SHORT PPT ON GASTRIC BENIGN & MALIGNANT PATHOLOGIES

1. IMAGING OF GASTRIC NEOPLASM

2. BENIGN TUMOURS

3. Hyperplastic polyps
• Hyperplastic polyps are by far the most common benign neoplasms of the
stomach.
• No malignant potential, but do occur more commonly in patients who
have other risk factors for developing gastric malignancy, such as atrophic
gastritis, and in patients with gastric resections and bile reflux gastritis[85].
• Radiographically, hyperplastic polyps are round, smooth sessile lesions.
• They are usually multiple and of uniform size (5–10 mm) [85] [86].
• They are most common in the fundus and body of the stomach .
• Hyperplastic polyps, hamartomas and/or inflammatory polyps may also be
found in other polyposis syndromes including Peutz-Jeghers, Cronkhite-
Canada and Cowdin's disease.

4. Dependant part of
stomach__filling defect
Anterior wall polyp__ring
Small, sessile,smooth
polyps__always benign
Polyp>1cm OR irregular
surface__further workup
needed

6. Fundic gland polyps are
considered a variant of
hyperplastic polyps believed to be
hyperplastic fundal glands. They
are therefore not found in the
antrum. These are identified in up
to 40 per cent of patients with
familial adenomatous polyposis
coli[87] .

7. Adenomatous polyps
• Adenomatous polyps are important because
they are pre-malignant neoplasms that may
degenerate into gastric carcinoma. Malignancy
is detected histologically in 50 per cent of
adenomas >2 cm in size[88].
• Adenomas are polypoid, usually solitary
lesions >1 cm in size, most often seen in the
antrum. They may be sessile or pedunculated
and are usually lobulated in contour.

8. • Villous tumours are adenomas characterized
by numerous frond-like projections that
radiographically may appear bubbly. These
tumours carry a very high risk of malignancy.
• Adenomatous polyps are often found in
patients with familial adenomatous polyposis
coexisting with hypertrophic polyps.

10. BENIGN SUBMUCOSAL TUMORS
• Include
1. Stromal tumours
2. Neurofibroma
3. Lipoma
4. Hemangioma
5. Lymphangioma
6. Glomus tumour
7. Neural tumour
8. Brunner gland hemartoma
9. Duplication cyst
10. Ectopic pancreatic rest

11. • Difficult to diagnose by endoscopy because
overlying mucosa may be intact
• Large tumours tend to ulcerate
• Smooth bulge into bowel lumen , margins
forming a right angle/obtuse angle with normal
bowel wall.

12. • Complications :
 Necrosis
 Ulceration
 Gastric outflow obstruction
 Intussusception
 Large abdominal mass

13. Radiographic Findings
• Barium Meal:
• En face, the preservation of a normal areae
gastricae pattern over the mass confirms the
presence of normal mucosa and the
extramucosal location of tumour.
• When there is ulceration it is usually seen as a
central collection of barium in a smooth or
slightly lobulated mass. This is sometimes
called a ‘target’ or ‘bulls-eye’ lesion.

14. • CT:
-well defined, homogenous mass
-larger tumours__ulceration, necrosis
-glomus tumour, pancreatic, carcinoid __
hypervascular
-stromal, glomus tumour, hemangioma
__calcifications

15. Benign stromal tumours
• Benign mesenchymal tumours arising in the submucosa constitute the
second most common type of polypoid lesion in the stomach after
hyperplastic polyps.
• Mesenchymal tumours of the gastrointestinal tract are referred to as
gastrointestinal stromal tumours (GISTs) and include most lesions
previously designated leiomyoma, leiomyoblastoma and
leiomyosarcoma[89].
• Approximately 70 per cent of GISTs occur in the stomach and most (70–
90 per cent) are benign[91].
• Most of the tumours are small and are discovered incidentally. Ulceration
becomes more common as the lesions grow to >2 cm in size and
symptoms, including epigastric pain and gastrointestinal bleeding, become
more common.
• EUS – diagnostic modality of choice
-mass arising from mucularis propria or muscularis mucosa
-smaller,echo-poor ,well-defined
• >3cm tumors surgically removed

17. • In about 15 per cent of cases the tumours grow
predominantly outside the stomach (exogastric) and may in
less than 5 per cent of cases have an intra- and extraluminal
growth pattern (‘dumbbell’). Occasionally they are
pedunculated and may obstruct the pylorus or
duodenum[93] or act as the lead point of an intussusception.
• Up to 10 per cent are malignant.
• GISTs are classified by their estimated risk of recurrence
and metastasis into low- or high-risk categories[94].
• A favourable prognosis is associated with tumour size <5
cm and lack of infiltration into adjacent organs.

18. Lipomas
• Soft , may change shape with peristalsis or
palpation
• May ulcerate , bleed , intussuscept
• Diagnosed by :
-EUS__echogenic tumour
• Confirmed by:
- CT

20. Hemangioma
• Capillary /cavernous type
• Solitary / multiple
-endoscopy for diagnosis
-may complicate into:
Phlebolith
GI bleeding

21. Duplication cysts
• Greater curve of antrum OR
anteromedialy in 1st or 2nd part of duodenum
• Congenital failure of bowel recanalization
• Gastric duplication present in early childhood
• Filled with clear mucinous fluid

23. Ectopic pancreatic rest
• Small __ 1-3 cm
• Distal end of greater curve OR proximal
duodenum
• Incidental finding
• If tissue well-diffrentiated,barium study may
show a central niche or fill a short ductal
system.

25. • Complications :
• Pancreatitis
• Pseudocyst
• Adenocarcinoma
• CT – variable appearance
-homogenous , strongly enhancing tumours
OR
-avascular cystic lesions

26. MALIGNANT NEOPLASMS

27. MALIGNANT TUMOURS
• Include :
1. Gastric carcinoma
2. Lymphoma
3. Malignant stromal tumours (GIST)
4. Kaposi sarcoma
5. Carcinoid tumour
6. Metastatic tumours

28. Gastric Carcinoma
• Risk factors:
• A difference in diet is the most strongly
implicated reason for this occurrence, although
there are also histopathological issues.
• Atrophic gastritis intestinal metaplasia
dysplasia neoplasia
• Pernicious anemia
• H. Pylori infection
• Partial gastrectomy
• Nitrates intake

29. • Symptoms:
• Anorexia
• Dyspepsia
• Weight loss
• Anemia

30. Early Carcinoma
• Early gastric cancer is defined as a lesion confined to the
gastric mucosa and submucosa with no invasion of the muscle
layer[96].
• The most common presentations on the double-contrast
upper gastrointestinal examination are as a flat lesion or as a
shallow ulceration with converging folds. The folds are often
thickened, irregular or nodular in shape and may have a club-
like appearance. The folds may appear to converge. This
appearance is due to a fibrous reaction induced by many of
these tumours.
• The ulceration is frequently irregular in shape and on
compression filming does not extend beyond the gastric
lumen.
• Around the central portion of the lesion, nodularity is
frequently observed.

31. ULCERS

34. Advanced gastric carcinoma
• Tumours most frequently present as large,
irregular masses that may or may not be
ulcerated.
• The margins of the masses may exhibit a shelf,
and form an acute angle with the gastric wall,
indicating the mucosal origin of the tumour.
• As the mucosa is primarily involved by the
tumour, the surface is generally irregular.
• The term ‘malignant ulcer’ is used to indicate an
ulcer within a gastric mass, usually a carcinoma.

35. Advanced gastric cancer. (A)
Large polypoid mass of the
cardia. Tumours in this region
are becoming more common
for unknown reasons. (B)
Polypoid mass of the cardia
shown on CT (arrowheads). This
patient was imaged in the right
lateral decubitus position. (C)
Large circumferential mass in
the body of the stomach with a
shelf at the proximal margin
sharply demarcating the cancer
from the proximal stomach. (D)
Large ulcerated mass in the
antrum. This is often referred to
as a ‘Carman’ ulcer.

36. • Stippled calcification in
mucin producing Ca
• Ulcerated early Ca
resembles benign ulcer
(meniscus sign)
• Large tumours__obvious
filling defects on barium
studies

38. Linitis Plastica
Linitis plastica is a descriptive term for a tumour of the stomach,
usually a carcinoma, which is diffusely infiltrating with considerable
fibrosis. Radiographically this usually appears as a narrowed, rigid
stomach.

39. Staging of gastric carcinoma
• The TNM classification system is used for staging gastric cancer. Two
important factors influencing survival in resectable gastric cancer are
depth of invasion and presence or absence of regional lymph node
involvement.
• On CT, gastric cancer may present as focal wall thickening with or without
ulceration, mass or diffuse wall thickening.
• In a well-distended stomach, a wall thickness of >1 cm is considered
abnormal[99]. Tumours may exhibit abnormal contrast enhancement of the
gastric wall and loss of the normal multilayered wall pattern[100].
• Wall thickness, the presence or absence of regional lymphadenopathy,
adenopathy in the left gastric, porta hepatis and peripancreatic area and
the presence or absence of liver metastases can be evaluated. The
pancreas, left lobe of the liver, spleen and transverse colon may all be
involved by direct extension of tumour. Distant or diffuse intraperitoneal
metastatic disease may also be detected.

40. Gastric lymphoma
• The stomach is the most frequent site of gastrointestinal lymphoma. Most
lymphomas involving the stomach are of the non-Hodgkin's type.
• Primary gastrointestinal lymphomas are best exemplified by MALT
lymphoma of the stomach and enteropathy T-cell lymphoma (ETL), which
usually involves the small bowel.
• Gastric involvement may be primary, due to direct extension from
involved lymph nodes, or part of generalized disease.
• MALT lymphoma is a type of non-Hodgkin's lymphoma that occurs in the
lung, thyroid and salivary glands and intestine, but the stomach is by far
the most common site.
• Normally, there is no lymphoid tissue in the gastric mucosa. Helicobacter
pylori, the only common bacterial antigen in the stomach, results in an
accumulation of gastric mucosa-associated lymphoid tissue. Therefore it
appears that most gastric MALT lymphomas arise in mucosa-associated
lymphoid tissue acquired in response to a H. pylori infection[101].

41. • Radiological appearance
o Often identical to gastric Ca, benign ulcers,
suspect lymphoma if:
• Giant cavitating lesions
• Pronounced gastric folds thickening
• Multiple polypoid tumours(bull’s eye)

42. CT
-Bulky homogenous tumour
-gastric wall thickness
-perigastric fat plane preserved
-transpyloric spread
-splenomegaly
-multicentricity
__CT used for staging

45. Tumours of mesenchymal origin
(gastrointestinal stromal tumours)
• Most malignant mesenchymal tumours seen in the
stomach are malignant GIST tumours many of which
are called leiomyosarcomas[105]. They are
indistinguishable from their benign counterparts
radiographically, and frequently histologically, except
for size. If the size of the mass is >5 cm, malignancy
should be strongly considered. As a result of the large
size of these tumours, they frequently outgrow their
blood supply and ulcerations are therefore common.
• Radiographically indistinguishable from one another.

47. Metastatic Carcinoma
• Most common mets in stomach from:
• Malignant melanoma
• Ca breast
• Kidney, lung, thyroid, testes

48. Malignant melanoma
• Bull’s eye / target lesion

49. Pad sign. Ca head of pancreas
Mets from Ca breast

50. Kaposi Sarcoma
• Tumour of blood vessels
• 1/3rd of homosexual male patients with AIDS
• Multifocal tumours throughout GIT

51. Diagnosed by
 Endoscopy
-hemorhagic patches on gastric mucosa
 Barium meal
- large polypoid tumors OR
-submucosal nodule,later ulcerates_bull’s
eye lesion
-linitis plastica
 CT
-retroperitoneal LN enlargement
-splenomegaly

52. Carcinoid Tumour
• Rare in stomach/duodenum
• Slow-growing__distal antrum,lesser curvature
• Submucosal nodules__may
ulcerate/pedunculate
• Hypervascular__both pri. n liver mets
___assess in both arterial and venous phase
on CT

53. Miscellaneous Causes of Gastric
narrowing
• Extrinsic compressions
• Gastric pseudotumours
• Bezoar

54. Extrinsic Gastric Compressions

55. • Diagnosed by :
 Endoscopy
 Barium studies
 USG
 CT

56. Gastric Pseudotumours
• Gastric fundal varices
-filling defect on barium
meal
• Intragastric prolapse of
sliding hiatus hernia
-mucosal folds form the
mass
-disappears in recumbent
position

57. Bezoar
• Mass of ingested material
• Dragging sensation/ fullness
• 2 types:
Trichobezoar
-mass of matted hair
-young girls , psychiatric patients
Phytobezoars
-vegetables/ fruit pith
-unripe persimons, gastric surgery

58. • Diagnosis:
-Barium meal
__filling defect
__outlines the mass
__may penetrate
__mottled appearance

60. • Rapunzel’s syndrome:
-severe case of trichobezoar
-extend into small bowel,
even caecum
• Plain radiograph of the abdomen
showing multiple air fluid levels with
dilated small intestinal loops and a
sizable soft tissue density within the
stomach