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송치성 외: 복부 MDCT 영상에서 국소 위장 병변의 위치 판정 예, 환자와 CT 스캔 상태가 좋지 않아 영상 훼손이 있었던 2 예, 도합 30예는 본 연구 대상에서 제외하였으며 나머지 72예 를 최종 연구 대상으로 하였다. 남자가 47예, 여자가 25예였 고 나이는 33세부터 89세(평균 56.2세)까지 분포하였다. 연구 대상이 된 국소 위장 병변의 최종 병리진단은 진행위암이 46 예, 조기위암이 15예, 위장관간질종양(GIST) 8예, 림프종이 2 예, 과증식성용종(hyperplastic polyp) 1예가 있었다. 과증식성 용종 1예는 용종 자체 때문에 수술한 것이 아니고 용종과 떨 어진 부위에 있던 작은 조기위암에 대해 위아전절제술을 시행 하였는데 MDCT에서 조기위암 병변은 보이지 않고 작은 용종 만이 뚜렷이 보였던 증례였다. 수술(위절제술 66예와 종양절 제술 6예) 결과를 최종 진단으로 정하였는데 위각 병변인 경 우는 위내시경 진단을 중요하게 참고하였다. 모든 환자에서 검 사 전에 검사에 대한 설명을 하였고 검사 동의서를 받았다. 사 용된 CT기는 LightSpeed 16(General Electric, Milwaukee, WI, U.S..)이었다. 의뢰된 검사 종류에 따라 CT 스캔을 시행 하였는데, 앙와위로 CT를 시행한 것이 37예, 복와위로 시행한 것이 2예, 30도 좌후사위(LPO)로 시행한 것이 33예이었다. 최 소한 8시간 이상 금식을 시켰으며, 앙와위와 복와위 자세로 시 행한 경우 800 ml 내외의 물을 먹여 위장을 팽창시켰고 좌후 사위로 시행된 경우는 발포제 (Top, Taejoon Pharmaceuticals, Gyeonggi-do, Korea) 6g을 물 5 ml와 함께 복용하도록 하 였다. 영상 지표, 촬영 조건, 스캔 범위는 세 체위의 축상면 CT 검사에 공통적으로 적용하였는데, 영상 지표는 폭조절 배치 16 0.625 mm, 절편 두께 3.75 mm, 테이블 이동 속도 13.75 mm/회전, 피치 1.375, 재구성 간격 3.75 mm 로 하였고, 촬영 조건은 200-400 ms, 120 kvp로 하였다. 비조영, 동맥기, 문맥기를 촬영을 하였는데, 조영 증강은 120 ml의 비이온성 조영제(Iopamiro 300; racco, Milano, Italy)를 3 ml/sec 로 주입한 뒤 동맥기는 35초 지연 후, 문맥기는 75초 지연 후 촬 영을 하였다. 스캔 범위는 비조영 영상과 동맥기의 경우 횡격 막 직상부부터 신장 하부까지를, 문맥기의 경우 횡격막 직상부 부터 항문환까지 스캔하였다. 영상 분석은 2명의 영상의학과 전문의들이 합의로 병변의 위치를 진단하도록 하였다. 1차 판독과 2차 판독, 두 번의 진 단 과정이 1주일 시간 간격을 두고 시행되었으며 팩스, 영상저 장 및 전송체계(PCS, picture archiving and communi-cating system) 모니터를 사용하였다. 1차 판독에서는 관찰자들에게 어떠한 정보도 제공되지 않았으며, 위장 병변의 중앙부 위치를 진단하도록 하였고 그 진단 근거를 함께 답하도록 하였다. 1차 판독 시기가 종료된 직후에, 판독한 증례들의 정답 진단을 알 려주지 않은 상태에서, 관찰자들에게 위장의 소만과 대만에는 Fig. 1. 60-year-old man with advanced gastric cancer in the greater curvature side of gastric antrum which was misdiagnosed as an anterior wall lesion in the first interpretation.. On MDCT, an excavated mass is noted in the anteriorly-located gastric wall of the antrum (arrow). In the second interpretation, observers could make a correct diagnosis that this lesion was in the greater curvature side because they perceived and traced the right gastroepiploic artery (arrowheads) on axial images of MDCT. On gastroscopy, a mass (arrow) is noted in the greater curvature side of the gastric antrum. C. subtotal gastrectomy specimen opened along the lesser curvature side shows an excavated mass (arrow) in the gastric antrum along the greater curvature side. C 392
Fig. 2. 58-year-old man with advanced gastric cancer in the lesser curvature side of the gastric antrum which was misdiagnosed as a posterior wall lesion in the first interpretation,. On MDCT, a mass with ulceration (arrow) is noted in the posteriorly-located gastric wall of the antrum. In the second interpretation, observers could make a correct diagnosis that this lesion was in the lesser curvature side because they perceived and traced the right and left gastric arteries (arrowheads) on axial images of MDCT. subtotal gastrectomy specimen reveals an ulcerative mass (arrow) along the lesser curvature side of the gastric antrum. 393
송치성 외: 복부 MDCT 영상에서 국소 위장 병변의 위치 판정 Fig. 3. 63-year-old woman with gastrointestinal stromal tumor in the greater curvature side of the gastric body which was misdiagnosed as a posterior wall lesion in the first interpretation.. lobulated mass (arrow) is noted in the posteriorly-located wall of the gastric body. In the second interpretation, observers could make a correct diagnosis that this lesion was in the greater curvature side because they perceived and traced the left gastroepiploic artery (arrowheads) on axial images of MDCT.. On endoscopic ultrasonography, a protruding mass (arrow) was found in the greater curvature side of the body. On operation, a lobulated mass was found along the greater curvature side of the gastric body and wedge resection was performed. Fig. 4. 