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
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
2
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.
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].
Keywords – gastric carcinoma; diverticulitis; comorbidities;
MSCT; thermography
Figure 1. Gastric carcinogenesis
I.
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
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
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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 coexisting 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.
II.
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.
III.
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
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of diverticulitis a colonoscopy was performed and
diverticulitis was verified. 5 days later the patient was
operated. The procedure went fine.
Figure 2. MSCT showing gastric carcinoma prior operation
Figure 3. MSCT prior operation showing colon diverticula and opacification
of the colon wall
IV.
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 noninvasive 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.
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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.
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