乐斌，王涛，等．多层螺旋CT成像技术在胃癌诊断中的应用[J]．中国医学影像技术杂志，2003，19(10)：1362-1363．
21. Gretschel S, Moesta KT. New concept of staging in gastrointestinal tumors as a basis of diagnosis and multimodal therapy[J]. Onkologie, 2004, 27 (1): 23-30.
22. Takao M, Fukuya T, Iwanaga S, et al. Gastric cancer: evaluation of triphasic spiral CT and radiologic-pathologic correlation [J]. J Comput Assist Tomogr, 1998, 22(2): 288-294.
23．武玉坤，李洪松，高长娟．MSCT与数字胃肠对溃疡型胃癌的对照研究[J]．中国医学影像学杂志，2003，13(4)：255-256．
24. Dvies J, Chalmens AG, Sue-Ling HM, et al. Spiral computed tomography and operative staging of gastric carcinoma: a comparision with histopathological staging [J]. Gut, 1997, 41 (3): 314-319.
25. Paramo JC, Gomez G. Dynamic CT in the preoperative evaluation of patients with gastric cancer: correlation with surgical findings and pathology [J]. Ann Surg Oncol, 1999, 6 (4): 379-384.
26. Vorbeck F, Osterreicher C, Puspok A. Comparison of spiral computer tomography with water-filling of the stomach and endosonography for gastric lymphoma of mucosa-associated lymphoid tissue-type[J]. Digestion, 2002, 65 (4): 196-199.
27．郭华，高剑波，杨学华，等．螺旋CT三期增强扫描对胃癌TNM分期的研究[J]．实用放射学杂志，2003，19(1)：37-40．
28．任刚，陈克敏。胃癌螺旋CT术前评估及与手术病理对照研究[J]．放射 学实践，2006，21，684-686
29. Healy JC, Reznek RH. The peritoneum, mesenteries and omenta: normal anatomy and pathological processes[J]. Eur. Radiol, 1998; 8, 886-900
30. Meyers MA, McSweeney J. Secondary neoplasm of the bowel[J]. Radiology,1972; 105, 1-11
31. Meyers MA, Oliphant M, Berne AS, Feldberg MAM. The peritoneal ligaments and mesenteries: pathways of intraabdominal spread of disease[J]. Radiology, 1987;163:593-604
32. Jang HJ, Lira HK, Kim HS, et al. intestinal metastases from gastric adenocarcinoma: helical CT findings[J]. J comput assist tomogr, 2001; 25(1):61-67
33. Kim KA, Park CM, Park SW, et al. CT findings in the abdomen and pelvis after gastric carcinoma resection[J]. A JR, 2002; 179: 1037-1041
34. Ha HK, Jee KR, Yu E, et al. CT features of metastatic linitis plastica to the rectum in patients with peritoneal carcinomatosis[J]. AJR, 2000; 174:463-466
35. Meyers MA, Volberg F, Katzen B, Abbott G. haustral anatomy and pathology: a new look.—roentgen identification of normal patterns and relationship[J]. Radiology,1973; 108: 497-504
36. Meyers MA, Volberg F, Katzen B, Abbott G. haustral anatomy and pathology: a new look.—roentgen interpretation of pathological alterations[J]. Radiology, 1973; 108: 505-512
37．渡 二郎、水上裕輔、田边裕貴 転移性大腸癌診断注腸X線検查再評価——CT檢查内視鏡検查診断能比較[J]．Japanese journal of clinical radiology, 1996; 41: 211-216
38．宫川国久 胃癌大腸転移画像診断[J]．千葉医学，1994；70：245-250
39．小林 店幸，渕上 忠彦，堺 勇二，他。転移性大腸癌形態学的特徵——X線像中心[J]．胃腸，2003；38：1815-1830
40．石川 勉，縄野 繁，水口安則，他。転移性大腸癌形態診断[J]．胃腸，1988；23：617-630
41．大田博俊，畦倉 薫，関 誠，他 転移性大腸癌臨床病理[J]．胃 肠，1988；32：633-643
42．牛尾恭輔，石川 勉，宫川国久，他．転移性小肠腫疡X線诊断[J]．胃肠，1992；27：793-804
