Gastric carcinoma: imaging diagnosis, staging and assessment of treatment response - PubMed (original) (raw)

Review

Gastric carcinoma: imaging diagnosis, staging and assessment of treatment response

James Thomas Patrick Decourcy Hallinan et al. Cancer Imaging. 2013.

Abstract

Gastric carcinoma (GC) is one of the most common causes of cancer-related death worldwide. Surgical resection is the only cure available and is dependent on the GC stage at presentation, which incorporates depth of tumor invasion, extent of lymph node and distant metastases. Accurate preoperative staging is therefore essential for optimal surgical management with consideration of preoperative and/or postoperative chemotherapy. Multidetector computed tomography (MDCT) with its ability to assess tumor depth, nodal disease and metastases is the preferred technique for staging GC. Endoscopic ultrasonography is more accurate for assessing the depth of wall invasion in early cancer, but is limited in the assessment of advanced local or stenotic cancer and detection of distant metastases. Magnetic resonance imaging (MRI), although useful for staging, is not proven to be effective. Positron emission tomography (PET) is most useful for detecting and characterizing distant metastases. Both MDCT and PET are useful for assessment of treatment response following preoperative chemotherapy and for detection of recurrence after surgical resection. This review article discusses the usefulness of imaging modalities for detecting, staging and assessing treatment response for GC and the potential role of newer applications including CT volumetry, virtual gastroscopy and perfusion CT in the management of GC.

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Figures

Figure 1

Figure 1

EUS of an ulcerative lesion in the antrum. The tumor (lesion) is seen to penetrate through the serosa with a hypoechoic lymph node (*) also apparent. The lesion was confirmed as a T4, N1 stage GC on histopathology after total gastrectomy (image courtesy of Professor Lawrence Ho, NUS, Singapore).

Figure 2

Figure 2

Example illustrating the importance of distension of the stomach for determining the extent of GC. A 58-year-old man with abdominal pain underwent routine CT (a, b) that showed some thickening (white arrow) of the stomach. An endoscopic biopsy confirmed an adenocarcinoma. Staging CT (c, d) shows the actual extent of the tumor (block black arrows) and the gastric fundus (*) is free of the tumor, which was not apparent in the initial CT due to collapsed normal gastric mucosa in an undistended stomach.

Figure 3

Figure 3

Use of multiplanar reformation for determination of invasion into adjacent organs. In this example, the GC (*) is not separable from the left lobe of the liver (arrow) on the axial image (a). On the coronal (b) and sagittal (c) reconstructions, it is clear that there is no direct invasion by the tumor but apposition of the stomach wall to the left lobe of the liver. The tumor was limited to the stomach wall at histopathology.

Figure 4

Figure 4

Large pyloric GC. TTP (a) simulating a double-contrast barium enema image. Coronal reformat image (b) showing the view position for VG (c) which demonstrates the tumor similar to the endoscopic view (d).

Figure 5

Figure 5

Selected axial images (a–c) from a CT study using a GC protocol. A large circumferential mass at the incisura (t) with enlarged perigastric and para-aortic lymph nodes (*) and free fluid noted in the pelvis. Peritoneal metastatic disease and metastatic para-aortic lymphadenopathy were confirmed during laparotomy and on histopathology.

Figure 6

Figure 6

Use of VG for early detection of GC. Transverse axial (a) and coronal reformat (b) images do not demonstrate any focal thickening apart from thick mucosal folds. The VG image (c) corresponds well with the polypoidal ulceration with fold truncation seen along the lesser curve (arrow) on endoscopy (d). This was confirmed as a T1b tumor on histopathology after a partial gastrectomy.

Figure 7

Figure 7

EUS for peritoneal invasion. Thickening in the antrum of the stomach (lesion), which is seen to penetrate the serosa at multiple points (*). In addition, there is free fluid (f) and peritoneal nodules (pn) consistent with peritoneal carcinomatosis confirmed at diagnostic laparoscopy (image courtesy of Professor Lawrence Ho, NUS, Singapore).

Figure 8

Figure 8

Multiplanar images from a CT (a, axial; b, sagittal; and c, coronal) and MRI (d, axial T1-weighted+contrast; e, sagittal; and f, coronal T1-weighted images) of a GC. There is an ulcerated mass along the lesser curve with superficial enhancement involving <50% of the gastric wall. No surrounding fat stranding or lymph nodes were detected. The involved gastric wall is in close approximation to the left lobe of the liver with a fat plane best demonstrated on the sagittal T1-weighted MRI sequence (e). A T2N0 stage gastric tumor with no evidence of peritoneal disease or liver invasion was confirmed after a subtotal gastrectomy.

Figure 9

Figure 9

Sequential axial images from an MRI (a, T1-weighted arterial phase; b, T1-weighted portal venous phase; c, T2-weighted) and CT (d–f) gastric protocol. There is a large circumferential mass in the antrum (t) with heterogeneous enhancement and surrounding fat stranding (*). Adjacent lymphadenopathy (thin arrow) and a small amount of peritoneal fluid (arrowheads) detected on the T2-weighted MRI sequence (c) suggesting peritoneal disease. Metastatic peritoneal disease was confirmed on diagnostic laparotomy and histopathology.

Figure 10

Figure 10

Axial contrast-enhanced CT (a) and FDG-PET/CT (b) in a case of T2 stage GC along the lesser curve (arrow) that shows uptake.

Figure 11

Figure 11

Axial CT images before (a) and after (b) neoadjuvant chemotherapy for pyloric GC. There was a 27% reduction in the tumor volume with no significant change in the gross appearance of the tumor. A partial gastrectomy was performed and complete necrosis was seen on histopathology.

Figure 12

Figure 12

CT TV for staging. Axial CT sections (a, d), magnified focal view of tumor (b, e) and volumetry overlay (c, f, yellow line showing the tumor outline) of a T2 stage tumor in the gastric cardia (top row, a–c) and a T3 stage tumor in the antrum (bottom row, d–f). These tumors appear to be similar in size on the axial images. A hypodense peripheral layer is seen in the case of the T2 tumor compared with the T3 tumor. The volume of the T2 tumor is 10 cm3 compared with 19 cm3 for the T3 tumor.

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