Paper Title (use style: paper title)
Thermography in abdominal comorbidity in gastric carcinoma: case report
Marko Banić 1*, Darko Kolarić 2, Tonći Božin 1, Tomislav Kuliš 3, Mirjana Vukelić 1, Željko Herceg 4, Lidija Petričušić 1, Svetlana Antonini 5
1 University Hospital Dubrava, Division of Gastroenterology, Zagreb, Croatia
2 Ruđer Bošković Institute, Centre for Informatics and Computing, Zagreb, Croatia
3 University Hospital Rebro, Department of Urology, Zagreb, Croatia
4 Universitiy Hospital Sestre Milosrdnice, Division of Radiology, Zagreb, Croatia
5 Primary Health Care Zagreb - Center, Department of Radiology, Zagreb, Croatia
* mbanic@kbd.hr
Abstract – There is a need for simple, noninvasive and reproducible test that could accurately reflect the inflammatory activity, and could be used safely and repeatedly in detecting gastrointestinal symptomatology, such as diverticulitis. The aim of this study was to present the possibility of thermal imaging in assessing the inflammatory activity of diverticulitis as a comorbid finding in gastric carcinoma. The authors present the case of male patient with newly diagnosed gastric carcinoma and diverticulitis. The MSCT showed diverticula but no inflammation witch was observed on the thermal image and confirmed on colonoscopy. This case report pointed out to diagnostic potential of infrared thermographs as a feasible and noninvasive method in evaluation of comorbidities in malignant disease, such as gastric carcinoma.
Keywords – gastric carcinoma; diverticulitis; comorbidities; MSCT; thermography
Introduction
Carcinoma of stomach is the leading cause of cancer related death in the last century worldwide but there are marked geographical variations in incidence [1]. It is extremely common in China, Japan and parts of South America (mortality rate 30-40 per 100 000), less common in the UK (12-13 deaths per 100 000) and uncommon in the USA [2]. Studies of Japanese migrants to the USA have revealed a much lower incidence in second-generation migrants, confirming the importance of environmental factors [3]. Gastric carcinoma is more common in men and the incidence rises sharply after 50 years of age. The overall prognosis is poor, with less than 30% surviving 5 years, and the best hope for improved survival lies in greater detection of tumours at an earlier stage. It is important to know that 20% of all carcinomas occur in the gastrointestinal tract, and gastric carcinoma is the second most common among them, after colon cancer. There is a strong link between H. pylori infection and gastric cancer. H.pylori infection results in chronic gastritis witch eventually leads to atrophic gastritis and intestinal metaplasia – a premalignant pathological change, as shown in Figure 1 [4]. Acquisition of infection at an early age may be important [5]. The cytotoxin-associated gene A (CagA) protein of H. pylori, which is delivered into gastric epithelial cells, is an oncoprotein that can induce malignant neoplasms in mammals [6]. Diets rich in salted, smoked or pickled foods and the consumption of nitrites and nitrates may increase cancer risk [7].
[pic]
Figure 1. Gastric carcinogenesis
Diets lacking fresh fruit and vegetables as well as vitamins C and A may also contribute. Smoking is also associated with an increased incidence of gastric cancer [8]. Pernicious anaemia carries a small increased risk for gastric carcinoma, as well as after partial gastrectomy [9]. No predominant genetic abnormality has been identified, although cancer risk is increased in first-degree relatives of patients. Virtually all tumours are adenocarcinomas. Cancers are either “intestinal”, arising from areas of intestinal metaplasia, or “diffuse”, arising from normal gastric mucosa. Intestinal carcinomas are more common. Diffuse cancers occur in younger patients. Early gastric cancer is usually asymptomatic but may occasionally be discovered during endoscopy. Two-thirds of patients with advanced cancer have weight loss and 50% have ulcer-like pain. Anaemia from occult bleeding is also common. Metastases occur most common in the liver, lungs, peritoneum and bone marrow. Standard diagnostic workup includes physical exam, laboratory testing, endoscopic visualization, and for disease staging we use endoscopic UZV and imaging methods such as MSCT of the thorax and abdomen. PET-CT should also be performed in disease staging. Identification of polyp on CT is size dependent, with large lesions (≥10mm) accurately detected and small lesions (6-9mm) identified with moderate to good sensitivity [10]. Resection offers the only hope of cure [11]. In patients with inoperable tumours, palliation of symptoms can sometimes be achieved with chemotherapy using FAM (5-fluorouracil, doxorubicin and mitomycin C) or ECF (epirubicin, cisplatin and fluorouracil). Various endoscopic procedures are in use for symptom relief. In our case the patient has gastric cancer and diverticulitis as comorbidity. Diverticula of the colon are, in most cases, acquired out-pouching of the mucosal layer of the bowel through gaps in the bowel wall musculature. Unlike congenital diverticula, their walls are not formed from all layers found in normal bowel. Their prevalence correlates significantly with advancing age [12]. With advancing age, there is increase in both the number and size of diverticula. Men and women are about equally affected. About 80-95% of diverticula develop in the sigmoid colon. The aetiology of diverticular disease is not completely understood. A crucial factor in the pathogenesis of diverticula is an increase in intraluminal pressure in the bowel and intensified intestinal motor activity. Decisive co-factors in the development of diverticula include changes in life-style and nutrition, in particular the increased consumption of foods low in dietary fibres [12]. Over 80% of persons with diverticula remain asymptomatic indefinitely. Inpatients with so-called “symptomatic” diverticulosis, complaints are often not due to the diverticula themselves but most often result from a co-existing irritable bowel syndrome [13]. Asymptomatic diverticulosis can progress to diverticular disease when complications occur. Complications of diverticulosis include diverticulitis, diverticular bleeding, covered or free perforation, diverticular stenosis and the formation of fistulae. The most common complication is diverticulitis. One consequence of stool retention may be the formation of fecoliths within the diverticular pouch, leading to bacterial inflammation of the diverticulum and pressure ulcerations. Consequences include perforation with abscess formation, peritonitis and fistulation. The clinical signs of acute diverticulitis include colicky abdominal pain, fever and alterations in laboratory parameters. There may also be diarrhoea or constipation, reduced general health, loss of appetite and sometimes vomiting. The physical examination of patients with diverticulitis reveals a bloated abdomen painful to pressure. As the patient progresses through the stages of peridiverticulitis and pericolitis, the spreading peritonitis leads to development of the clinical picture of acute abdomen. Solitary or multiple diverticula, especially in older patients, are a common coincidental findings of radiological (barium enema) or endoscopic (colonoscopy) examinations obtained primarily for some other indication. More recently, however, ultrasound has enjoyed increasing application in the diagnosis of diverticulitis. Limiting factors for the sonographic detection of diverticula include significant obesity in the patient, distal diverticula and very small diverticula. Computed tomography (CT) is capable of providing data not only on the presence or absence of diverticula but also in regard to inflammatory thickening of the bowel wall and infiltration of the perisigmoid and pericolic adipose tissue. Abscesses, because they are collections of fluid, are also reliably identified. Mild to moderate cases of diverticulitis are treated conservatively with intravenous antibiotics, parenteral nutrition and adequate water and electrolytes intake. Perforations with peritonitis and/or abscess formation, as well as persistent intestinal obstruction and persistent bleeding represent clear indications for surgery.
The aim of this study was to present the possibility of thermal imaging in gastric cancer comorbidities.
methods
In this case report, for the purpose to evaluate the extent of gastric carcinoma and presence of diverticulitis the male patient underwent the standard diagnostic workup that included physical exam, laboratory tests, EGD and total colonoscopy with terminal iloescopy and pathohistologial analysis as well. The MSCT imaging of the abdomen and thorax was performed in order to stage the malignant disease. The patient also underwent the thermal imaging, provided in real time using infrared camera Thermo Tracer TH7102WL (NEC, Japan). The imaging itself was preformed accordingly; patient was positioned in front of the camera, approximately at 1m so that the whole abdomen was captured by the camera lens. He was undressed and asked to stand in front of the camera not touching his abdomen in order to achieve thermal equilibrium. This process took about 5 to 10 minutes and was documented as a thermogram. Upon achieving equilibrium the patient´s abdomen was cooled with alcohol and then interval thermograms were taken until equilibrium was achieved again. Differences in thermal patterns and peak temperatures were documented. The measurements were done before the preparations for endoscopy, to exclude the potential influence of bowel cleansing and endoscopic procedure itself, as well. The thermographic imaging itself was performed after the MSCT scanning and prior to colonoscopy.
case report
We present the case of a 43-year old with newly diagnosed gastric adenocarcinoma. The patient presented to the emergency room with severe abdominal pain. Before admittance to Clinical Hospital Dubrava an esophagogastroduodenoscopy was performed witch showed carcinoma on the back wall of the gastric corpus. The patohistological analysis confirmed the diagnosis of adenocarcinoma. After admittance the preoperative workup included laboratory testing and imaging methods for staging the carcinoma. Laboratory testing showed no abnormalities but the preformed MSCT showed thickening of the gastric small curve 4 cm in diameter and a couple of affected perigastric lymph nodes, as shown on Figure 2. Alongside the findings in the stomach the MSCT also showed nonspecific opacification of the colon wall that could indicate an inflammatory process (Figure 3). Beside the diverticula there were no radiological sings of diverticulitis. Encouraged by this finding the authors performed thermal imaging of the patient’s abdomen. The thermal image showed signs of inflammation in spots that could reflect the position of the diverticula shown on the MSCT, as shown on Figure 4. To confirm the diagnosis of diverticulitis a colonoscopy was performed and diverticulitis was verified. 5 days later the patient was operated. The procedure went fine.
[pic]
Figure 2. MSCT showing gastric carcinoma prior operation
[pic]
Figure 3. MSCT prior operation showing colon diverticula and opacification of the colon wall
[pic]
Figure 4. Thermal image showing hot spot indicating inflammation
Surgical team performed total gastrectomy with splenectomy. However, the planed adjuvant chemo-radiotherapy was postponed due to the newly diagnosed diverticulitis having in mind that chemo-radiotherapy could provoke perforation of the inflamed diverticula and potentially be fatal for the patient.
disscusion
In evaluating gastric carcinoma the standard workup includes physical exam, laboratory work, esophagogastroduodenoscopy and imaging methods such as MSCT for staging and evaluation of associated disease. Taking into account the standard imaging procedures for evaluating the activity and extent of inflammatory disease, the thermal imaging, also known as clinical thermography, is capable of providing non-contact, in vivo diagnostic information in regard to body temperature. Infrared imaging also has the possibility to map small variations of the body surface temperature and identify thermal abnormalities that accompany various physiological conditions. Being a passive technique, (i.e. without external sources of radiation) thermography is non-invasive and therefore intrinsically harmless. The findings in this case report indicate that thermography was superior to radiological imaging techniques in detecting inflammatory conditions such as diverticulitis in a setting of gastric carcinoma. The MSCT showed diverticula but no clear signs of inflammation opposed to thermography. We believe that blood vessel activity during the process of active inflammation induces the increase in body surface temperature that would be higher than in normal tissue [14]. Our findings point out to diagnostic potential of infrared thermography as a feasible and noninvasive method in evaluation of disease activity, in the patient with inflammatory abdominal comorbidities, such as diverticulitis [15-16]. There is a need for further basic and clinical studies, in order to evaluate and validate the method of thermal imaging by the means of infrared thermography in assessing the activity and extent of intestinal inflammation, and other intraabdominal inflammatory conditions, as well.
References
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