성균관의대 삼성서울병원 영상의학과 최동일

Carcinoma, GIST & Carcinoma, GIST &

Neuroendocrine Tumor in the Neuroendocrine Tumor in the

Gastrointestinal Tract – Gastrointestinal Tract –

Radiopathologic CorrelationsRadiopathologic Correlations

성균관의대 삼성서울병원 영상의학과

최동일

CarcinomaHistological Classification

• WHO international classification (1997) - Papillary

- Tubular - Mucinous - Signet ring cell

• Lauren classification - Intestinal type - Diffuse type

• Ming’s classificationMing’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

• 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)

동맥기 – enhancing문맥기 – wash-out지연기 – wash-out

동맥기

지연기

문맥기

위암

만성간염환자에서 생긴 위암

T2 MR : 고신호강도MR 동맥기영상 : 조영증강문맥기와 지연기 : 테두리 있는 저신호강도 wash-out ??

동맥기

T2

지연기

문맥기

Healing ulcer

Cancer

Stomach

Liver

Papillary adenocarcinoma

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; 59:619Radiology 2005;236:879-885

T1 (EGC)

T3T2

T4

? T4 on transverse CTT3 on MPR image

Pathologic T3 cancer.

? T1 on transverse CTT2 on MPR image

Pathologic T2 cancer

? T2 on transverse CTT3 on MPR image

Pathologic T3 cancer

Irregular perigastric fat infiltration

Pathologic T2 stage

!!! Irregular and nodular strands

• 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.

eAGC vs. eEGC – Samsung study

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 low-attenuating middle or outer layer (57% of patients) in mucinous carcinomas. Only two mucinous tumors showed miliary punctate calcifications in infiltrative

lesions.

• Mesenchymal tumor (mc)

- 50% of gastric benign tumor

- 1-5% of gastric malignant tumor

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

Gastric Submucosal Diseases

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%

- Well-defined smooth-surfaced

mass

- Right or obtuse angle to the

lumen

- Central ulcer

- Overlying normal mucosal fold

(bridging fold and fading folds)

UGIS 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

CT of gastric GIST

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

1 years after Imatinib Tx.

Mets 3 years after Gastrectomy

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

시험 -

6 월 15 일 5 시 20 분부터영상의학과 의사가 아닌 분들은 풀 필요없는

영상의학과 의사 전용 문제들도 있음

과제물 -

복부영상의학 관련 2011 년 이후 발간된 SCI 논문 하나에 대한 감상문 (A4 한페이지 이내 ) 메일로 제출 – 감상문과 논문 pdf

4 월 10 일까지 논문 제목 ( 잡지명과 페이지포함 ) 제출 후 OK 받은 후 5 월20 일까지감상문과 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 )

77 HU

44 HU (43% 감소 )

FOLFRI/SUTENE

XELOX/avastin

Inoperable HCCs treated with Sorafenib

57 HU

31 HU (56% 감소 )

50 HU

25 HU (50% 감소 ) 2 년후

Gastric GIST

• 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

PET

Heaptic mets after Ileal GIST resection

Suspicious lesion after Rt. hemihepatectomy

Responses of Imatinib

Size decrease & cystic change

3M F/U Before Tx

F/62 Exon 11 deletion

Cystic change

3M F/U Before Tx

M/62 Exon 9 insertion

Size decrease

3M F/U Before Tx

F/66 Exon 11 insertion

Therapeutic Efficacy of Malignant GISTs with c-KIT Mutations: CT with Imatinib Mesylate

Size decrease & cystic changeSize decrease & cystic change

Number

Exon 11 deletion 93% (14 of 15)

Other mutations 50% (4 of 8)

(p=0.032, Fisher’s exact test)(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)

14 months with Imatinib Tx.

Neoadjuvant Imatinib Tx. to downsize GIST

• KIT (+)

• Well defined enhanced mass

• Necrosis, hemorrhage

• LN metastasis rare, Ca++: rare

• Cystic degeneration after imatinib Tx.

GIST- Summary

Classification of NET1.Well differentiated endocrine tumor -

carcinoid2.Well-differentiated endocrine

carcinoma – malignant carcinoid3.Poorly differentiated endocrine

carcinoma

• 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 MarkersGeneral Neuroendocrine Markers

• Chromogranin AChromogranin A

• SynaptophysinSynaptophysin

• Neuron-specific enolase (NSE)Neuron-specific enolase (NSE)

Specific Neuroendocrine MarkersSpecific 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

B

Duodenal carcinoid

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 )