Carcinoma, GIST & Neuroendocrine
Tumor in the Gastrointestinal Tract
– Radiopathologic Correlations
성균관의대 삼성서울병원
영상의학과
최동일
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
Gross Classification of EGC
Elevated
Superficial
Excavated
* most predominant patterns listed first
Advanced Gastric Cancer
Gross Classification of AGC
B II
B II
B
III
B IV
T-staging of Gastric Cancer
LN metastases
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EGC ; ~10%, AGC ; ~80%
Size criteria ; > 6-8 mm
Round shape, enhancement on CT
Accuracy ; ~60%
Peritoneal seeding
• About 25-40%
• Rectovesical space, SB mesentery(RLQ),
Sigmoid mesocolon, paracolic gutter
• “drop” metastases Krukenberg’s tumors
(especially signet-ring cell ca)
• Omental cake
– irregular, beaded thickening
and stranding
– Nodules
• Loculated fluid collections
Hematogeneous Metastasis
• Liver (m/c), lungs, adrenal gland, bone, brain,
다른 GI tract (rectum, small intestine)
위암
만성간염환자에서
생긴 위암
동맥기 – enhancing
문맥기 – wash-out
지연기 – wash-out
동맥기
문맥기
지연기
T2 MR : 고신호강도
MR 동맥기영상 : 조영증강
문맥기와 지연기 : 테두리 있는
저신호강도 wash-out ??
T2
동맥기
문맥기
지연기
Cancer
Healing ulcer
Papillary adenocarcinoma
Stomach
Liver
Gastric Cancer: CT T-staging
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
T1 (EGC)
T2
T3
T4
? T4 on transverse CT
T3 on MPR image
Pathologic T3 cancer.
? T1 on transverse CT
T2 on MPR image
Pathologic T2 cancer
? T2 on transverse CT
T3 on MPR image
Pathologic T3 cancer
Irregular perigastric fat infiltration
Pathologic T2 stage
!!! Irregular and nodular strands
eAGC vs. eEGC – Samsung study
• The tumor detection - 61% (64 of 105) 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.
Endoscopic submucosal
dissection (ESD) using IT
knife
> 650 μm
Long performance time, High rate of Cx
High level of technical skills
Hepatic mets after EMR for EGC (M/82)
- SM2 (+), surgery refused
28 months after EMR
Mucinous adenocarcinoma
Park MS, et al. Radiology 2002;223:540
The most common type of gross appearance in both
carcinomas was fungating: It occurred in 71% of patients
with mucinous carcinomas 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 most
common contrast enhancement pattern was
homogeneous (61% of patients) in nonmucinous
carcinomas and layered (62% of patients) in mucinous
carcinomas (P = .001). These findings were significantly
different. The predominantly affected thickened layer was
the high-attenuating inner layer or the entire layer (88% of
patients) in nonmucinous carcinomas and the lowattenuating middle or outer layer (57% of patients) in
mucinous carcinomas. Only two mucinous tumors
showed miliary punctate calcifications in infiltrative
lesions.
Gastric Submucosal Diseases
• Mesenchymal tumor (mc)
- 50% of gastric benign tumor
- 1-5% of gastric malignant
tumor
Gastric Submucosal Diseases
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Gastrointestinal Tumor (GIST)
Leiomyoma/sarcoma
Lymphoma
Neural Tumor
Lipoma
Hemangioma
Lymphangioma
Neuroendocrine tumor
Glomus Tumor
Ectopic pancreas
Duplication cyst
Inflammatory fibroid polys
Metastasis
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%
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)
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
Gastric GIST
Gastric GIST
Hepatic
mets after
gastrectomy
of gastric
GIST
Tx
Gastric lymphoma
Gastric CA (Adenocarcinomas)
Gastric CA (Adenocarcinomas)
EGC type I+IIc : W/D tubular adenocarcinoma (0.5
cm) in the herniated gastric mucosa (2 cm)
Gastric Schwannomas
Duodenal GISTs
Ileal GIST
Ileal GIST
Jejunal GIST
Mesenteric GIST
Colonic GIST
Multiple rectal GISTs
Managements of GISTs
• Complete resection
• Imatinib mesylate (Gleevec)
– Phenylaminopyrimidine derivative
– Selective inhibits protein tyrosine kinases
Cystic change
- Idx: Incomplete resection, metastatic tumor
- Cx: Rupture
Mets 3 years after Gastrectomy
1 years after Imatinib Tx.
