Gastric carcinoma radiology ppt

JSS Medical College, Mysuru
Radiology of Ca Stomach and
gastric lymphoma.
Moderator :
Dr Anupama C
Consultant Radiologist.
Presenter :
Dr Sidharthan S
Junior resident.

EPIDEMIOLOGY
• Environmental factors - highest incidences reported in Japan,
Chile, Finland, Poland and Iceland.
• Dietary habits(diets rich in salted, smoked, or poorly
preserved foods).
• Helicobacter pylori infection of the stomach (Major risk factor).
• Other predisposing conditions:
 include atrophic gastritis,
 pernicious anemia,
 gastric polyps,
 partial gastrectomy,
 Ménétrier’s disease, and
 hereditary factors.

ROUTES OF SPREAD
• Direct extension - invasion to liver, pancreas, and spleen.
• Lymphatic spread - involvement of local (perigastric) nodes and, subsequently,
regional (celiac, hepatic, left gastric, and splenic) or distant (left supraclavicular and left
axillary) nodes.
• Intraperitoneal seeding – Gastric CA may develop to malignant ascites,
resultingintraperitoneal-seeded or omental metastases.
 Diffuse carcinomatosis - small bowel obstruction.
 Signet ring cell adenocarcinomas - bilateral “drop” metastases to the ovaries, known as
Krukenberg tumors.
• Hematogenous metastases - liver is the most common site of hematogenous (as
stomach is drained by portal vein) metastases from gastric carcinoma.

Radiological procedures for Gastric
carcinoma
• Double contrast barium study
• UGI endoscopy
• Endoscopic ultrasound
• Computed tomography
• Perfusion CT
• MRI
• PET

RADIOGRAPHIC FINDINGS
 Early Gastric Cancer:
• The double-contrast upper GI examination has been widely recognized
as the best radiologic technique for the diagnosis of early gastric
cancer.
• Type I lesions are elevated lesions that protrude more than 5 mm into
the lumen.
• Type II lesions are superficial lesions that are further subdivided into
three groups—types IIa, IIb, and IIc depending on their morphologic
features.
 Type IIa lesions are elevated but protrude less than 5 mm into the
lumen.
 Type IIb lesions are essentially flat.
 Type IIc lesions are slightly depressed but do not penetrate beyond the
muscularis mucosae.
• Type III lesions are true mucosal ulcerations, with the ulcer penetrating
the muscularis mucosae but not the muscularis propria.

gastric carcinoma on abdominal
radiographs
B. In another patient, the
gas-filled stomach has a
narrowed, tubular appearance
(arrow) caused by a scirrhous
carcinoma (linitis plastica).
A. Close-up view from an
abdominal radiograph shows a
soft tissue mass (arrows) indenting
the lesser curvature of the gas-
filled stomach.

Appearance of the Stomach in DC
barium studies
B. Rugal fold on posterior wall of
gastric body is depicted as tubular,
slightly undulating, radiolucent
filling defect (black arrowheads) in
shallow barium pool. Dense barium
pool outlines contour (white
arrowheads) of gastric fundus(F).
C. Shows normal areae gastricae
pattern in antrum as 2–3-mm
polygonally shaped radiolucent tufts
of mucosa outlined by barium in
grooves. Areae gastricae are slightly
larger in distal gastric body than in
antrum.
A. Shows normal gastric cardia with
smooth folds radiating to central
point at closed gastroesophageal
junction, also known as cardiac
rosette. Black arrows denote normal
extrinsic impression by adjacent
spleen.

Gastric cancer – anterior or
posterior wall in barium study??
Dependent or
posterior wall
Filling defects in the
barium pool
Nondependent or
anterior wall
Etched in white by a thin
layer of barium trapped
between the edge of the
mass and adjacent
mucosa.

Early gastric cancers
A. A type I lesion is seen as a
polypoid mass (arrow) on
the greater curvature of the
gastric body.
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.

Malignant gastric ulcer
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.
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).

