Nghiên cứu giá trị của hình ảnh cắt lớp vi tính và kết quả điều trị phẫu thuật ung thư 1/3 dưới dạ dày ttta

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INTRODUCTION
1. Necessary
Gastric cancer (GC) is the most common malignancy in
gastrointestinal cancers. According to the announcement of the
International Organization for Research on Cancer, in 2018, the
world had 1,033,701 new cases and 782,685 deaths from gastric
cancer, accounting for 5.7% of all cancers and 8.2% of the total
mortality, ranking 5th in the world among common cancers and 2nd
in mortality after lung cancer.
Vietnam belongs to an area of medium-high risk of gastric
cancer, with a new incidence of 21.8 for men and 10.0 for women per
100,000 population.
Computed tomography (CT), a non-invasive method of
diagnosing gastric cancer, allows to perform thin sections, reconstruct
images in the vertical and horizontal directions. Based on that, CT scan
not only identifies the tumor, tumor location but also assesses the
extent of invasion, invasive lymph nodes, metastasis of the tumor to
intra-abdominal viscera, or distant metastasis to the lungs, bones, and
other distant organs, play an important role in the diagnosis of TNM
stages and help in better treatment options. Currently, the CT scanning
system is quite popular in many hospitals. The application of
preoperative CT scanning technique for gastric cancer patients is
relatively convenient. There are not many studies on CT in diagnosis
and follow-up of gastric cancer, so we carried out a study on the topic:
" Research on the value of computed tomography and results of
surgical treament in 1/3 lower gastric cancer”.
2. Objectives
- Imaging characteristics and value of computed tomography in
patients with the lower third of the gastric cancer treated with radical
surgery.

- Evaluation of the results of radical surgery in the treatment of
the lower third gastric cancer.
3. Valudation of the project
The results obtained through the research contribute to the
specialty on the characteristics of computed tomography,
histopathology in the diagnosis of the lower third of the gastric


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cancer and the results after radical surgery to treat the lower third the
gatric cancer.
The topic has scientific significance, practical value, contributing
to improving the quality of diagnosis and treatment, saving patients'
lives, improving survival time in patients with the lower third of the
gatric cancer.
4. Structure of the project
The thesis has 118 pages, including the following parts:
Introduction (2 pages), Chapter 1 (Review of literature 35 pages),
Chapter 2 (Subjects and methods) 23 pages; Chapter 3 (Results) 28
pages; Chapter 4 (Discussion) 27 pages; Conclusion 2 pages;
Recommendation 1 page.
The thesis has 49 tables, 9 charts, 27 figures and 109 references
(20 Vietnamese documents, 89 English documents).
CHAPTER 1
REVIEW OF LITERATURE
1.1. Epidemiological features of gastric cancer
1.2. Pathology and classification of gastric cancer
1.2.1. Pathological features of gastric cancer
1.2.2.1. Tumor location characteristics: Gastric cancer can be found
in any location, but it is most common in the antrum-pyloric region

with a rate of 70-80%; next, the lesser curvature region with the rate
of 10-15%; in the cardiac, bulge region is about 3-5%; Greater
curvature is rare.
1.2.2.2. Macroscopic characteristics: Bormann classification
includes nodules, ulcers, invasive ulcer, and infiltrate
1.2.2.3. Microscopic characteristics: classified according to World
Health Organization and JGCR 3rd.
1.2.2. Hình thức xâm lấn, di căn của ung thư dạ dày: Invasive and
metastatic form of gastric cancer: local invasion, lymphatic
metastasis, peritoneal cavity metastasis, hematogenous metastasis.
1.2.3. Gastric cancer classification: gastric cancer classification
according to the Japanese Gastric Cancer Association (2011)
1.3. Clinical and sublinical features of lower third gastric cancer
Gastric cancer often has no obvious clinical symptoms, nonspecific symptoms can be epigastric pain, flatulence, dyspepsia,


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fatigue, anorexia, weight loss.... Anemia is also a symptom.
commonly found in UTIs.
The typical X-ray images of gastric cancer: lacunae, amputation
usually corresponds to nodule, lenticular shapes correspond to ulcers,
small rigid tubular stomach, loss of peristalsis corresponds to
infiltrates.
Endoscopy is the earliest and most accurate diagnostic method
available today. The more biopsies, the greater the accuracy.
Endoscopy is a method of early diagnosis of gastric cancer,
especially when combined with Indigocalmin staining to indicate the
biopsy area.
1.4. Computed tomography to diagnose gastric cancer
1.4.1. A brief history of the study of computed tomography in the

diagnosis of gastric cancer
1.4.2. Anantomy of gastric computed tomography
1.4.3. Valuation and limitations of computed tomography in the
diagnosis of gastric cancer
1.4.3.1. Image of gastric cancer on computed tomography: Focal
thickening of the gastric wall with mucosal abnormalities, may form
a protrusion into the lumen of the stomach, with a multilobar margin,
jagged, may have or no ulcers; may or may not be symmetrical, after
injection of strongly enhanced or non-enhanced contrast agent.
Normal gastric wall thickness is less than 5mm, gastric wall in
cancerous lesions is defined as ≥1cm thickness. Wall thickening with
loss of normal mucosal folds. Changes in gastric wall thickness
accompanied by strong contrast enhancement are more pronounced
than in the rest.
1.4.3.2. Detecting tumor:
1.4.3.3. Tumor location: The most common gastric cancer is in the
antrum and pyloric areas. In recent years, cardiac gastric cancer tends
to increase.
1.4.3.4. Macroscopic assessment of gastric cancer: early gastric
cancer, nodular, non-invasive ulcerative, invasive ulcerative,
infiltrative and unclassified.
1.4.3.5. Assessment of tumor invasion: T1, T2, T3, T4 invasion.
1.4.3.6. Evaluation of lymph node metastasis: Evaluation of lymph
node metastasis on CT remains a big challenge even with the
generation of multi-detector arrays. The lymph node is considered