78-year-old-woman with advanced gastric cancer in the antrum and esophageal hiatal hernia causing overt rotation of the gastric axis in the distal stomach.. On MDCT at the level of the lower esophagus, the herniated portion of the stomach (arrow) is noted.. t the level of the gastric antrum, a mass with ulceration is noted in the right side of the gastric wall (solid arrow). In the second interpretation, observers could make a correct diagnosis that this lesion was in the anterior wall of the gastric antrum because they perceived and traced right gastric artery (arrow) and gastroepiploic artery (open arrow) on axial images of MDCT. C. subtotal gastrectomy specimen reveals a mass with ulceration (arrow)in the anterior wall of the gastric antrum. C 394
Fig. 6. 2D MPR in the sagittal orientation shows an irregular mass (solid arrow) in the anteroinferior portion of the gastric antrum. Without perception of the right gastric artery (open arrow) and right gastroepiploic artery (arrow), it is hard to make a correct diagnosis that this mass is mainly in the posterior wall of the gastric antrum rather than in the anterior wall. Perception and trace of the gastric arteries are essential for correct diagnosis of the location of the gastric lesion. Fig. 5. 65-year-old woman with a tiny hyperplastic polyp in the anterior wall of gastric antrum which was misdiagnosed as posterior wall lesion even in the second interpretation.. tiny polyp (open arrow) is noted in the prepyloric antrum of the stomach. In the second interpretation, observers made an incorrect diagnosis that this lesion was in the posterior wall because they overlooked the reversed direction of gastric lumen at the distal antrum.. subtotal gastrectomy specimen with formalin fixation shows a tiny polyp (arrow) in the anterior wall of the prepyloric antrum. 395
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Localization of the Focal Gastric Lesion on bdominal MDCT: The Importance of the Right and Left Gastric rteries and Gastroepiploic rteries 1 Chi Sung Song, M.D., Young Ho Choi, M.D., yung Jae Yoon, M.D., Sang Min Lee, M.D. 2, Kwang Nam Jin, M.D. 2, Jong Seung Kim, M.D. 3 1 Department of Radiology, oramae Hospital 2 Department of Radiology, Seoul National University Hospital 3 Department of Family Medicine, oramae Hospital Purpose: To identify the importance of the right and left gastric arteries, as well as the gastroepiploic arteries, for the localization of focal gastric lesions from axial images of abdominal MDCTs. Materials and Methods: xial image interpretations from abdominal MDCTs were performed to diagnose the location of focal gastric lesions. The interpretations were performed on 72 patients retrospectively by two radiologists who were blinded from the endoscopic and surgical results by consensus at two different time intervals. No information was provided to the observers, who were asked to determine the precise location of the focal gastric lesion, for the first interpretation. Next, the observers were informed that the right and left gastric arteries, as well as the gastroepiploic arteries, are on the lesser and greater curvature, respectively. Moreover, the gastric angle is on the course of the right and left gastric arteries. One week later, the second interpretation was performed using the same subjects and methods as the first interpretation. The diagnostic accuracy of each interpretation was comparatively evaluated. Results: The diagnostic accuracy of the first and second interpretations was 52.8% (38/72) and 98.6% (71/72), respectively (p < 0.05). Conclusion: The results of this study suggest that the right and left gastric arteries, as well as the gastroepiploic arteries, are reliable markers for the localization of the focal gastric lesions on axial images of abdominal MDCTs. Index words : Stomach rteries Gastroepiploic artery Tomography, X-ray Computed ddress reprint requests to : Chi Sung Song, M.D., Department of Radiology, oramae Hospital, 425 Shindaebang 2-dong, Tongjak-gu, Seoul, 156-707, Korea Tel. 82-2-840-2270 Fax. 82-2-840-2489 E-mail: chiss@brm.co.kr 398