Localized scirrhous carcinoma
A short, annular lesion is seen in the prepyloric
region of the antrum. Note how the lesion has
an abrupt, shelflike proximal border.
Irregular narrowing is seen in the gastric
fundus and body with sparing of the antrum.
ANTRUM PROXIMAL STOMACH

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

Calcified scirrhous carcinoma
A. Abdominal radiograph shows a large
cluster of punctate or sand-like calcifications
in the region of the stomach.
B. Barium study in the same patient reveals
marked antral narrowing .
C. CT scan shows lobulated thickening of the
gastric wall with extensive calcification in
another patient.

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

Carcinoma of the cardia
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).
The cardiac rosette has been
replaced by a relatively flat
mass with a central ulcer.
The tumor extends into the
distal esophagus.
There is diffuse nodularity in the
fundus with obliteration of the
normal cardiac landmarks.
Also note involvement of the distal
esophagus.

Secondary achalasia
Secondary achalasia caused by gastric carcinoma. (mostly due to submucosal spread)
A. There is smooth, tapered narrowing of the distal esophagus, producing the classic
beaklike appearance of achalasia.
B. A radiograph of the stomach reveals an advanced scirrhous carcinoma of the gastric
fundus that has invaded the distal esophagus.

COMPUTED TOMOGRAPHIC
FINDINGS
• Requires optimal gastric distention - neutral (water-attenuation)
contrast agent / oral effervescent agent.
• Optimal MDCT detection of gastric cancer requires that imaging data
be collected with the thinnest possible detector configuration (0.6-0.75
mm).
• Overlapping reconstructions enable the creation of 3D data sets with
near-isotropic voxels.
• Display images are created at 3- to 4-mm intervals and are transmitted
directly to PACS. Clinically useful 3D images displaying the gastric
tumor and extragastric extension can be created and selected for the
patient’s electronic imaging database.
• Intravenous administration of iodinated contrast material is critical, not
only for assessing the primary tumor but also for local staging and
detection of distant metastases.

MDCT of gastric carcinoma correlated
with Borrmann classification
A- Type I polypoid
neoplasm.
B- Type II fungating
neoplasm
C- Type III ulcerated
neoplasm
D- Type IV infiltrating
neoplasm

MDCT to predict the histology of
the tumor??
• Can MDCT be used to predict histological variants - ?
NO.
* However calcification and/or areas of low attenuation within a
thickened gastric wall should suggest the presence of a mucinous
carcinoma.

Perfusion CT in Gastric Ca
• Perfusion CT (P-CT) allows measurement of physiologic parameters
associated with tumor perfusion and is an established marker of
angiogenesis.
• The main hemodynamic parameter assessed is the tumor blood flow.
• Preliminary studies with P-CT of Gastric Ca have shown that blood
volume was significantly increased in Gastric Ca and there was no
difference between Gastric Ca with and without lymph node metastases.
• Another study by Yao et al. showed that a decreased blood flow value
may reflect a progressive state of Gastric Ca.
• P-CT can assess the malignancy grade of Gastric Ca non-invasively.
• P-CT-derived blood volume correlated significantly with microvessel
density of the tumor, which may be valuable information during
preoperative assessment with potential for targeted therapies.

MRI in Gastric Ca
• MRI is promising for T staging of GC as individual layers may be
better differentiated compared with CT.
• MRI is performed with gastric distension using water or
effervescent granules.
• The detection rates of gastric tumors were similar for MRI and
MDCT (92%).
• Currently, the use of MRI for staging of GC is limited to special
circumstances when patients are allergic to iodinated contrast
media, there is concern about radiation exposure with CT or
invasiveness of EUS, or as a problem-solving tool when both CT
and EUS are inconclusive.

PET in Gastric Ca
• PET (FDG) with CT has been recognized as a useful diagnostic
technique in clinical oncology and several studies for assessing
the accuracy for nodal and metastatic staging in Gastric Ca.
• PET has low sensitivity for the primary tumor and lymph node
metastases, therefore is limited in the preoperative work-up and
best used as part of a comprehensive work-up.
• The major advantage of FDG-PET/CT is in the detection of distant
metastases to the liver, lungs, and skeleton.
• However, small peritoneal nodules may be missed due to the low
resolution of FDG-PET/CT, and MDCT remains the most widely
used technique for the detection of peritoneal metastases.