43. Ginaldi S, Lindell MMjr, Zornoza J. the striped colon -radiologic observation in metastatic serosal implants[J]. AJR, 1980; 134:453-455
44. Oliphant M, Berne AS. Computed tomography of the subperitoneal space: demonstration of direct spread of intraabdominal disease[J]. J comput assist tomogr, 1982; 6(6):1127-1137
45. Nelson RC, Chezmar JL, Hoel MJ, et al. peritoneal carcinomatosis: preoperative CT with intraperitoneal contrast material[J]. Radiology, 1992; 182: 133-138
46. Rha SE, Ha HK, Kim JG, et al. CT features of intraperitoneal manifestations of parasitic infestation[J]. AJR, 1999; 172:1289-1292
47. Ha HK, Jung JI, Lee MS, et al. CT differentiation of tuberculous peritonitis and peritoneal carcinomatosis[J]. AJR, 1996; 167: 743-748
48. DeMeo JH, Fulcber AS, Austin R. anatomic CT demonstration of the peritoneal spaces, ligaments, and mesenteries: normal and pathologic processes[J]. Radiographics, 1995; 15:755-770
49. Coakley FV, Choi PH, Gougoutas CA, et al. peritoneal metastases: detection with spiral CT in patients with ovarian cancer[J]. Radiology 2002; 223:295-499
50. Davies J, Chalmers AG, Sue-Ling HM, et al. Spiral computed tomography and operative staging of gastric cancer: a comparison with histopathological staging[J].Gut, 1997; 41:314-319
51. Raptopoulos V, Gourtsoyiannis N. peritoneal carcinomatosis[J]. Eur. Radiol, 2001; 11:2195-2206
52. Oliphant M, Berne AS, Meyers MA. Spread of disease via the subperitoneal space: the small bowel mesentery[J]. Abdom Imaging, 1993; 18:109-116
53. Oliphant M, Berne AS, Meyers MA. Imaging the direct bidirectional spread of disease between the abdomen and the female pelvis via the subperitoneal space[J]. Gastrointest Radiol, 1988; 13:285-298
54. Dodds Wj, Foley WD, Lawson TL, et al. Anatomy and imaging of the lesser peritoneal sac[J]. AJR, 1985; 144: 567-575
55. Kim KW, Choi BI, Han JK, et al. postoperative anatomy and pathologic finding at CT following gastrectomy[J]. RadioGraphics, 2002; 22: 323-336
56. Min PQ, Yang ZG, Lei QF et al. peritoneal reflections of left perihepatic region: radiologic-anatomic study[J]. Radiology, 1992; 182: 553-557
57. Stafford-Johnson DB, Bree RL, Francis IR, Korobkin M. CT appearance of primary papillary serous carcinoma of the peritoneum[J]. AJR, 1998; 171:687-689
58．岡部 聡，金子慶虎，竹村克二 他 術後5年目発症回盲部限局胃癌結腸転移1例[J]．胃腸，1988；23(6)：663-676
59．力武 浩 納富昌德 平木幹久 他 胃癌治癒切除後転移性大腸癌2手術例[J]．日本臨床外科医学会雜誌，1992；53(2)：405-410
60．井上育夫 更科広実 斎藤典男他 転移性大腸癌臨床病理学的検討[J]．日本大腸肛門誌，1987，40：186-191
61. Balthazar EJ. CT gastroimestinal tract: principles and interpretation[J]. AJR, 1991; 156:23-32
62. Chang DK, Kim JW, Kim BK, et al. Clinical significance of CT-defined minimal ascites in patients with gastric cancer[J]. World J Gastroenterol. 2005; 11(42): 6587-6592
63．日本胃癌学会，胃癌取扱規約(第13版)[M]．東京，金原出版社，1999．6
64．大腸癌研究会，大腸癌取扱規約(第6版) [M]．東京，金原出版社，1998．11
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