Choi H, et al. J Clin Oncol 2007;25:
시험 6월15일 5시20분부터
영상의학과 의사가 아닌 분들은 풀 필요없는
영상의학과 의사 전용 문제들도 있음
과제물 복부영상의학 관련 2011년 이후 발간된
SCI논문 하나에 대한 감상문 (A4 한페이지
이내) 메일로 제출 – 감상문과 논문 pdf
4월10일까지 논문 제목 (잡지명과
페이지포함) 제출 후 OK 받은 후
5월20일까지감상문과 논문 pdf 제출
Overall survival
according to KIT mutation
42 HU
30 HU (29%감소)
Hepatic Mets from Colon CA treated with targeted agents
35 HU
25 HU (29%감소)
FOLFRI/SUTENE
77 HU
44 HU (43%감소)
XELOX/avastin
Inoperable HCCs treated with Sorafenib
57 HU
31 HU (56%감소)
Gastric GIST
50 HU
25 HU (50%감소)
2년후
PET
• Sensitive in early tumor response, but given its cost and
availability, it is not easy to include it in basic imaging tests.
• The use of PET is considered in cases of:
(1) suspected metastatic lesions not clearly delineated by CT
(2) exploration of an undetectable primary lesion
(3) inconclusive CT findings
(4) when early confirmation of tumor response to imatinib is
required (for example, when surgery is considered after tumor
regression)
2008 Japanese guideline on GIST (Nishida T, Hirota S, Yanagisawa A, et al. Clinical practice
guidelines for gastrointestinal stromal tumor in Japan: English version. Int J Clin Oncol
2008; 13:416–430
Heaptic mets after Ileal GIST resection
Suspicious lesion after Rt. hemihepatectomy
Responses of Imatinib
F/62 Exon 11 deletion
Size decrease & cystic change
Before Tx
3M F/U
M/62 Exon 9 insertion
Cystic change
Before Tx
3M F/U
F/66 Exon 11 insertion
Size decrease
Before Tx
3M F/U
Therapeutic Efficacy of Malignant GISTs with
c-KIT Mutations: CT with Imatinib Mesylate
Size decrease & cystic change
Number
Exon 11 deletion
93% (14 of 15)
Other mutations
50% (4 of 8)
(p=0.032, Fisher’s exact test)
Choi D, et al. AJR 2009 Aug.
Recurrence after initial response
CT findings suggesting relapse or resistance after
initial response to imatinib:
(1) nodules in necrotic or degenerated masses
(2) new lesions
(3) growth of tumors that previously had decreased in
size
2008 Japanese guideline on GIST (Nishida T, Hirota S, Yanagisawa A, et al. Clinical
practice guidelines for gastrointestinal stromal tumor in Japan: English
version. Int J Clin Oncol 2008; 13:416–430)
Neoadjuvant Imatinib Tx. to downsize GIST
14 months with Imatinib Tx.
GIST- Summary
• KIT (+)
• Well defined enhanced mass
• Necrosis, hemorrhage
• LN metastasis rare, Ca++: rare
• Cystic degeneration after imatinib Tx.
Classification of NET
1. Well differentiated endocrine tumor carcinoid
2. Well-differentiated endocrine carcinoma
– malignant carcinoid
3. Poorly differentiated endocrine carcinoma
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•
Fig. 4. WHO classification of endocrine tumors. (Hematoxylin & Eosin stain,
x200).
A. Well-differentiated endocrine tumor shows round, regular, isomorphic
cells.
B. Well-differentiated endocrine carcinoma shows characteristic well-formed
rosettes.
C. Poorly-differentiated endocrine carcinoma shows densely packed, small
cells with scanty cytoplasm and finely granular nuclear chromatin. The
fusiform shape is prominent in this microphotograph.
200 patients with NETs in SMC,
Rectum (51.9%) > stomach (21.9%) > duodenum
(11.2%) > colon (5.9%) > appendix (3.2%) >
esophagus (3.2%) > small intestine (2.1%).
The majority of NETs occur sporadically, that is, nonfamilial. However, they may
sometimes occur as part of complex familial endocrine cancer syndromes
such as multiple endocrine neoplasia type I (MEN-I) (Fig. 1) [5] and
neurofibromatosis type I (NF-1) [6].
General Neuroendocrine Markers
• Chromogranin A
• Synaptophysin
• Neuron-specific enolase (NSE)
Specific Neuroendocrine Markers
• Serotonin, glucagon,….
Electron Microscopic
Findings
• Dilated mitochondria,
rough endoplasmic
reticulum, free ribosomes
• Membrane-bound
secretory granules
MEN type I (Multiple endocrine neoplasia)
Synaptophysin
Esophaseal cancer and carcinoid
Chromogranin-A
Malignant carcinoid in the stomach
Gastric P/D endocrine carcinoma
(Small cell carcinoma)
Gastric P/D endocrine carcinoma
(Large cell NE carcinoma)
Like Borrmann type II AGC
Duodenal carcinoid
B
Ileal carcinoid
Appendiceal carcinoid
Sx. : Acute appendicitis
Cecal NE carcinoma + adenocarcinoma
Rectal carcinoid
Rectal malignant carcinoid
Radiologic Findings of Neuroendocrine Neoplasms (GIT)
•2008 삼성서울병원 소화기영상의학과 워크샵 (용인
에버랜드)