Approach for imaging
Mass is suspected at the gastroesophageal junction
Repeat scanning with oral effervescent agent in the prone or left-side down
decubitus position
index of suspicion for malignant tumor??
YES NO
Endoscopic ultrasound (EUS) Double-contrast
and biopsy. barium study
Approach of radiological imaging for a suspected malignant gastric tumour
Contrast enhanced MDCT :
IV iodinated contrast at 3ml/s.
Enhancing pattern : Bright enhancement - mucosal and serosal layers and
Less enhancement - submucosal and muscular layers.

Gastric carcinoma with stratified
enhancement patterns on MDCT.
A. Contrast-enhanced MDCT scan shows a malignant posterior wall ulcer with irregular
margins. Note: decreased enhancement of the adjacent mucosa and a relatively
hypodense submucosa.
B,C. Contrast-enhanced MDCT scans through the proximal stomach in a 35-year-old man
show an irregularly thickened gastric wall extending to the gastroesophageal
junction secondary to a primary scirrhous carcinoma with linitis plastica.

Why gastric distension is essential
for imaging ??
Inadequate gaseous distention
mimicking a fundal tumor.
A. Doublecontrast radiograph of
the stomach shows a possible
infiltrating lesion (arrows) on
the posterior wall of the fundus.
B. After administration of
additional effervescent agent,
there is better distention of the
fundus, eliminating the
possibility of tumor.
Note: how the normal cardiac
rosette is now visible.

Lymph node metastasis
Perigastric lymph node metastases from gastric carcinoma.
A. Ulcerative gastric carcinoma with perigastric lymphnodes.
B. Post gastrectomy (for gastric carcinoma) with peripancreatic lymphnodes.

TNM Staging classification

Staging
• Computed Tomography,
• Endoscopic Ultrasonography,
• Magnetic Resonance Imaging (MRI), and
• Positron Emission Tomography (PET/CT).

Staging - Computed Tomography
 To assess disease spread beyond the gastric wall,
 Intraperitoneal seeding and
 Blood-borne metastases.
 T-stage accuracy improved from 77% on axial images to 84% on
volumetric images.
 the accuracy of MDCT for serosal invasion was 93%. (So, MDCT is more
useful for advacned cases.)
• MDCT enabled detection of 96% of advanced gastric cancers and 41%
of early gastric cancers, with an overall T-stage accuracy of 85%.
• CT gastroscopy: By using an effervescent agent to maximize gastric
distention and create a 3D volume-rendered “luminal cast” with
multiplanar reformatted images and IV contrast enhancement, other
investigators have been able to achieve high accuracy in differentiating
T1a from T1b tumors.

Computed Tomography
• CT is limited by its inability to identify lymphatic metastases in lymph
nodes that are not enlarged.
• The detection of such metastases could potentially be improved by
using monoenergetic, low-keV images derived from dual-energy CT
acquisitions.
• In patients with advanced gastric carcinoma, peritoneal carcinomatosis
may be manifested on MDCT by characteristic findings,
 Including soft tissue masses and nodules in peritoneal reflections,
 Retraction of the mesenteric root,
 Omental caking, and
 Loculated ascites.
However detection of intraperitoneal metastases by MDCT remains
poor.
• In one study, 18-FDG-PET/ CT was found to have an even lower
sensitivity than MDCT for detecting these intraperitoneal implants.

Pathologic T stages and MDCT
criteria for T stages of Gastric Ca
Pathologic T stage MDCT criteria
pT1: tumor invades the lamina
propria, muscularis mucosae or
submucosa.
T1: strong enhancement with focal thickening in the inner
and/or middle layer, but the outer layer shows no
enhancement; enhancement of the stomach wall only but
the wall is not thickened; wall thickening with intense
enhancement of the inner layer and the presence of a
hypodense stripe/layer.
pT2: tumor invasion into the
muscularis propria.
T2–3: the entire stomach wall thickness is thickened to
variable extent but there is a regular surface of outer layer
pT3: tumor invades subserosa. of gastric wall; normal appearance of perigastric fat.
pT4a: tumor perforates the
serosa.
T4a: the entire stomach wall is thickened with
homogeneous or inhomogeneous enhancement; irregular
surface of the outer layer of the gastric wall; presence of
micronodules or dense stranding in the perigastric fat
pT4b: tumor invades adjacent
structures.
T4b: There is extension of the tumor into adjacent
contiguous organs in addition to wall thickening

