Korean J Radiol.  2015 Feb;16(1):80-89. 10.3348/kjr.2015.16.1.80.

The Role of Three-Dimensional Multidetector CT Gastrography in the Preoperative Imaging of Stomach Cancer: Emphasis on Detection and Localization of the Tumor

Affiliations
  • 1Department of Radiology, Chonnam National University Medical School, Gwangju 501-757, Korea. kjradsss@dreamwiz.com
  • 2Center for Aging and Geriatrics, Chonnam National University Medical School, Gwangju 501-757, Korea.
  • 3Department of Radiology, Chonnam National University Hospital, Gwangju 501-757, Korea.
  • 4Department of Surgery, Chonnam National University Medical School, Gwangju 501-757, Korea.

Abstract

Multidetector CT (MDCT) gastrography has been regarded as a promising technique for the preoperative imaging of gastric cancer. It has the ability to produce various three-dimensional (3D) images. Because 3D reconstruction images are more effective and intuitive for recognizing abnormal changes in the gastric folds and subtle mucosal nodularity than two-dimensional images, 3D MDCT gastrography can enhance the detection rate of early gastric cancer, which, in turn, contributes to the improvement of the accuracy of preoperative tumor (T) staging. In addition, shaded surface display and tissue transition projection images provide a global view of the stomach, with the exact location of gastric cancer, which may replace the need for barium studies. In this article, we discuss technical factors in producing high-quality MDCT gastrographic images and present cases demonstrating the usefulness of MDCT gastrography for the detection and T staging of gastric cancer while emphasizing the significance of preoperative localization of gastric cancer in terms of surgical margin.

Keyword

Gastric cancer; MDCT; T-staging; Virtual endoscopy; Oncologic imaging

MeSH Terms

Humans
Image Processing, Computer-Assisted
Imaging, Three-Dimensional
Neoplasm Staging
Stomach Neoplasms/pathology/*radiography/surgery
Tomography, X-Ray Computed

Figure

  • Fig. 1 Case of Borrmann type II advanced gastric cancer (AGC) visualized on various three-dimensional CT gastrography images.Virtual endoscopy (VE) (A), shaded surface display (SSD) (B), and tissue transition projection (TTP) (C) images show Borrmann type II AGC (arrowheads) at gastric angle. As compared to SSD image, central ulceration of mass is depicted more clearly on VE image. Note that interactive two-dimensional image is concomitantly displayed in corner of VE image. Red line on TTP image indicates viewpoint path, along which center of VE image is located.

  • Fig. 2 Various features of early gastric cancers (EGCs) on virtual endoscopy and conventional endoscopic images.A. EGC (type IIb, superficial flat type) is seen with uneven base (arrows). B. EGC (type IIc, superficial depressed type) shows shallow depressed lesion with abnormal gastric fold convergence (arrows). C. EGC (type IIa, superficial elevated type) is demonstrated as bulbous enlargement (arrows). D. EGC (type I, protruded type) is seen as polypoid lesion (arrows).

  • Fig. 3 Diagrams showing possibility of re-operation due to location difference for gastric cancer between preoperative conventional endoscopy and surgery.A. Illustration shows location of gastric cancer at gastric angle, as is determined using preoperative conventional endoscopy. Black dotted lines indicate proximal and distal resection lines of planned laparoscopic subtotal gastrectomy with sufficient proximal resection margin (blue arrow). B. Illustration shows different location of gastric cancer between preoperative conventional endoscopy and surgery. If gastric cancer is located more proximally (green arrow) along lesser curvature at surgery than conventional endoscopy, planned proximal and distal resection lines (black dotted lines) would not secure sufficient proximal resected margin. Thus, in this case, additional total gastrectomy (red dotted line) may be required for sufficient proximal resected margin (blue arrow) after primary subtotal gastrectomy.

  • Fig. 4 Case of early gastric cancer (EGC) (type IIa) in which re-operation was performed because location of EGC was incorrectly determined by conventional endoscopy, in contrast to CT gastrography.A. EGC (arrows) was determined to be at lesser curvature of gastric mid-body using conventional endoscopy. Laparoscopic distal gastrectomy was planned based on conventional endoscopic findings. B, C. In contrast to conventional endoscopic findings, EGC (arrow) is depicted at upper body on both virtual endoscopy (B) and tissue transition projection (C) images. However, planned laparoscopic distal gastrectomy was finally performed according to location of EGC using conventional endoscopy. With surgical specimen, EGC was confirmed to be located at upper body. Re-operation (near-total gastrectomy) was subsequently performed due to insufficient proximal resected margin after initial laparoscopic distal gastrectomy.

  • Fig. 5 T1a cancer (type IIc) in 62-year-old man that is not seen on two-dimensional CT image despite being detected on both virtual endoscopy (VE) and tissue transition projection (TTP) images.A. Oblique, axial, contrast-enhanced CT image shows no discernible lesion at corresponding site (arrow) where early gastric cancer (EGC) is detected on three-dimensional images. B. VE image demonstrates shallow depressed lesion (arrows) with converging folds and uneven margins. C. Conventional endoscopic image shows malignant ulcer (arrows) with converging folds and uneven margin, which are similar morphologic features with B. D. TTP image depicts location of EGC (arrow) that is seen on VE (B).

