성균관의대 삼성서울병원 영상의학과 최동일

1. Carcinoma, GIST & Neuroendocrine Tumor in the Gastrointestinal Tract – Radiopathologic Correlations 성균관의대 삼성서울병원 영상의학과 최동일

2. Carcinoma Histological Classification • WHO international classification (1997) - Papillary - Tubular - Mucinous - Signet ring cell • Lauren classification - Intestinal type - Diffuse type • Ming’s classification - Expanding type - Intestinal type

3. Gross Classification of EGC Elevated Superficial Excavated * most predominant patterns listed first

4. Advanced Gastric Cancer Gross Classification of AGC

5. B II B II B III B IV

6. T-staging of Gastric Cancer

7. LN metastases • EGC ; ~10%, AGC ; ~80% • Size criteria ; > 6-8 mm • Round shape, enhancement on CT • Accuracy ; ~60%

8. Peritonealseeding • About 25-40% • Rectovesical space, SB mesentery(RLQ), Sigmoid mesocolon, paracolic gutter • “drop” metastases Krukenberg’s tumors (especially signet-ring cell ca)

9. Omental cake irregular, beaded thickening and stranding Nodules Loculated fluid collections

10. Hematogeneous Metastasis • Liver (m/c), lungs, adrenal gland, bone, brain, 다른 GI tract (rectum, small intestine)

11. 만성간염환자에서 생긴 위암 위암 동맥기 – enhancing 문맥기 – wash-out 지연기 – wash-out 동맥기 문맥기 지연기

12. T2 MR : 고신호강도 MR 동맥기영상 : 조영증강 문맥기와 지연기 : 테두리 있는 저신호강도 wash-out ?? T2 동맥기 문맥기 지연기

13. Cancer Healing ulcer

14. Papillary adenocarcinoma Stomach Liver

15. Detectability of Tumor Helical CT 77-100% (63-81% for EGC) MDCT ~ 100% T-staging Helical CT 48-82% MDCT 77% with trans. CT vs. 84% with vol. CT N staging (more important than T- staging for prog.) Helical CT 51%-56% MDCT 62% with trans. CT vs. 64% with vol. CT Gastrointest Endosc. 2004; 59:619 Radiology 2005;236:879-885 Gastric Cancer: CT T-staging

16. T1 (EGC) T2 T3

17. T4

18. ? T4 on transverse CT T3 on MPR image Pathologic T3 cancer.

19. ? T1 on transverse CT T2 on MPR image Pathologic T2 cancer

20. ? T2 on transverse CT T3 on MPR image Pathologic T3 cancer

21. Irregular perigastric fat infiltration Pathologic T2 stage !!! Irregular and nodular strands

22. eAGC vs. eEGC – Samsung study • The tumor detection - 61% (64 of105) for 3 orthogonal MPR imaging by at least 2 radiologists. • In 30 eAGCs, the accuracies for all T staging - 3 MPR imaging > transverse imaging • However, in 34 eEGCs, the only accuracy of muscular invasion (T2 or higher) 3 MPR imaging > transverse imaging- In eEGC, it may be enough to evaluate the preoperative staging and make a treatment plan with transverse CT imaging only. MPR images including coronal or sagittal reconstruction may have little impact on the diagnostic accuracy for tumor that is impressed as EGC in the gastric endoscopy.

23. > 650 μm Endoscopic submucosal dissection (ESD) using IT knife Long performance time, High rate of Cx High level of technical skills

24. Hepatic mets after EMR for EGC (M/82) - SM2 (+), surgery refused

25. 28 months after EMR

26. Mucinous adenocarcinoma Park MS, et al. Radiology 2002;223:540

27. The most common type of gross appearance in both carcinomaswas fungating: It occurred in 71% of patients with mucinouscarcinomas and in 59% of patients with nonmucinous carcinomas.The next most common gross appearance type was ulcerative (24%of patients) in nonmucinous carcinomas and diffusely infiltrative(29% of patients) in mucinous carcinomas (P = .009). The mostcommon contrast enhancement pattern was homogeneous (61% ofpatients) in nonmucinous carcinomas and layered (62% of patients)in mucinous carcinomas (P = .001). These findings were significantlydifferent. The predominantly affected thickened layer was thehigh-attenuating inner layer or the entire layer (88% of patients)in nonmucinous carcinomas and the low-attenuating middle orouter layer (57% of patients) in mucinous carcinomas. Only twomucinous tumors showed miliary punctate calcifications in infiltrativelesions.

29. Gastric Submucosal Diseases • Mesenchymal tumor (mc) - 50% of gastric benign tumor - 1-5% of gastric malignant tumor

30. Gastric Submucosal Diseases • Gastrointestinal Tumor (GIST) • Leiomyoma/sarcoma • Lymphoma • Neural Tumor • Lipoma • Hemangioma • Lymphangioma • Neuroendocrine tumor • Glomus Tumor • Ectopic pancreas • Duplication cyst • Inflammatory fibroid polys • Metastasis

31. GIST • Age: > 50 yr (75%), median, 58 yr • Asx. ------- Sx. (palpable mass, pain, GI bleeding) • Size: 1-35 cm, median, 5 cm • Most common mesenchymal tumor in GIT - Stomach; 50-60% (2-3% of gastric tumor) - Small bowel; 20-30% - Anorectum, colon; 10% - Esophagus; 5% - mesentery, omentum; 5%

32. UGIS of gastric GIST - Well-defined smooth-surfaced mass - Right or obtuse angle to the lumen - Central ulcer - Overlying normal mucosal fold (bridging fold and fading folds)

33. CT of gastric GIST • Well defined enhanced mass • Malignant GIST large size, direct organ invasion, metastasis (liver, lung, bone) • Cystic degeneration, ulceration, mesenteric fat infiltration, • Necrosis, hemorrhage • LN metastasis, Ca++: rare

34. Gastric GIST

35. Gastric GIST

36. Hepatic mets after gastrectomy of gastric GIST Tx

37. Gastric lymphoma

38. Gastric CA (Adenocarcinomas)

39. Gastric CA (Adenocarcinomas) EGC type I+IIc : W/D tubular adenocarcinoma (0.5 cm) in the herniated gastric mucosa (2 cm)

40. Gastric Schwannomas

41. Duodenal GISTs

42. Ileal GIST

43. Ileal GIST

44. Jejunal GIST

45. Mesenteric GIST

46. Colonic GIST

47. Multiple rectal GISTs

48. Managements of GISTs • Complete resection • Imatinib mesylate (Gleevec) • Phenylaminopyrimidine derivative • Selective inhibits protein tyrosine kinases - Cystic change - Idx: Incomplete resection, metastatic tumor - Cx: Rupture

49. Mets 3 years after Gastrectomy 1 years after Imatinib Tx.

50. Choi H, et al. J Clin Oncol 2007;25: