Carcinoma of Stomach

Dr. Naveed AshrafRadiologic Pictorial Review
Carcinoma Of Stomach
1

TEACHING POINTS
Complete resection of a gastric tumor and adjacent lymph nodes is
considered the only proved, effective curative treatment
A gastric mass that abuts an adjacent organ and absence of the fat plane
between the mass and the organ are suggestive of but not diagnostic for
organ invasion.
The major advantage of FDG PET over anatomic imaging modalities is its
capacity to help detect distant solid organ metastases.
Ascites is one of the most common findings of peritoneal dissemination,
with these tumors. Other CT findings accompanying peritoneal metastasis
include a nodular, plaque-like or infiltrative soft-tissue lesion in the
peritoneal fat or on the peritoneal surface; parietal peritoneal thickening
or enhancement; and small bowel wall thickening or distortion
Two patterns of FDG uptake are known to be indicators of peritoneal
metastasis: (a) diffuse uptake spreading uniformly throughout the
abdomen and pelvis, obscuring visceral outlines (normal serpiginous
pattern of the large and small bowel and physiologic hepatic and splenic
uptake) and (b) discrete foci of uptake located randomly and anteriorly
within the abdomen or dependently within the pelvis and unrelated to
solid viscera or nodal stations
2

• Tis Carcinoma in situ
• T1 Tumor invades mucosa / submucosa
• T2 tumor invades muscularis propria
• T3 tumor penetrates subserosal tissue without invasion of visceral
peritoneum or adjacent structures
• T4a tumor penetrates serosa (visceral peritoneum)
• T4b tumor directly invades adjacent organs or structures
3

Japanese classification:
■ Type I polypoid: >5 mm protruding into lumen
■ Type II superficial: IIa elevated (<5 mm) ▸ IIb flat ▸ IIc depressed
■ Type III: excavated
4

Early gastric cancers. A. A type I lesion is seen as a polypoid mass (arrow)
on the greater curvature of the gastric body. Despite its size, this lesion
was found to be an early cancer. B. A type IIa lesion is manifested by a
focal cluster of shallow elevations and nodules (arrows) in the gastric body.
C. A type IIc lesion is manifested by shallow, irregular areas of ulceration
and nodularity (arrows) in the gastric antrum. D. A type III lesion is seen as
a scalloped, irregular antral ulcer with nodular, clubbed folds surrounding
the ulcer crater. (
5

Calcified scirrhous carcinoma. A. Close-up view from an abdominal
radiograph shows a large cluster of punctate or sandlike calcifications in
the region of the stomach. B. Barium study in the same patient reveals
marked antral narrowing caused by a scirrhous carcinoma of the stomach.
Again, note multiple calcifications in this mucin-producing tumor. C. CT
scan shows lobulated thickening of the gastric wall with extensive
calcification in another patient with a scirrhous carcinoma.
6

Ulcerated gastric carcinoma. A. Double-contrast view of the stomach
shows a relatively large mass that is etched in white (large arrows) near
the lesser curvature of the gastric body. Also note a second curvilinear
density (small arrows) secondary to barium coating the rim of an unfilled
central ulcer. B. Prone compression view shows the mass as a radiolucent
filling defect (black arrows) on the anterior wall of the stomach. Note how
the central ulcer (white arrows) fills with barium when the patient is in the
prone position. The ulcer has a convex inner border and an intraluminal
location, demonstrating the features of a Carman meniscus complex.
7

Malignant gastric ulcers. A. A meniscoid ulcer (white arrows) is seen on
the lesser curvature of the antrum. Note the rind of malignant tumor
(black arrows) surrounding the ulcer. B. Another malignant ulcer (arrow) is
seen on the lesser curvature of the antrum. This ulcer has an intraluminal
location. Also note how the folds converging to the ulcer have a nodular,
clubbed appearance because of infiltration by tumor. C. A third patient has
an ulcerated mass on the greater curvature of the antrum. Again, note
how the ulcer (white arrow) has an intraluminal location. Also note how
the mass itself is etched in white (black arrows).
8

Infiltrating gastric carcinomas. A. Irregular narrowing and ulceration are
seen in the antrum because of an advanced, infiltrating carcinoma. B. In
another patient, an infiltrating carcinoma of the proximal stomach causes
marked narrowing and spiculation of the upper gastric body.
9

Scirrhous carcinomas of the stomach. A. There is marked narrowing of the
antrum caused by infiltration of the wall by tumor. B. In another patient,
there is encasement of the entire stomach by a scirrhous tumor, producing
a diffuse linitis plastica appearance
10

Carcinoma of the cardia. A. The normal anatomic landmarks at the cardia
have been obliterated and replaced by a plaquelike lesion (straight arrows)
containing a shallow area of ulceration (curved arrow). B. In another
patient, the cardiac rosette has been replaced by a relatively flat mass
(straight black arrows) with a central ulcer (white arrow). The tumor
extends into the distal esophagus (curved black arrow). C. In a third
patient, there is diffuse nodularity in the fundus with obliteration of the
normal cardiac landmarks. Also note involvement of the distal esophagus.
11

MDCT of gastric carcinoma correlated with Borrmann classification.
Images from four different patients show the various CT appearances of
gastric carcinoma (arrows). A. Type I polypoid neoplasm. B. Type II
fungating neoplasm. Also note the presence of multiple hepatic
metastases in this patient. C. Type III ulcerated neoplasm. D. Type IV
infiltrating neoplasm.
12

Metastatic breast cancer involving the stomach. There is antral narrowing
with distortion of the normal surface pattern and a nodular, irregular
mucosa in this region. A primary scirrhous carcinoma of the stomach could
produce identical findings.
13

Coronal reformatted image shows a stage T1 tumor (arrows) with
focal nontransmural enhancement in the upper body.
14

Axial CT scan shows a stage T2 tumor (arrow), a localized, transmurally
enhancing ulcerative mass without perigastric extension, in the lower
body.
15

Coronal reformatted image shows a stage T3 tumor (arrows), with gross
infiltration of the perigastric fat tissue in the antrum.
16

Axial CT scan shows a stage T4 tumor with invasion of the colon. The
tumor represents an advanced cancer of the antrum and is accompanied
by obliteration of the fat plane and thickening of the colonicwall (arrows).
17

Coronal reformatted image shows a stage T4 tumor (arrow) infiltrating the
distal pancreatic body.
18

Axial CT scan shows a stage T4 tumor (arrows), an advanced cancer with
gross infiltration of the lateral segment of the liver.
19

Axial CT scan shows diffuse thickening of nearly the entire gastric wall
(arrowheads) due to linitis plastica.
Coronal PET scan shows no discernible FDG uptake in the stomach
(arrows).
20

Drawing illustrates lymph node locations according to the Japanese
Research Society for Gastric Cancer (28). 1 right paracardium, 2 left
paracardium, 3 lesser curvature, 4 greater curvature, 5 suprapylorum, 6
infrapylorum, 7 left gastric artery, 8 common hepatic artery, 9 celiac
artery, 10 splenic hilum, 11 proximal splenic artery, 12 hepatoduodenal
ligament, 13 posterior surface of the pancreatic head, 14 superior
mesenteric vessels (SMA superior mesenteric artery, SMV superior
mesenteric vein), 15 middle colic vessels, 16 abdominal aorta.
21

Station 7 and 8 lymph node metastases in a 63-year-old man with stomach
cancer. Axial CT scan demonstrates a station 7 lymph node (white
arrowhead) adjacent to the left gastric artery (white arrow) and a station 8
lymph node (black arrowhead) adjacent to the common hepatic artery
(black arrow). The diagnosis of lymph node metastasis may be difficult if
only size criteria are used.
22

Station 12 lymph node metastases in a 65-year-old man with stomach
cancer. Axial CT scan demonstrates an enlarged lymph node (arrowhead)
in the hepatoduodenal ligament adjacent to the proper hepatic artery
(arrow).
23

Multiple station 13 and 14 lymph node metastases in a 52-year-old man
with stomach cancer. Axial CT scan demonstrates conglomerated station
13 lymph node metastases (black arrowheads) on the posterior surface of
the pancreatic head (black arrow) and station 14 metastasis (white
arrowheads) along the superior mesenteric vessel (white arrow).
24

Station 16 lymph node metastasis in a 55-yearold man with stomach
cancer. Coronal reformatted CT image demonstrates a necrotic enlarged
lymph node (arrow) around the abdominal aorta.
25

Multiple hepatic metastases in a 58-year-old man with stomach cancer. (a)
Portal venous phase CT scan shows multiple metastatic nodules in both
hepatic lobes.
26

Small hepatic metastases in a 54-year-old man with stomach cancer. (a)
Portal venous phase CT scans show four metastatic nodules (arrowheads),
none of which is easily discernible. (b) Axial PET scans more clearly depict
the nodules (arrowheads). (c) Axial superparamagnetic iron oxide–
enhanced gradient-recalled echo T2*- weighted magnetic resonance
images (repetition time msec/echo time msec 120/10, 30° flip angle) help
confirm the presence of all four metastatic nodules (arrowheads).
27

Krukenberg tumor in a 34-year-old woman with stomach cancer. (a) CT
scan shows a mixed cystic- solid tumor (arrows) in the pelvis. (b) Axial PET
scan demonstrates the tumor (arrows) with increased FDG uptake.
Metastatic involvement of the ovary was proved at histologic analysis of
the gross specimen.
28

Supraclavicular lymph node metastasis in a 44-year-old woman with
stomach cancer. (a) Chest CT scan shows bilateral supraclavicular lymph
nodes (arrows) less than 1 cm in diameter. (b, c) Axial (b) and coronal (c)
PET scans show the lymph nodes (arrows) with increased FDG uptake.
Metastatic involvement was confirmed at needle aspiration biopsy.
29

Peritoneal metastasis in a 38-year-old man with stomach cancer. (a) CT
scan shows small metastatic nodules in the omentum (arrows) and
enhanced peritoneal thickening (arrowheads). Peritoneal metastasis was
confirmed at histologic analysis of ascitic fluid obtained with fine-needle
aspiration.
30

Peritoneal metastasis in a 34-year-old woman with stomach cancer. Axial
contrast material– enhanced CT scan shows a peritoneal implant (arrows)
in the left pelvic peritoneum.
31

Peritoneal metastasis from poorly differentiated adenocarcinoma
(confirmed at endoscopic biopsy) in a 59-year-old man with stomach
cancer. (a) Coronal reformatted CT image shows omental infiltration
(arrows). (b) Coronal reformatted CT image demonstrates ascitic fluid (*)
and parietal peritoneal thickening (arrows), findings that suggest
peritoneal metastasis.
32

Local tumor recurrence following subtotal gastrectomy in a 63-year-old
man. (a) Axial contrastenhanced CT scan shows mild gastric wall
thickening (arrows) at an anastomotic site. This finding was misinterpreted
as a postoperative change (possibly plication-induced fibrotic change or
reflux gastritis). (b) Axial PET scan shows prominent increased FDG uptake
(arrows) in the anastomotic site. Cancer recurrence was proved at
histologic analysis of tissue obtained at endoscopic biopsy.
33

Suspected tumor recurrence in a 44-year-old woman with stomach cancer.
(a, b) Axial contrast-enhanced CT scan (a) and PET scan (b) obtained prior
to chemotherapy show prominent diffuse gastric wall thickening (arrows
in a) with prominent FDG uptake (arrow in b). (c) Follow- up PET scan
obtained approximately 5 months after chemotherapy shows markedly
decreased FDG uptake in the stomach (arrow). (d) Follow-up CT scan
obtained 3 months later demonstrates obstruction of a pyloric stent
(arrow), a finding that suggests residual tumor. A radical subtotal
gastrectomy was performed for palliation, but no residual tumor was
detected in the resected specimen.
34

Perigastric lymph node metastases from gastric carcinoma. A. 3D MDCT
scan shows an ulcerated carcinoma of the gastroesophageal junction
manifested by an irregular mass with central ulceration (arrow). Enlarged
perigastric lymph nodes (asterisks) are present in a periceliac distribution.
B. In another patient who underwent a previous gastrectomy for gastric
carcinoma, an MDCT scan shows peripancreatic lymphadenopathy
simulating a carcinoma of the head of the pancreas.
35

Gastric carcinoma invading the transverse colon via the gastrocolic
ligament on sequential axial MDCT scans. A. The gastric tumor (T) is
manifested by localized wall thickening in the midportion of the stomach.
B. Nodular densities are present in the gastrocolic ligament (arrow). C.
Another segment of localized wall thickening (arrowhead ) is seen in the
transverse colon secondary to invasion by tumor.
36

Carcinoma of Stomach

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