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pathological when the short axial diameter of the lymph node is more
than 6 mm for perigastric lymph nodes and more than 8 mm for other

sites. N1, N2, N3 lymph node metastasis.
1.4.3.7. Evaluation of distant metastases: Gastric cancer often
metastasizes to the liver, lymph nodes, peritoneum, ovaries, etc.
Distant metastasis is a poor prognostic factor.
1.5. Stomach cancer surgical treatment
1.5.1. Radical treatment
Surgery is the mainstay of treatment for GC. In the early stage, the
cancer is still localized, surgery is the method of choice for radical
treatment. At a later stage, surgery is considered a basic method
combined with adjuvant methods such as postoperative chemotherapy,
pre- and postoperative radiation therapy, and biological treatment.
1.5.2. Temporary treatment of the lower third gastric cancer
1.6. Results of treatment for gastric cancer
1.6.1. Early results of surgery
The early surgical outcomes include intraoperative accidentes
and deaths, complications, and postoperative mortality. Postoperative
mortality was defined as patients who were critically ill, dying, or
died within the first 30 days after surgery. Postoperative
complications may be encountered such as: peritonitis, oesophageal
fistula, duodenal apex fistula, postoperative bleeding, oropharyngeal
bleeding….
1.6.2. Late results after surgery: Cancer in general and gastric
cancer in particular often recur in the first 2 years after treatment,
especially in the first 5 years. Surgery for radical treatment of gastric
cancer with the expectation of cure of gastric cancer. In the US and
Western countries, the 5-year survival rate in patients undergoing
radical surgery is about 25-30%, the 5-year overall survival rate is
about 4-10%. In Japan, the 5-year overall survival rate is about 57%,
the 5-year survival rate after gastrectomy is about 61%, and the
surgical mortality rate is only about 1%.

CHAPTER 2
SUBJECTS AND METHODS
2.1. Subjects
Including 66 gastric cancer patients diagnosed as the lower third
gastric cancer, preoperatively computed tomography, operated at


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Military Hospital 103 and K Hospital (Tan Trieu campus) from 2009
to 2017.
2.1.1. Criteria of selection
Patients
with
histopathological
diagnosis
of
adenocarcinoma of the lower third of the stomach (defined as
carcinoma according to WHO regulations and the tumor location in
the lower third according to JGCA 3rd).
- Get a computerized tomography (CT) film of the abdomen
with contrast injection.
- Have not had any other type of cancer.
- The patient was treated with radical surgery to treat gastric
cancer. The radical treatment of the lower third gastric cancer is
performed according to the following principles:
+ Gastric bypass: in the lower part of the duodenum, 2 - 3 cm
from the pylorus. At the top, cut at least 6cm from the lesion.
+ Remove all the great omentum, the small omentum
together with the superior area of the transverse mesentery.
+ Remove the metastatic lymph node system: remove gastric

lymph nodes to level D2.
+ Radical resection of invasive or metastatic organs: Invaded
organs such as colon, tail of pancreas, liver or metastases, such as
ovaries, need to be removed along with the tumor.
2.1.2. Exclusion criteria
- The patient did not receive surgical treatment.
- Patients with incorrect technique of CT scan.
- Patient has cancer in other organs.
- The medical record is not full of research information.
2.2. Methods
- Retrospective, prospective, descriptive cross-sectional study,
longitudinal follow-up to evaluate postoperative outcomes.
2.2.1. Research indexes
2.2.1.1. Research criteria and general characteristics of patients
- Age (year), gender (male/female).
- Time of illness
- Functional symptoms, physical symptoms
2.2.1.2. Research indicators on computed tomography with gastric
cancer
- Tumor diagnostic signs:


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- Tumor limit:
- Tumor position:
- Tumor size:
- Tumor thickness:
- Tumor shape: nodules, ulcerative, invasive and infiltrative.
- Density, tumor enhancement properties:
- Invasive nature: T1, T2, T3, T4 level.

- Research criteria on lymph node metastasis: number of lymph
nodes, lymph node location, degree of lymph node metastasis N1,
N2, N3.
- Research criteria on distant metastasis on CT: M0, M1.
- Research indicators on diagnosis of disease stage on CT: Based
on CT results of T, N, and M, determine the stage of lower third
gastric cancer on CT according to JGCA3rd.
2.2.1.3. Research criteria for radical treatment of the lower third
gastric cancer
- Surgical methods; Method of closing the duodenal apex;
Methods of re-establishing gastrointestinal circulation; Surgery time:
- Early post-operative results: time after surgery, length of
hospital stay, complications, postoperative complications, mortality
rate due to surgery.
- Late results after surgery: postoperative complications,
recurrence rate, postoperative metastasis, postoperative survival time.
2.2.1.3. Research criteria on pathology
2.3. Statistically analysis
The study was processed using SPSS 22.0 software
2.4. Research ethics
- This study was conducted after the detailed outline was
approved by the Department, permission and support from the Party
Committee, the Board of Directors of the Military Medical Academy,
the 103 Military Hospital and the K hospital. Tan Trieu) and
authorities.
- The data collected in this study is honest, the research
process does not affect the medical examination and treatment
activities at the relevant clinical departments.
- Patient information is kept confidential.
- Medical records during the research process are stored and

preserved carefully, without causing loss.


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CHAPTER 3
RESULTS
There were a total of 66 patients (51 patients treated at Military
Medical Hospital 103 and 15 patients treated at K Hospital - Tan
Trieu facility) who met the selection criteria and were included in the
study. We get the following results:
3.1. Some characteristics of the lower third gastric cancer
3.1.1. Epidemiological features
Table 3. 1. Age and sex characteristics
Sex (n, %)
Age group
n
Rate %
Male
Female
≤ 40
2(4.17)
4(22.22)
6
9.09
41 – 50
5(10.42)
4(22.22)
9
13.64
51 – 60

22(45.83)
4(22.22)
26
39.39
61 – 70
11(22.9)
4(22.2)
15
22.7
> 70
8(16.67)
2(11.11)
10
15.15
Total
48(72.73)
18(27.27)
66
100
Mean
59.04 ± 10.56
54.33 ± 14.21
57.76 ± 11.74
Min-Max
(31 – 79)
(36 – 81)
(31 – 81)
Comment: The average age of the study group was 57.76 ±
11.74 (years), in which the oldest person was 81, the youngest was
31. The rate of gastric cancer in men was 72.73% higher than female

is 27.27%. The age group 51-60 is the age group with the highest rate
of gastric cancer with 39.39%, the rate of gastric cancer is low in the
age group ≤ 40 (9.09%).
3.1.2. Clinical and paraclinical features
Table 3. 2. Clinical features
Symptoms
Number (n)
Rate (%)
Anorexia-full stomach
28
42.42
Indigestion-nausea
28
42.42
Fatigue-loss weight
32
48.48
Epigastric pain
50
75.76
intermittently
Constant abdominal
25
37.88


