The Radiology

Point of view
Gastric Carcinoma

Prof.Dr.Abdul Rasyid,SpRad(K),PhD
Medical Faculty , Universitas Sumatera Utara /
R.S. H.Adam Malik
Medan,Indonesia
 GASTRIC CANCER

is still one of the most common

causes of cancer death
worldwide .

In INDONESIA and the areas

without screening for gastric
cancer, it is diagnosed late and
has a high frequency of nodal
involvement
 NCCN

NATIONAL
COMPREHENSIVE
CANCER
NETWORK

GUIDELINE FOR
GASTRIC CANCER
NCCN

The Role of Radiology Imaging

1. Screening to detect early cancer
2. Preoperatif Staging
3. Post Operatif
4. Radiotherapy Planning System contouring
1. USG
2. Radiography
3. CT Scan
4. MRI
5. PET CT Scan
 Screening and diagnosis

Routine screening
Western Countries : not
performed
because the disease is so uncommon

Japan : Mass screening

since 1960  Survival 2.5 x 

INDONESIA not performed

 Screening and diagnosis

DOUBLE-CONTRAST BARIUM X-RAYS

Can detect the initial cancer

USG
USG NORMAL

early (intramucosal) gastric cancer. Focal wall thickening, which is limited to the mucosal layer
Gold Standard for
Gastric Cancer Diagnosis
Initial Diagnosis

Endoscopy

Direct visualization: 2 mm can be image

Direct Biopsies
 CONVENTIONAL With IODINE STAINING

BMC Gastroenterol. 2011; 11: 135.

ENDOSCOPY Published online 2011 December 14.
d10.1186/1471-230X-11-135
Gastric Precancerous lesion
DOUBLE-CONTRAST BARIUM X-RAYS

Can detect the extent of cancer

 CASTRIC CANCER

CT SCAN
Multidetector computed tomography
(MDCT) with its ability to assess
Tumor depth,
Nodal disease and
Metastases
is the preferred technique for
staging
 CT Scann
NORMAL
The stomach is distended
by using water as a negative
intra luminal contrast agent.
Results of this examination are
normal
Coronal (a) and axial oblique (b) contrast-enhanced 3D volume-
rendered CT scans obtained in a patient with gastric cancer
demonstrate focal thickening of the pylorus and distal antrum (arrow).
Carcinoma of the lesser curve. Prepyloric carcinoma of antrum
Note the focal mural thickening The circularmass of the tumor
due to a tumor plaque obstruct the contrast passage
Axial contrast-enhanced CT (a) and FDG-
PET/CT (b) in a case of T2 stage GC along
the lesser curve (arrow) that shows
uptake.
Images in this article
 lesser curvature.

a b

c Lymphnode

And Liver Metastases

 The American joint committee on cancer (AJCC)
TNM staging for gastric cancer

Depth of invasion
– EARLY GASTRIC CA - mucosa & submucosa
– ADVANCED GASTRIC CA - into or through muscularis
propria

T1 tumor invades lamina propria or muscularis mucosae, T2 tumor invades muscularis

propria, T3 tumor penetrates subserosal tissue without further invasion, and T4 tumor
invades visceral peritoneum or adjacent structures
JAPAN
Gastric cancer

 Early gastric cancer - 5 yr survival 95%

 Advanced cancer - 5 yrs. survival 10%
Involvement of regional lymph
node is a critical sign in prognosis
of gastric cancer.

Radiological techniques are commonly used to

evaluate the extension of gastric cancer. But their
sensitivity and specificity are low especially in the
early stage.

Ann R Coll Surg Engl. 2006 Nov; 88(7):

632–638.
doi: 10.1308/003588406X149200
N stage

N1 ( 1–2 positive lymph nodes),

N2 (3–6 positive lymph nodes), and

N3 (7 or more positive lymph nodes).

LymphNode

Endoscopic Ultrasound
assessment of LN invasion
( correct in 50-80% of the cases).

PET
superior for diagnosis of LN metastasis.
Endoscopic Ultrasound
The gastric wall is
visualized as 5 concentric
bands:
• Mucosa - Echogenic
• Muscularis mucosa –
Hypoechoic
• Submucosa - Echogenic
• Muscularis propria –
Hypoechoic
• Serosa – Echogenic
 T1

ENDOSCOPIC ULTRASOUND
LymphNode CT SCAN and MRI
Diagnosis of lymph node involvement

Metastasis was noted in:

5% of LN < 5mm
21% of LN 5-9 mm
23% of LN 10-14 mm

Diagnosis of metastasis is
difficult in LN < 14 mm
CT Lymphography
 CASTRIC CANCER

CT SCAN- LYMPHOGRAPHY

CT images were obtained before and at 1,

3, and 5 minutes after endoscopic
submucosal peritumoral injection of 2 mL
iopamidol.
CT lymphography. (A) Upper endoscopy for peritumoral injection of iopamidol at the
CT scanning table. (B) Successful preitumoral submucosal injection of iopamidol
showing swelling of the lesion. (C) Axial CT image after iopamidol injection (long
arrow: ...
 A tumor was located
on the lower side and
posterior wall of the
stomach . The CT
lymphography
successfully detected
and enhanced lymph
node (arrowhead)
and lymphatic flow
toward the
infrapyloric lymph
node (arrow)..
A tumor was located on the lower side and
anterior wall of the stomach .The CT
lymphography successfully detected two
enhanced lymph nodes (arrowheads) and
lymphatics toward the infrapyloric lymph
nodes (arrow).
 Gastric carcinoma

Surgical Resection
the only cure available
and is dependent on the
stage at presentation,
which incorporates :
depth of tumor invasion,
extent of lymph node and
distant metastases
 The Role of Radiology Imaging

1. To detect the DEPTH of the gastric cancer

2. To detect LYMPHNODES
3. To detect METASTASE
PRE OPERATIVE STAGING
Accurate preoperative staging of Gastric Cancer
is essential for planning the optimal treatment method and inflluence SURVIVAL

Minimally invasive procedures

Endoscopic mucosal resection (EMR),

Endoscopic submucosal dissection (ESD),

Laparoscopic partial gastrectomy

Radical complete gastrectomy

and lymph node dissection.
Accurate preoperative staging

is therefore essential for optimal

surgical management with
consideration of preoperative and/or
postoperative staging
Recent trends in gastric cancer treatment

How to improve SURVIVAL ? DETECT Early

How to improve the Quality of Life ?

Reduce the extent of surgery.

J Tschmelitsch – Memorial Sloan Kettering

Surg Oncol 2000 Jul; 9(1)
Gastric Tumor Surgery
Reduce the extent of surgery

x CUT what you SEE

but

SEE what you cut

 CONCLUSION

Surgery is the fundamental curative

option for gastric cancer patients.
Imaging scans are routinely prescribed
in an attempt to stage the disease prior to
surgery. Consequently, the correlation
between radiology exams and pathology is
crucial for appropriate treatment
planning.
 What is the role of the radiologist?

A radiologist is a specially trained doctor who has special experience in

interpreting imaging studies. In a way, a radiologist can see things
that other physicians cannot see. This is very important when cancer
is diagnosed. The radiologist gives the most accurate assessment of
the tumor size, site and extent.
THANK YOU