성균관의대 삼성서울병원 영상의학과 최동일
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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 )