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pain
Black stools
10

15.15
Vomiting with blood
2
3.03
Vomiting without blood
18
27.27
pyloric stenosis
2
3.03
Comment: The symptoms encountered with the highest rate were:
abdominal pain (75.76%), followed by fatigue, weight loss (48.48%),
anorexia, bloating (42.42%), hematemesis symptoms (3.03%),
pyloric stenosis are rare.
3.2. Value of computed tomography image of the lower third gastric
cancer
3.2.1. Tumor characteristics on computed tomography
Table 3.3. Tumor location on CT
Tumor location on CT
Number (n)
Rate (%)
Bờ cong nhỏ
17
25.76
Lesser curvature
Pyloric antrum
49
74.24
Total
66

100
Comments: In 66 patients with gastric tumor detected on CT
film, tumors in the antrum and pyloric positions accounted for
74.24%; the remaining 25.76% are tumors in the position of lesser
curvature.
Table 3.4. Invasion, metastasis of tumor on computed
tomography
Tumor
Number (n=66)
Rate (%)
T1
7
10.61
T2
17
25.76
T3
26
39.39
T4a
16
24.24
Tổng
66
100
Lymph nodes
N0
23
34.85
N1

16
24.24
N2
23
34.85
N3
4
6.06
Tổng
66
100
Metastasis


9
M0
64
96.97
M1
2
3.03
Comments: On CT scan, tumors with T3 invasiveness are
predominant, accounting for 39.39%; T4 invasion was 24.24%; T2
invasion was 25.76%; T1 invasion was 10.61%. On CT scan, no
metastatic lymph nodes were detected, accounting for 34.85%.
Metastasis in the group of lymph nodes N1, N2 and N3 was 24.24%,
respectively; 34.85% and 6.06%. There were two cases with
diagnosis of distant metastasis on CT, liver metastasis.
Table 3.5. Stage of gastric cancer on computed tomography
Stages

Number (n)
Rate (%)
Ia
3
4.55
Ib
9
13.64
IIa
16
24.24
IIb
15
22.73
IIIa
10
15.15
IIIb
7
10.61
IIIc
4
6.06
IV
2
3.03
Total
66
100
Nhận xét: Comment: Stage IIa has the highest rate with 24.24%;

stage IIb is 22.73%; stage Ia (4.55%); stage Ib (13.64%); stage IIIa
(15.15%); stage IIIb (10.61%); stage IIIc (6.06%); stage IV (3.03%).
There are 2 cases in stage IV (3.03%), both are liver metastases.
3.2.2. Value of computed tomography in the diagnosis of gastric
cancer of the lower third
Table 3.6. Comparison of invasiveness between computed tomography
and pathology
Pathology
CT

T1

T4
T2

T1
T2
T3

T1a

T1b

1(50.00
)
1(50.00
)

4(57.14
)

1(7.69)

0(0.00)

12(92.31
)

1(4.55)

2(13.33)

0(0.00)

19(86.36
)

2(13.33)

0(0.00)

2(28.57
)

Total

T3
T4a
1(4.55)

0(0.00)

T4b
0(0.00)

7(10.61)

1(14.29
)
3(42.86
)

17(25.76
)
26(39.39
)


10
T4a

0(0.00)

Total

2(3.03)

1(14.29
)
7(10.61

)

0(0.00)

1(4.55)

13(19.70
)

22(33.33
)

11(73.33
)
15(22.73
)

3(42.86
)
7(10.61
)

16(24.24
)
66(100)

Comment: The rate of correct diagnosis of invasiveness of CT scan with
pathology: (5+12+19+14)/66 = 75.76%. Sensitivity corresponding to the
degree of invasion, respectively: T1: 5/9 = 55.56%; T2: 12/13 = 92.31%;
T3: 19/22 = 86.36%; T4: 14/22 = 63.64%. The specificity corresponds to

the levels of invasion, respectively: T1: 55/57 = 96.49%; T2: 48/53 =
90.57%; T3: 37/44 = 84.09%; T4: 42/44 = 95.45%. The positive
predictive value corresponds to the levels of invasion, respectively: T1:
5/7 = 71.43%; T2: 12/17 = 70.59%; T3: 19/26 = 73.08%; T4: 14/16 =
87.50%. The negative predictive value corresponds to the levels of
invasion, respectively: T1: 55/59 = 93.22%; T2: 48/49 = 97.96%; T3:
37/40 = 92.50%; T4: 42/50 = 84.00%. The accuracy in diagnosis
corresponds to the levels of invasion, respectively: T1: 60/66 = 90.91%;
T2: 60/66 = 90.91%; T3: 56/66 = 84.85%; T4: 56/66 = 84.85%.
Table 3.7. Comparison of visceral metastases between computed
tomography and pathology
Pathology
CT
Total
M0
%
M1
%
M0
64
100
0
0.00
64(96.97)
M1
0
0.00
2
100
2(3.03)

Total
64
96.97
2
3.03
66(100)
Comment: There were 2 patients with visceral metastases identified
on preoperative abdominal CT. Through the above table, we found
that the sensitivity in detecting visceral metastases of the abdominal
CT scan method: 2/2 = 100%; specificity: 64/64 = 100%; positive
predictive value: 2/2 = 100%; negative predictive value: 64/64 =
100%. Accuracy: (64 + 2)/66 = 100%.
Table 3.8. Comparison of lymph node metastasis between
computed tomography and pathology
Pathology
CT

N0

N0

N1

N2

13(65.00)

1(8.33)

6(26.09)

N3

Total

N3a

N3b

3(37.50)

0(0.00)

23(34.85)


11
N1

4(20.00)

9(75.00)

1(4.00)

2(25.00)

0(0.00)

16(24.24)

N2

2(10.00)

2(16.67)

17(68.00)

1(12.50)

1(100)

23(34.85)

N3

1(5.00)

0(0.00)

1(4.00)

2(25.00)

0(0.00)

4(6.06)

Total

20(30.30)

12(18.18)

25(37.88)

8(12.12)

1(1.52)

66(100)

Comment: Accurate diagnosis rate of abdominal CT scan in
diagnosing metastasis in gastric cancer lymph nodes:
(13+9+17+2)/66 = 62.12%. Sensitivity corresponding to the
diagnosis of lymph node metastasis and the degree of lymph node
metastasis, respectively: N: 36/46 = 78.26%; N1: 9/12 = 75.00%; N2:
17/25 = 68.00%; N3: 2/9 = 22.22%. The specificity corresponding to
the diagnosis of lymph node metastasis and the degree of lymph node
metastasis, respectively: N: 13/20 = 65.00%; N1: 47/54 = 87.04%;
N2: 35/41 = 85.37%; N3: 55/57 = 96.49%. The positive predictive
value corresponds to the diagnosis of lymph node metastasis and the
degree of lymph node metastasis, respectively: N: 36/43 = 83.72%;
N1: 9/16 = 56.25%; N2: 17/23 = 73.91%; N3: 2/2 = 50.00%. The
negative predictive value corresponds to the diagnosis of lymph node
metastasis and the degree of lymph node metastasis, respectively: N:
13/23 = 56.52%; N1: 47/50 = 94.00%; N2: 35/43 = 81.40%; N3:
55/62 = 88.71%. The accuracy corresponding to the diagnosis of
lymph node metastasis and the degree of lymph node metastasis,

respectively: N: 49/66 = 74.24%; N1: 56/66 = 84.85%; N2: 52/66 =
78.79%; N3: 57/66 = 86.36%.
Table 3.9. Comparison of disease stage between computed
tomography and pathology
Pathology

Total

CT
Ia

Ib

IIa

IIb

IIIa

IIIb

IIIc

Ia

3
(100)

0
(0.00)

0
(0.00)

0
(0.00)

0
(0.00)

0
(0.00)

0
(0.00)

Ib

1
(11.11
)

5
(55.5
6)

1
(11.11
)

0
(0.00)

0
(0.0)

1
(6.25)

1
(11.11
)
2
(12.5
0)

0
(0.00)

IIa

1
(11.11
)
6
(37.5
0)

4
(25.0

0)

1
(6.25)

2
(12.5
0)

IV
0
(0.00
)
0
(0.00
)
0
(0.00
)

3
(4.55)
9
(13.64
)
16
(24.24
)

12
Pathology

Total

CT
Ia

Ib

IIa

IIb

IIb

0
(0.00)

3
(20.0
0)

1
(6.67)

IIIa

0
(0.00)

0
(0.00)

0
(0.00)

IIIb

0
(0.00)

0
(0.00)

0
(0.00)

IIIc

0
(0.00)

0
(0.00)

0
(0.00)

IV

0
(0.00)

0
(0.00)

0
(0.00)

0
(0.00)

Tota
l

4
(6.06)

9
(13.6
4)

8
(12.1
2)

16
(24.2
4)

10
(66.6
7)
1
(10.0
0)
1
(14.2
9)
1
(25.0
0)

IIIa

IIIb

IIIc

0
(0.00)

1
(6.67)

0
(0.00)

5

(50.0
0)
1
(14.2
9)

1
(10.0
0)
1
(14.2
9)
1
(25.0
0)

3
(30.0
0)
4
(57.1
4)
2
(50.0
0)

0
(0.00)

0

(0.00)

0
(0.00)

10
(15.1
5)

6
(9.09)

11
(16.6
7)

0
(0.00)

IV
0
(0.00
)
0
(0.00
)
0
(0.00
)
0

(0.00
)
2
(100
)
2
(3.03
)

15
(22.73
)
10
(15.15
)
7
(10.61
)
4
(6.06)
2
(3.03)
66
(100)

Comment: Accurate diagnosis rate of abdominal CT scan in
diagnosing gastric cancer stage: (3+5+6+10+5+1+2+2)/66 = 51.52%.
Sensitivity corresponding to disease stages, respectively: Ia: 3/4 =
75.00%; Ib: 5/9 = 55.56%; IIa: 6/8 = 75.00%; IIb: 10/16 = 62.50%;
IIIa: 5/10 = 50.00%; IIIb: 1/6 = 16.67%; IIIc: 2/11 = 18.18%; IV: 2/2

= 100.00%. Specificity corresponding to the disease stages
respectively: Ia: 62/62 = 100.00%; Ib: 53/57 = 92.98%; IIa: 48/58 =
82.76%; IIb: 45/50 = 90.00%; IIIa: 51/56 = 91.07%; IIIb: 54/60 =
90.00%; IIIc: 53/55 = 96.36%; IV: 64/64 = 100.00%. Positive
predictive value corresponding to the disease stages respectively: Ia:
3/3 = 100.00%; Ib: 5/9 = 55.56%; IIa: 6/16 = 37.50%; IIb: 10/15 =
66.67%; IIIa: 5/10 = 50.00%; IIIb: 1/7 = 14.29%; IIIc: 2/4 = 50.00%;
IV: 2/2 = 100.00%. Negative predictive value corresponding to the
disease stages respectively: Ia: 62/63 = 98.41%; Ib: 53/57 = 92.98%;
IIa: 48/50 = 96.00%; IIb: 45/50 = 88.24%; IIIa: 51/56 = 91.07%; IIIb:
54/59 = 91.53%; IIIc: 53/62 = 85.48%; IV: 64/64 = 100.00%. The
accuracy corresponding to the disease stages in turn: Ia: 65/66 =
98.48%; Ib: 58/66 = 87.88%; IIa: 54/66 = 81.82%; IIb: 55/66 =
83.33%; IIIa: 56/66 = 84.85%; IIIb: 55/66 = 83.33%; IIIc: 55/66 =
83.33%; IV: 66/66 = 100.00%.


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3.3. Results of surgery for the lower third gastric cancer
3.3.1. Surgical method
Table 3.10. Relationship between surgical way and surgery time
The way of
surgery

Numbe
r (n)

Rate
(%)

Surgery time
(minutes)

p

Laparotomy
39
59.09
153.85 ± 34.31
surgery
<0.0
1
Endoscopic
27
40.91
197.78 ± 58.08
surgery
Total
66
100
171.82 ± 50.11
Comment: There were 39 gastric cancer patients treated with
laparotomy (59.09%); 27 patients were treated with laparoscopic
surgery (40.91%). Average surgery time 171.82 ± 50.11 (minutes),
laparoscopic surgery (197.78 ± 58.08 minutes) needed more time
than laparotomy (153.85 ± 34.31) minutes), p<0.01.
Table 3.11. Relationship between to surgical methods and surgery time
Rat
Number
Surgery time

Surgical method
e
p
(n)
(minutes)
(%)
Cắt bán phần dưới
dạ dày
93.9
62
169.27 ± 45.45
Partially gastric
4
>0.0
resection
5
Totally gastric
4
6.06 211.25 ± 101.03
resection
Total
66
100
171.82 ± 50.11
Nhận xét: Phẫu thuật cắt bán phần dưới dạ dày là phương pháp phẫu
Comment: Partially gastric resection is the main surgical method
accounting for 93.94%. Total gastrectomy only accounted for 6.06%.
In which: all 4 cases have T4 invasion; Tumor location (in greater
curvature: 1 patient; Lesser curvature: 2 patients; antrum: 1 patient);
Infiltrative form: 3 patients, invasive ulcerative form: 1 patient.

Poorly differentiated tumor type: 2 patients; Ring cell carcinoma
type: 2 patients. The time required for the lower gastrectomy (169.27
± 45.45 minutes) was less than the total gastrectomy (211.25 ±


14
101.03 minutes), but it did not show that the difference in surgery
time between these two methods p>0.05.
3.3.2. Results after surgery
* Early results after surgery
Results after surgery, the patient recovered after 2.2 ± 0.23
days, and fart after 50.2 ± 6.8 hours. The patients in our study were
removed drain after 3.8 ± 0.5 days. The mean hospital stay was 7.4 ±
1.2 days.
Table 3.12. Complications after surgery
Complications after surgery
Number (n)
Rate (%)
No
65
98.48
Bowel obstruction
1
1.52
Total
66
100
Comment: There was 1 case with complications of intestinal
obstruction after surgery
* Late results after surgery

Table 3. 13. Follow-up results after 5 years
Follow-up results after 5 years
n
Rate (%)
Alive
37
56.06
Deaths
29
43.94
Total
66
100
Comments: Of the 66 research subjects, 37 were alive (accounting for
56.06%), 29 were dead (43.94%). The surviving diseases were reexamined, no local recurrence and distant metastasis were detected.
The patients who died, we asked, learned information related to the
cause of death, the patients died mainly due to old age, weakness,
high dose chemotherapy, patients with reduced ability to eating and
drinking leads to weariness and exhaustion. No patient died from
recurrence or distant metastasis.
Table 3. 14. Total survival time according to Kaplan-Meier
Survival time
≥1
≥2
≥3
≥4
≥5
The survival ability
year year year year year
s

s
s
s
s
Cumulative number of dead
8
22
29
29
29
patients
Cumulative survival rate (%) 87.9 66.4 54.0 54.0 54.0


15
TB ± SE (months)
73.16 ± 6.35
95% CI
60.71 – 85.61
Comment: The mean overall survival time was 73.16 ± 6.35 months.
There were 29 patients died during the follow-up period, the overall mortality
rate after 5 years was 29/66 (43.94%). Overall survival according to KaplanMeier at 1 year was 87.9%. Overall survival according to Kaplan-Meier after
2 years was 66.4%. Overall survival according to Kaplan-Meier after 3, 4 and
5 years were 54.0%.

Figure 3.1. Total survival time
Table 3. 15. Overall survival time by disease stage
5-year
Stages
N

survival rate
TB ± SE
95% CI
(%)
Ia
4
100
Ib
9
77.8
98.67 ± 12.69
73.80 – 123.53
IIa
8
72.9
68.96 ± 9.15
51.03 – 86.89
IIb
16
37.6
53.53 ± 10.60
32.75 – 74.31
IIIa
10
70.0
57.50 ± 7.99
41.85 – 73.15
IIIb
6
33.3

32.83 ± 6.17
20.75 – 44.92
IIIc
11
36.4
26.18 ± 6.88
12.69 – 39.67
IV
2
0.0
11.50 ± 1.50
8.56 – 14.44
Total
66
70.46 ± 6.55
57.62 – 83.31
Comment: There are 4 patients in stage Ia who are 100% alive.
The 5-year survival rate at the respective stages is as follows: Ia, Ib, IIa,
IIb, IIIa, IIIb, IIIc respectively 77.8%; 72.9%; 37.6%; 70.0%; 33.3%;
36.4%. There are 2 cases of stage IV survival 11.50 ± 1.50 months. 1
case lived for 10 months, 1 case lived for 13 months. The overall
survival time according to stages Ib, IIa, IIb, IIIa, IIIb, IIIC, IV is 70.46 ±

p
Test
Log
Rank
χ2 =
21.822
df = 6

p=
0.001


16
6.55 months, statistically significant difference with p<0.01 (Test Log
Rank χ2 = 21.822; p = 0.001).

Figure 3.2. Overall survival time by disease stage
Table 3.16. Overall survival time according to lymph node
metastasis stage
5-year
Node
N survival
TB ± SE
95% CI
p
s
rate (%)
2
86.88 ±
65.60 –
N0
64.5
0
10.86
108.17
Test Log
1
66.72 ±

42.09 –
N1
55.6
Rank
2
12.57
91.35
χ2 =
2
34.68 –
N2
47.4
46.95 ± 6.26
14.498
5
59.21
df = 4
16.36 –
p = 0.006
N3a
8
50.0
32.63 ± 8.30
48.89
N3b 1
0.0
9.00
9.00
6
60.71 –

Total
73.16 ± 6.35
6
85.61
Comment: There was 1 case of N3b lymph node metastasis
who survived for 9 months. The 5-year survival rate according to
lymph node metastasis stage N0 (64.5%), N1 (55.6%), N2 (47.4%),
N3a (50.0%). The overall survival time according to lymph node
metastasis stage N0, N1, N2, N3a, N3b was 73.16 ± 6.35, the
difference was statistically significant with p<0.01 (Test Log Rank χ2
= 14.498; p) = 0.006).


17

Figure 3.3. Survival time according to the stage of lymph node
metastasis
CHAPTER 4: DISCUSSION
4.1. Characteristics of the lower third gastric cancer
4.1.1. Epidemiological features
The average age of the study group was 57.76 ± 11.74 years
(age), in which the oldest person was 81, the youngest was 31. The
rate of gastric cancer for men was 72.73 % higher than female is
27.27%. The age group 51-60 is the age group with the highest rate
of gastric cancer with 39.39%, the rate of gastric cancer is low in the
age group ≤ 40 (9.09%). In the study of author Chao-Yun Chen
(2007), the common age was 37 to 84, the average age was 63 years
old. Author Furukawa K et al (2011) mean age 66.3 ± 10.5 years, age
range from 33 to 85 years old [80]. According to Su Jin Kim et al.,
the average age of stomach cancer was 59.6 years (27 - 89 years old).

In our study, the symptoms encountered with the highest rate
were: severe abdominal pain (75.76%); followed by fatigue, weight
loss (48.48%); anorexia, bloating (42.42%); symptoms of vomiting
blood (3.03%); pyloric stenosis is rare. Research by Shi et al (2015),
performed on 26 gastric cancer patients, showed that the main
symptoms of gastric cancer include abdominal pain, distention,
heartburn, black stools, nausea and vomiting, and vomiting. blood,
weight loss, anemia of unknown cause. Pham Van Nam (2019),
abdominal pain (100%), poor appetite (85.14%), weight loss
(68.92%), pyloric stenosis (6.76%), anemia syndrome (5 ,41%),
palpable tumor (0%), gastrointestinal bleeding (1.35%).


18
4.2. Value of computed tomography image of the lower third
gastric cancer
4.2.1. Tumor characteristics on computed tomography
Tumor location: In our study, CT scan helped detect gastric
tumors at the following locations: tumors in the antrum and pyloric
positions accounted for 74.24%; the remaining 25.76% are tumors in
the position of small curvature. According to a study by Chen C. Y.
(2007) the position of the antrum - the pylorus 62%, the body 25.5%;
In Joon Lee (2010), position of antrum - pylorus 48.7%, lesser
curvature: 18.9%, body area 30.4%. Zytoon et al (2020), showed that
gastric cancer detected on CT was mainly in the lesser curvature of
the stomach with 45%, followed by the greater curvature with 42.5%,
the other sites The stomach and fundus account for a small proportion
of 7.5% and 5%, respectively.
Tumor form: In this study, gastric tumor on CT film:
ulcerative tumor accounted for 48.48%; infiltrative form accounts for

33.33%; nodule accounted for 18.18%. Evaluation of tumor form on
CT, author Zytoon et al (2020) recorded in 40 gastric cancers with
polyp form accounted for 5%, warts (7.5%), ulcers (5%) and
infiltrates mainly with 82.5%.
4.2.1. Value of computed tomography in the diagnosis of gastric
cancer of the lower third
Diagnosis of invasiveness:
Our study showed the following results: T3 invasive tumors
were the main ones, accounting for 39.39%; T4 invasion was
24.24%; T2 invasion was 25.76%; T1 invasion was 10.61%. The rate
of correct diagnosis of invasiveness of CT with pathology: 75.76%;
Sensitivity corresponding to the level of invasion, respectively: T1:
55.56%; T2: 92.31%; T3: 86.36%; T4: 63.64%. The specificity
corresponds to the levels of invasion, respectively: T1: 96.49%; T2:
90.57%; T3: 84.09%; T4: 95.45%. The positive predictive value
corresponds to the levels of invasion, respectively: T1: 71.43%; T2:
70.59%; T3: 73.08%; T4: 87.50%. The negative predictive value
corresponds to the levels of invasion, respectively: T1: 93.22%; T2:
97.96%; T3: 92.50%; T4: 84.00%. The accuracy in diagnosis
corresponds to the levels of invasion, respectively: T1: 90.91%; T2:
90.91%; T3: 84.85%; T4: 84.85%. In 2012, Kumano S. compared
the ability to diagnose T stage before surgery of multi-sequential CT


19
when using water and air to distend the stomach and found the
accuracy of T-stage assessment of multi-sequence CT when using
gas is 83%, when using water is 86%. CT has value in diagnosing
serosal invasion with sensitivity 83%, specificity 95%, accuracy
91% when using water, sensitivity 88%, specificity 93%, accuracy

91% when used. gas, the difference is not statistically significant.
Almeida's study (2018) performed on 14 diseases, but stomach
cancer recorded 35.7% patients with stage T1/T2, 28.5% patients
with stage T3 and 35.7% patients with stage T4 , in which, the author
has determined that the diagnostic accuracy of invasive T stage of
gastric cancer patients with T1/T2, T3 and T4 respectively is 85%,
78% and 90%; The sensitivity and specificity for T1/T2, T3 and T4
were 71% and 100% for T1/T2, respectively, 66% and 81% for T3,
100% and 90%, respectively.
Diagnosis of lymph node metastasis:
In our study, CT was difficult to detect metastatic lymph
nodes, the results were as follows: no metastatic lymph nodes were
detected, accounting for 34.85%. Metastasis in the group of lymph
nodes N1, N2 and N3 was 24.24%, respectively; 34.85% and 6.06%.
Accurate diagnosis rate of abdominal CT scan in diagnosing lymph
node metastasis in gastric cancer: 62.12%. Sensitivity corresponding
to the diagnosis of lymph node metastasis and the degree of lymph
node metastasis, respectively: N: 78.26%; N1: 75.00%; N2: 68.00%;
N3: 22.22%. The specificity corresponding to the diagnosis of lymph
node metastasis and the degree of lymph node metastasis,
respectively: N: 65.00%; N1: 87.04%; N2: 85.37%; N3: 96.49%.
Positive predictive value corresponding to the diagnosis of lymph
node metastasis and the degree of lymph node metastasis,
respectively: N: 83.72%; N1: 56.25%; N2: 73.91%; N3: 50.00%.
Negative predictive value corresponding to the diagnosis of lymph
node metastasis and the degree of lymph node metastasis,
respectively: N: 56.52%; N1: 94.00%; N2: 81.40%; N3: 88.71%. The
accuracy corresponding to the diagnosis of lymph node metastasis
and the degree of lymph node metastasis, respectively: N: 74.24%;
N1: 84.85%; N2: 78.79%; N3: 86.36%. In 2015, Barros R. H. et al.,

studied the accuracy of CT in determining lymph node metastasis
from 45.5% to 60.6%. Almeida's study (2018) evaluated 14 patients
with gastric cancer, including 11 patients with regional lymph node


20
metastasis, the author evaluated the sensitivity, specificity and
accuracy in determining regional lymph nodes. Metastasis in gastric
cancer patients was 88%, 60% and 78%, respectively.
Diagnosis of distant metastasis:
In our study, there were 2 patients with visceral metastases
detected on abdominal CT scan. We found that the sensitivity in
detecting visceral metastases of abdominal CT scanning method:
100%; specificity: 100%; positive predictive value: 100%; negative
predictive value: 100%. Accuracy: 100%. In 2015, Barros R. H. et
al., studied the accuracy of CT in determining distant metastasis was
89.6%. In 2013, Doan Tien Luu et al. Studying the role of CT in
diagnosing gastric cancer stage, CT has high value in preoperative
assessment of gastric cancer staging, visceral metastasis has 45.5%
sensitivity, 100% specificity, and high accuracy. exactly 84.6%.
Diagnosis of disease stage:
Accurate diagnosis rate of abdominal CT scan in the
diagnosis of gastric cancer stage: 51.52%. Sensitivity corresponding
to disease stages in turn: Ia: 75.00%; Ib: 55.56%; IIa: 75.00%; IIb:
62.50%; IIIa: 50.00%; IIIb: 16.67%; IIIc: 18.18%; IV: 100.00%.
Specificity corresponding to disease stages in turn: Ia: 100.00%; Ib:
92.98%; IIa: 82.76%; IIb: 90.00%; IIIa: 91.07%; IIIb: 90.00%; IIIc:
96.36%; IV: 100.00%. Positive predictive value corresponding to the
disease stages respectively: Ia: 100.00%; Ib: 55.56%; IIa: 37.50%;
IIb: 66.67%; IIIa: 50.00%; IIIb: 14.29%; IIIc: 50.00%; IV: 100.00%.

The negative predictive value corresponds to the disease stages,
respectively: Ia: 98.41%; Ib: 92.98%; IIa: 96.00%; IIb: 88.24%; IIIa:
91.07%; IIIb: 91.53%; IIIc: 85.48%; IV: 100.00%. The accuracy
corresponding to the disease stages in turn: Ia: 98.48%; Ib: 87.88%;
IIa: 81.82%; IIb: 83.33%; IIIa: 84.85%; IIIb: 83.33%; IIIc: 83.33%;
IV: 100.00%.
4.3. Results of surgery for the lower third gastric cancer
4.3.1. Surgical method
In our study, 39 patients with gastric cancer were treated with
laparotomy (59.09%); 27 patients were treated with laparoscopic
surgery (40.91%). Average surgery time 171.82 ± 50.11 (minutes),
laparoscopic surgery (197.78 ± 58.08 minutes) needed more time
than laparotomy (153.85 ± 34.31) minutes), p<0.01. The study of
author Thanh HC et al (2020) performing laparoscopic surgery for


21
radical treatment of gastric cancer with D2 lymph node dissection
also recorded the time from proximal laparoscopic surgery to assisted
laparoscopy. all in the range of 165.8 minutes to 245.3 minutes.
4.3.1. Early results after surgery
Our results after surgery, recorded the patient recovered
movement after 2.2 ± 0.23 days, defecation after 50.2 ± 6.8 hours.
The patients in our study were drained after 3.8 ± 0.5 days. The mean
hospital stay was 7.4 ± 1.2 days. The rate of complications occurring
after surgery included: 1 case had complications of intestinal
obstruction after surgery (1.52%). Research by Nguyen Cuong Thinh
(2013), showed complications after gastric cancer surgery,
anastomosis accounted for 1.75%, residual abscess (3.07%),
duodenal fistula 0.87%, pleural effusion 3.94%, bleeding 2.19%,

pancreatic fistula 1.31%. Kubota et al. (2013), a study on 1,395
gastric cancer patients showed that 14.8% of patients had
complications after surgery to treat gastric cancer, in which mainly
fistula fistula, pancreatic fistula, and focal bacterial infection. belly.
Studies have shown that the rate of complications after gastric bypass
surgery is low and most of them are handled appropriately, not
leading to postoperative mortality. The issue of good control of the
surgery and close follow-up after surgery will reduce the rate of
complications as well as the danger of these complications.
4.3.2. Late results after surgery
The mean overall survival time was 73.16 ± 6.35 months.
There were 29 patients died during the follow-up period, the overall
mortality rate after 5 years was 43.94%. Overall survival (according
to Kaplan-Meier) after 1 year was 87.9%, 2 years was 66.4%, 3 years
was 54.0%, 4 years was 54.0%. 5 years is 54.0%. In the study of
author Wei-Juan Zeng (2014), a long-term follow-up study on 533
gastric cancer patients with an average time of 38.6 months, showed
that the median survival time was 25.3 months, the overall survival
rate according to Kaplan-Meier after 1 year, 2 years, 3 years and 5
years respectively was 78.4%; 61.4%; 53.3% and 48.4%.
The stage of cancer is one of the prognostic factors for the
survival time of gastric cancer, the higher the stage, the shorter the
survival time after surgery. Our study shows that stage Ia is now
100% alive. The 5-year survival rate at the respective stages is as
follows: Ia, Ib, IIa, IIb, IIIa, IIIb, IIIc respectively 77.8%; 72.9%;


22
37.6%; 70.0%; 33.3%; 36.4%. Stage IV survival 11.50 ± 1.50
months. There was 1 case living 10 months, 1 case living 13 months.

The overall survival time according to stages Ib, IIa, IIb, IIIa, IIIb,
IIIC, IV is 70.46 ± 6.55 months, the average survival time according
to each stage Ib, IIa, IIb, IIIa, IIIb , IIIc and IV were 98.67 ± 12.69
months, 68.96 ± 9.15 months, 53.53 ± 10.60 months, 57.50 ± 7.99
months, 32.83 ± 6.17 months, respectively. months, 26.18 ± 6.88
months, 11.50 ± 1.50 months, the difference was statistically
significant with p<0.01 (Test Log Rank χ2 = 21.822; p = 0.001). In
the study of Nguyen Quang Bo (2017), the overall survival time after
5 years according to Kaplar - Meier in stage I reached 75%, stage II
reached 34%, stage III reached 22.2%, the difference Statistically
significant difference, p = 0.012 (p < 0.05).
Following the survival time of the study subjects according
to the lymph node metastasis stage, there was 1 case of N3b lymph
node metastasis who survived for 9 months. The 5-year survival rate
according to lymph node metastasis stage N0 (64.5%), N1 (55.6%),
N2 (47.4%), N3a (50.0%). The overall survival time according to the
metastatic node stage N0, N1, N2, N3a, N3b is 73.16 ± 6.35, the
average survival time according to each stage of lymph node N0, N1,
N2, N3a is 86, respectively. 88 ± 10.86 months, 66.72 ± 12.57
months, 46.95 ± 6.26 months, 32.63 ± 8.30 months, statistically
significant difference with p<0.01 (Test Log Rank χ2 = 14.498; p =
0.006). Research by author Ho Chi Thanh (2016), N1 lymph node
metastasis, the average survival time is 46.0 ± 5.57 months; N2 is
39.9 ± 4.01 months; N3 is 21.4 ± 2.89 months, this difference is
statistically significant (Test Log Rank χ2 = 9,974; p = 0.007).
Research results, T1a invasiveness is currently 100% alive.
The 5-year survival rate according to the invasiveness of T1b, T2, T3,
T4a and T4b respectively was 85.7%; 61.5%; 55.8%; 37.3% and
28.6%. Overall survival according to T1b, T2, T3, T4a and T4b
invasion was 71.62 ± 6.48 months, the overall survival time

according to each level of invasion T1b, T2, T3, T4a and T4b times.
respectively 77.71 ± 11.37 months, 83.69 ± 12.42 months, 67.73 ±
9.16 months, 26.63 ± 3.28 months, 24.00 ± 8.08 months, the
difference is not yet has statistical significance with p>0.05 (Test Log
Rank χ2 = 8,979; p = 0.062). According to Ho Chi Thanh (2016), the
overall mean survival time in groups T2 and T3 was 44.4 ± 2.54


23
months; group T2 is 53.1 ± 2.80 months; group T3 was 33.3 ± 3.16
months, the difference between groups T2 and T3 was statistically
significant (Test Log Rank χ2 = 15.705; p = 0.000). Through the
research results of the authors, we found that: the higher the level of
invasion, the lower the survival time after treatment. This is
significant in predicting early detection of gastric cancer in order to
implement effective treatment and prolong the patient's survival time.
CONCLUSION
Research on 66 stomach cancers of the lower third,
abdominal computed tomography and surgical treatment at Military
Hospital 103, K Hospital (Tan Trieu campus) from 2009 to 2016, we
Some conclusions are drawn as follows:
- Value of abdominal computed tomography in the
diagnosis of the lower third gastric cancer treated with radical
surgery
Computed tomography is a good method to diagnose cancer
of the lower third of the stomach, helping to accurately assess tumor
invasion, degree of lymph node metastasis, distant metastasis and
stage of disease.
The rate of correct diagnosis of invasiveness by computed
tomography is 75.76%. Sensitivity, specificity, positive predictive

value, negative predictive value and accuracy of T1 invasion were
55.56%; 96.49%; 71.43%; 93.22%; 90.91%. T2: 92.31%; 90.57%;
70.59%; 97.96%; 90.91%. T3: 86.36%; 84.09%; 73.08%; 92.50%;
84.85%. T4: 63.64%; 95.45%; 87.50%; 84.00%; 84.85%.
Sensitivity in detecting visceral metastasis of abdominal CT:
100%; specificity: 100%; positive predictive value: 100%; negative
predictive value: 100%.
Accurate diagnosis rate of abdominal computed tomography
in the diagnosis of lymph node metastasis: 62.12%. Sensitivity,
specificity, positive predictive value, negative predictive value and
accuracy in the diagnosis of lymph node metastasis are 78.26%;
65.00%; 83.72%; 56.52%; 74.24%. N1: 75.00%; 87.04%; 56.25%;
94.00%; 84.85%. N2: 68.00%; 85.37%; 73.91%; 81.40%; 78.79%.
N3: 22.22%; 96.49%; 50.00%; 88.71%; 86.36%.


24
Abdominal computed tomography accurately diagnosed the
stage of the disease, reaching 51.52%. Sensitivity, specificity,
positive predictive value, negative predictive value and accuracy in
diagnosing stage Ia are 75.00%; 100.00%; 100.00%; 98.41%;
98.48%. Stage Ib: 55.56%; 92.98%; 55.56%; 92.98%; 87.88%. Stage
IIa: 75.00%; 82.76%; 37.50%; 96.00%; 81.82%. Stage IIb: 62.50%;
90.00%; 66.67%; 88.24%; 83.33%. Stage IIIa: 50.00%; 91.07%;
50.00%; 91.07%; 84.85%. Stage IIIb: 16.67%; 90.00%; 14.29%;
91.53%; 83.33%. Stage IIIc: 18.18%; 96.36%; 50.00%; 85.48%;
83.33%. Stage IV: 100%; 100%; 100%; 100%; 100%.
- Results of radical surgery in the treatment of the lower
third gastric cancer
The outcome of gastric cancer surgery in the study was

positive with low complication rate and encouraging survival time.
Early complications after surgery for stomach cancer in the
lower third, intestinal obstruction has a rate of 1.5%.
The mean overall survival time was 73.16 ± 6.35 months.
Overall survival rate according to Kaplan-Meier after 1 year was
87.9%, 2 years was 66.4%, 3 years was 54.0%, 4 years was 54.0%, 5
years was 54.0% .
The 5-year survival rate at the respective stages is as follows:
Ia, Ib, IIa, IIb, IIIa, IIIb, IIIc respectively 77.8%; 72.9%; 37.6%;
70.0%; 33.3%; 36.4%. The overall survival time according to stages
Ib, IIa, IIb, IIIa, IIIb, IIIC, IV was 70.46 ± 6.55 months, the
difference was statistically significant with p<0.01. Stage Ib is 98.67
± 12.69 months. Stage IIa is 68.96 ± 9.15 months; stage IIb is 53.53 ±
10.60 months; stage IIIa is 57.50 ± 7.99 months; stage IIIb is 32.83 ±
6.17 months; stage IIIc is 26.18 ± 6.88 months.
The 5-year survival rate according to lymph node metastasis
stage N0 (64.5%), N1 (55.6%), N2 (47.4%), N3a (50.0%). Overall
survival time according to lymph node metastasis N0, N1, N2, N3a,
N3b was 73.16 ± 6.35, the difference was statistically significant with
p<0.01. The survival time according to each stage of lymph node
metastasis, N1 lymph node metastasis was 66.72 ± 12.57 months; N2
lymph node metastasis is 46.95 ± 6.26 months; N3a lymph node
metastasis was 32.63 ± 8.30 months, no N0 lymph node metastasis
was 86.88 ± 10.86 months.