  • Fig. 6 T1b cancer (type IIa + IIc) in 62-year-old man, detected on both two-dimensional and three-dimensional (virtual endoscopy [VE]) images.A. Sagittal contrast-enhanced CT image shows well-enhanced ulcerative lesion in thickened mucosal layer (arrows), which invades low-density-stripe layer to degree of less than 50% of thickness at lesser curvature of gastric lower body. B. VE image demonstrates shallow ulcerative lesion (arrows) with uneven margins. C. Conventional endoscopic image shows malignant ulcer (arrows) with uneven margins, similar to morphological features in B.

  • Fig. 7 T2 cancer in 69-year-old man.A. Axial contrast-enhanced CT image shows well-enhancing mucosal thickening (arrow) and disruption of low-density-stripe layer (> 50% of thickness) at greater curvature of gastric body, without abutting outer, slightly higher-attenuating layer. This lesion was correctly classified as T2 cancer in preoperative imaging. B. Virtual endoscopy image shows ulceroinfiltrative mass (arrows). C. Conventional endoscopic image reveals poorly demarcated ulceroinfiltrative lesion (arrows), suggestive of advanced gastric cancer.

  • Fig. 8 T1b early gastric cancer (type IIc) in 74-year-old woman that was overestimated as T2 cancer at multidetector CT gastrography.A, B. Conventional endoscopic (A) and virtual endoscopy (VE) (B) images clearly show focal ulcerative lesion (arrow). C. Oblique axial contrast-enhanced CT image shows focal ulcerative lesion with enhancing thickened mucosa (arrow) and uneven gastric layers in thickness. Because of relatively thin low-density-stripe layer (curved arrow) of proximal antrum, compared to distal antrum (arrowhead), disruption degree of low-density-stripe layer was estimated as greater than 50% of thickness. This lesion was judged preoperatively as T2 cancer. However, gastric cancer was confirmed pathologically as SM3 T1b cancer.

  • Fig. 9 Residual food mimicking true gastric lesion.A. Residual food (arrows) in gastric antrum mimics focal mucosal lesion. Note tiny ulcer (arrowheads) in vicinity of residual food. B. Axial CT image demonstrates residual food (arrows) in gastric antrum and upper body. C. Conventional endoscopy reveals residual food (arrows) and tiny ulcer (arrowheads) in gastric antrum.


Cited by  1 articles

Effect of Preoperative Tumor Under-Staging on the Long-term Survival of Patients Undergoing Radical Gastrectomy for Gastric Cancer
Mi Lin, Qi-Yue Chen, Chao-Hui Zheng, Ping Li, Jian-Wei Xie, Jia-Bin Wang, Jian-Xian Lin, Chang-Ming Huang
Cancer Res Treat. 2021;53(4):1123-1133.    doi: 10.4143/crt.2020.651.


