Direct Invasion from Noncontiguous Primary Tumors

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Invasion Along Mesenteric Reflections

The mesenteric reflections provide an important natural pathway for extension of primary neoplasms to other sites that may not be in actual contiguity.1'9

In the upper abdomen, peritoneal reflections constitute nine major ligaments and mesenteries that provide continuity of anatomic planes for the spread of malignancies (Figs. 4-1 and 4-2; Table 4-2). These not only connect intraperitoneal sites, but also extend between intraperitoneal and extraperitoneal sites.9-12 Neither the mesenteries nor the ligaments should be thought of as veil-like membranes but rather as connective tissue-laden peritoneal reflections of often considerable substance. The areolar tissue within these planes contains

Table 4-2. Major Upper Abdominal Peritoneal Reflections

Gastrohepatic ligament Hepatoduodenal ligament Gastrocolic ligament Transverse mesocolon Duodeno colic ligament Gastrosplenic ligament Splenorenal ligament Phrenicocolic ligament Small bowel mesentery lymphatics accompanying blood vessels so that this interconnecting abdominal network provides discrete pathways of spread of disease. The sites of lymph node metastases from gastric carcinoma, for example, have been meticulously analyzed (Fig. 4-3). Yet, it is apparent that these lymphatics and draining nodal groups constitute an architecture, for the most part, within identifi-

Parietal Reflections

Fig. 4—1. Peritoneal ligaments and mesenteries.

Drawing of the posterior parietal wall of the upper abdomen showing the planes of peritoneal reflections constituting the major ligaments and mesenteries. Anatomic continuity is established along the "bare areas" at the roots of origin between intraperitoneal structures and between extraperitoneal and intraperitoneal sites. (Reproduced from Meyers et al.9)

Fig. 4—1. Peritoneal ligaments and mesenteries.

Drawing of the posterior parietal wall of the upper abdomen showing the planes of peritoneal reflections constituting the major ligaments and mesenteries. Anatomic continuity is established along the "bare areas" at the roots of origin between intraperitoneal structures and between extraperitoneal and intraperitoneal sites. (Reproduced from Meyers et al.9)

Fig. 4—2. Major mesenteric reflections in the upper abdomen, shown on coronal MR image.

Abdominal organs, mesenteries, and ligaments are floating in a large amount of ascites. The falciform ligament (FL) attaches the liver (L) superiorly. The portal vein (PV) courses within the hepatoduodenal ligament. Further demarcation of the lesser sac (LS) is provided by the lesser omentum (LO), stomach (ST), gastrosplenic (GSL), and splenoral (SRL) ligaments as they are related to the spleen (SP) and the transverse me-socolon (TM).

(Reproduced from Auh et al.10)

Infrapyloric Lymph Node

Fig. 4—3. Lymph node stations in gastric cancer as classified by the Japanese Research Society for Gastric Cancer.

Involvement of nodes along the lesser or greater curvature (groups 1-6) constitutes N1 disease, and the celiac axis and its three branches are N2 (7-11), N3 (12-14), and N4 (15,16). N1: 1 = right paracardial; 2 = left paracardial; 3 = lesser curvature; 4 = greater curvature; 5 = suprapyloric; 6 = infrapyloric. N2: 7 = left gastric artery; 8 = common hepatic artery; 9 = celiac artery; 10 = splenic hilus; 11 = splenic artery. N3: 12 = hepatic pedicle; 13 = retropancreatic; 14 = mesenteric root. N4: 15 = middle colic artery; 16 = paraaortic.

(Data from Japanese Research Society for Gastric Cancer. Japanese Classification of Gastric Carcinoma: General Rules for the Gastric Cancer Study. Tokyo, Kanehara, 1995, pp 1—104.)

Fig. 4—2. Major mesenteric reflections in the upper abdomen, shown on coronal MR image.

Abdominal organs, mesenteries, and ligaments are floating in a large amount of ascites. The falciform ligament (FL) attaches the liver (L) superiorly. The portal vein (PV) courses within the hepatoduodenal ligament. Further demarcation of the lesser sac (LS) is provided by the lesser omentum (LO), stomach (ST), gastrosplenic (GSL), and splenoral (SRL) ligaments as they are related to the spleen (SP) and the transverse me-socolon (TM).

(Reproduced from Auh et al.10)

Ligament Treitz Landmark

able peritoneal reflections. The ligaments and mesenteries are generally readily recognizable on CT and MRI by either their typical location and organ relationships or the landmarks provided by their major constituent vessels.

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