Endoscopic Ultrasonography
• The introduction and dissemination of EUS has substantially
improved the accuracy of local staging for gastric cancer.
• A major advantage of EUS is its ability to visualize the various
layers of the gastric wall, perigastric lymph nodes, and
relationship of the tumor to the surrounding tissues, enabling
determination of the depth of wall invasion and extent of
regional lymph node involvement by tumor.
• EUS is best performed as a complementary test to cross-sectional
imaging studies such as CT for local tumor staging.
• Technique:
• Frequency range of 5 to 12 MHz,
• Clinical resolution of 200 μm.

• There are two basic types of endosonographic equipment available for
clinical use—
 a dedicated EUS endoscope with maneuvering and biopsy capabilities
and
 a standard endoscope in which the EUS equipment is fitted onto
catheters and passed through the endoscope.
• EUS requires a trained examiner and is therefore operator dependent.
The examination is usually performed under conscious sedation in an
outpatient setting.
• Dedicated echo-endoscopes have a suction capability, so air can be
removed from the stomach and deaerated water instilled to allow for
better acoustic coupling.
• An inflatable balloon surrounds the transducer and is filled with
deaerated water to increase the surface contact area and improve the
imaging window.

LAYER REPRESENTS
first hyperechoic layer balloon-mucosal interface
second hypoechoic layer deep mucosa
third hyperechoic layer Submucosa
fourth hypoechoic layer muscularis propria
fifth hyperechoic layer subserosa and serosa
• With standard technique, EUS visualizes the stomach as a five-
layered structure; each individual layer corresponds to a
histologically defined layer of the gastric wall.

• EUS is performed from the transgastric position, allowing visualization
of the gastric wall, adjacent lymph nodes, and nearby organs, including
the pancreas, spleen, left kidney, and, to a limited degree, the liver.
• EUS is limited by its inability to assess for metastases in the right lobe
of the liver or more remote sites because of a limited depth of
penetration and imaging window.
• EUS the examination can be combined with a standard upper
endoscopy for biopsy specimens of the primary tumor.
• LIMITATIONS:
 As on CT, it may be difficult on EUS to differentiate neoplastic
involvement of the stomach from inflammatory processes or fibrosis.
 T classification of gastric cancer because differentiation of subserosal
(T2) from serosal (T3) invasion can be extremely difficult.

• EUS has been shown to be a highly accurate technique for
assessing the depth of tumor invasion and presence or
absence of regional lymph node involvement in patients
with gastric carcinoma.
• the overall accuracy of EUS for T staging has ranged from
85% to 88%.
• The finding of a thickened muscularis propria is almost
pathognomonic of a malignant gastric tumor, usually
gastric carcinoma.
• EUS is also the most sensitivity imaging technique for
detecting perigastric lymph nodes.
• The overall diagnostic accuracy of EUS for determining
nodal status (N classification) has ranged from 70% to
90%.

Endoscopic Ultrasound Grading

Other investigations for staging
• Diffusion weighted imaging (DWI) has been shown to be
comparable to MDCT for local staging but is more sensitive than
MDCT for detecting lymph node metastases.
• 18-FDG-PET/CT is also a useful test for whole-body imaging of
distant metastases from gastric cancer and for detecting
recurrent tumor after treatment.
• However, 18-FDG-PET/CT has been shown to be inferior to MDCT
and diffusion-weighted MRI for detecting regional lymph node
metastases.

Barium vs PET CT vs MDCT vs
DW-MRI

Gastric lymphoma
• Lymphoma involves the stomach more frequently than any other portion of
the gastrointestinal tract.
• PRIMARY GASTRIC LYMPHOMA- Confined to stomach and regional
lymphnodes.
• SECONDARY GASTRIC LYMPHOMA- generalised lymphoma with gastric
involvement.
• The vast majority of gastric lymphomas are non-Hodgkin’s lymphomas of B-
cell origin.(mostly arise from mucosa-associated lymphoid tissue (MALT) in
patients with chronic H-pylori gastritis.)
• Low grade lymphoma (AKA-Pseudolymphoma) (untreated)  High grade
lymphoma.
[But now, monoclonal B-cell proliferations or true B-cell MALT is Pseudolymphoma].
• Difficult to differentiate from gastric carcinoma on radiologic or endoscopic
examination.

Various forms of gastric lymphoma

Development & staging of Gastric
lymphoma
• Chronic H. pylori gastritis leads to the acquisition of lymphoid
follicles and aggregates in the lamina propria (MALT) and the
subsequent development of low-grade, B-cell MALT lymphomas.
ANN ARBOR STAGING
STAGE INVOLVEMENT
stage IE lesions involve the gastric wall
stage IIE lesions involve regional lymph nodes in the abdomen
stage III lesions lymph nodes above and below the diaphragm
stage IV lesions widely disseminated lymphomas

Gastric lymphoma on CT
Marked thickening of the gastric wall with
homogeneous enhancement caused by the
infiltrative form of gastric lymphoma.
A large ulcer crater is present within a soft
tissue mass in the stomach.

ENDOSCOPIC FINDINGS
Low-grade gastric MALT
lymphomas
shallow ulcers, polypoid lesions, or
erythematous,
nodular mucosa
high-grade gastric MALT
lymphomas
enlarged rugal folds, infiltrative masses, nodular,
polypoid or ulcerated lesions in the stomach.
Gastric lymphomas may be difficult to differentiate from other malignant lesions bassed
on endoscopic findings.

Approach to gastric lymphoma!!
Define the lesion in Barium study.
Uniform sharply
marginated Thickened
area gastricae
Multiple , confluent, rounded nodules
H-Pylori Gastritis
Poorly defined
confluent nodules with
central umblications
Low grade MALToma
Solitary lesion in stomach
GIST
Bull eye’s lesions – DD – Lyphoma , Kaposi sarcoma , metastasis , carcinoid tumor.

Response of gastric lymphoma to
chemotherapy



6 months- Cavitation
CHEMOTHERAPHY
1 yearBefore treatment

Refrences
• Marc S. Levine Alec J. Megibow Michael L. Kochman;Textbook of gastrointestinal
radiology. 2015;sec 5;546-569.
• Kikuchi S, Hiki Y, Shimao H, Sakakibara Y, Kakita A. Tumor volume: a novel prognostic
factor in patients who undergo curative resection for gastric cancer. Langenbecks Arch
Surg. 2000;385:225–228.
• Kikuchi S, Sakuramoto S, Kobayashi N, et al. A new staging system based on tumor
volume in gastric cancer. Anticancer Res. 2001;21:2933–2936. PMid:11712789.
• Cuenod CA, Fournier L, Balvay D, Guinebretière JM. Tumor angiogenesis:
pathophysiology and implications for contrast-enhanced MRI and CT
assessment. Abdom Imaging. 2006;31:188–193.
• Lee TY, Purdie TG, Stewart E. CT imaging of angiogenesis. Q J Nucl Med. 2003;47:171–
187.PMid:12897709.
• Yao J, Yang ZG, Chen TW, Li Y, Yang L. Perfusion changes in gastric adenocarcinoma:
evaluation with 64-section MDCT. Abdom Imaging. 2010;35:195–202.
• Satoh A, Shuto K, Okazumi S, et al. Role of perfusion CT in assessing tumor blood flow
and malignancy level of gastric cancer. Dig Surg. 2010;27:253–260.
• Yao J, Yang ZG, Chen HJ, Chen TW, Huang J. Gastric adenocarcinoma: can perfusion CT
help to noninvasively evaluate tumor angiogenesis? Abdom Imaging. 2011;36:15–21.

Thank you…

Gastric carcinoma radiology ppt

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