Reference

1. Jemal A, Center MM, DeSantis C, Ward EM. Global patterns of cancer incidence and mortality rates and trends. Cancer Epidemiol Biomarkers Prev. 2010; 19:1893–1907. PMID: 20647400.
Article
2. Chung HW, Noh SH, Lim JB. Analysis of demographic characteristics in 3242 young age gastric cancer patients in Korea. World J Gastroenterol. 2010; 16:256–263. PMID: 20066747.
Article
3. Kim JW, Shin SS, Heo SH, Choi YD, Lim HS, Park YK, et al. Diagnostic performance of 64-section CT using CT gastrography in preoperative T staging of gastric cancer according to 7th edition of AJCC cancer staging manual. Eur Radiol. 2012; 22:654–662. PMID: 21965037.
Article
4. Lee IJ, Lee JM, Kim SH, Shin CI, Lee JY, Kim SH, et al. Diagnostic performance of 64-channel multidetector CT in the evaluation of gastric cancer: differentiation of mucosal cancer (T1a) from submucosal involvement (T1b and T2). Radiology. 2010; 255:805–814. PMID: 20501718.
Article
5. Shen Y, Kang HK, Jeong YY, Heo SH, Han SM, Chen K, et al. Evaluation of early gastric cancer at multidetector CT with multiplanar reformation and virtual endoscopy. Radiographics. 2011; 31:189–199. PMID: 21257941.
Article
6. Park HS, Lee JM, Kim SH, Lee JY, Yang HK, Han JK, et al. Three-dimensional MDCT for preoperative local staging of gastric cancer using gas and water distention methods: a retrospective cohort study. AJR Am J Roentgenol. 2010; 195:1316–1323. PMID: 21098189.
Article
7. Kim SH, Han JK, Lee KH, Chung JW, Yang HK, Choi BI. Computed tomography gastrography with volume-rendering technique: correlation with double-contrast barium study and conventional gastroscopy. J Comput Assist Tomogr. 2003; 27:140–149. PMID: 12703002.
Article
8. Kim HJ, Kim AY, Lee JH, Yook JH, Yu ES, Ha HK. Positioning during CT gastrography in patients with gastric cancer: the effect on gastric distension and lesion conspicuity. Korean J Radiol. 2009; 10:252–259. PMID: 19412513.
Article
9. Yan C, Zhu ZG, Yan M, Zhang H, Pan ZL, Chen J, et al. Value of multidetector-row computed tomography in the preoperative T and N staging of gastric carcinoma: a large-scale Chinese study. J Surg Oncol. 2009; 100:205–214. PMID: 19530124.
Article
10. Kim JH, Eun HW, Choi JH, Hong SS, Kang W, Auh YH. Diagnostic performance of virtual gastroscopy using MDCT in early gastric cancer compared with 2D axial CT: focusing on interobserver variation. AJR Am J Roentgenol. 2007; 189:299–305. PMID: 17646454.
Article
11. Chen CY, Hsu JS, Wu DC, Kang WY, Hsieh JS, Jaw TS, et al. Gastric cancer: preoperative local staging with 3D multi-detector row CT--correlation with surgical and histopathologic results. Radiology. 2007; 242:472–482. PMID: 17255419.
Article
12. Kim HJ, Kim AY, Oh ST, Kim JS, Kim KW, Kim PN, et al. Gastric cancer staging at multi-detector row CT gastrography: comparison of transverse and volumetric CT scanning. Radiology. 2005; 236:879–885. PMID: 16020558.
Article
13. Kim SH, Lee JM, Han JK, Lee JY, Yang HK, Lee HJ, et al. Effect of adjusted positioning on gastric distention and fluid distribution during CT gastrography. AJR Am J Roentgenol. 2005; 185:1180–1184. PMID: 16247129.
Article
14. Yu JS, Choi SH, Choi WH, Chung JJ, Kim JH, Kim KW. Value of nonvisualized primary lesions of gastric cancer on preoperative MDCT. AJR Am J Roentgenol. 2007; 189:W315–W319. PMID: 18029842.
Article
15. Park KJ, Lee MW, Koo JH, Park Y, Kim H, Choi D, et al. Detection of early gastric cancer using hydro-stomach CT: blinded vs unblinded analysis. World J Gastroenterol. 2011; 17:1051–1057. PMID: 21448358.
Article
16. Dicken BJ, Bigam DL, Cass C, Mackey JR, Joy AA, Hamilton SM. Gastric adenocarcinoma: review and considerations for future directions. Ann Surg. 2005; 241:27–39. PMID: 15621988.
17. Bozzetti F, Bonfanti G, Bufalino R, Menotti V, Persano S, Andreola S, et al. Adequacy of margins of resection in gastrectomy for cancer. Ann Surg. 1982; 196:685–690. PMID: 7149820.
Article
18. Wang SY, Yeh CN, Lee HL, Liu YY, Chao TC, Hwang TL, et al. Clinical impact of positive surgical margin status on gastric cancer patients undergoing gastrectomy. Ann Surg Oncol. 2009; 16:2738–2743. PMID: 19636636.
Article
19. Jeong SH, Bae K, Ha CY, Lee YJ, Lee OJ, Jung WT, et al. Effectiveness of endoscopic clipping and computed tomography gastroscopy for the preoperative localization of gastric cancer. J Korean Surg Soc. 2013; 84:80–87. PMID: 23396626.
Article
20. Choi JI, Joo I, Lee JM. State-of-the-art preoperative staging of gastric cancer by MDCT and magnetic resonance imaging. World J Gastroenterol. 2014; 20:4546–4557. PMID: 24782607.
Article
21. Kumano S, Okada M, Shimono T, Kuwabara M, Yagyu Y, Imaoka I, et al. T-staging of gastric cancer of air-filling multidetector-row CT: comparison with hydro-multidetector-row CT. Eur J Radiol. 2012; 81:2953–2960. PMID: 22304982.
Article
22. Furukawa K, Miyahara R, Itoh A, Ohmiya N, Hirooka Y, Mori K, et al. Diagnosis of the invasion depth of gastric cancer using MDCT with virtual gastroscopy: comparison with staging with endoscopic ultrasound. AJR Am J Roentgenol. 2011; 197:867–875. PMID: 21940574.
Article
23. Minami M, Kawauchi N, Itai Y, Niki T, Sasaki Y. Gastric tumors: radiologic-pathologic correlation and accuracy of T staging with dynamic CT. Radiology. 1992; 185:173–178. PMID: 1523303.
Article
24. Ahn HS, Kim SH, Kodera Y, Yang HK. Gastric cancer staging with radiologic imaging modalities and UICC staging system. Dig Surg. 2013; 30:142–149. PMID: 23867591.
Article
Full Text Links
  • KJR
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr