77

Exophytic Adenocarcinoma of
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the Stomach: CT Findings

Dong Ho Lee1 OBJECTIVE. Exophytic adenocarcinomas of the stomach are tumors that have
Byung lhn Choi2 large extraluminal portions. Exophytic growth of gastric carcinoma is rare, and such
tumor may be confused with gastric Ieiomyosarcoma. The purpose of this study was
Moon Gyu Lee3
to assess the CT findings of exophytic adenocarcinoma of the stomach and to deter-
Cheol Mm Park4
mine their value in distinguishing between it and gastric leiomyosarcoma.
Ki Soon Parki
MATERIALS AND METHODS. Twenty patients with exophytic adenocarcinomas of
Young Tae Ko the stomach confirmed by surgery or endoscopic biopsy were included in the study. CT
Jae Hoon Lim1’5 scans were assessed retrospectively for the size, location, and character of the mass
Yong HoAuh3 and the presence of adjacent thickening of the gastric wall and outlet obstruction.
RESULTS. The masses were from 5 to 14 cm in diameter (mean, 9 cm). The mass
was in the gastric antrum in 11 cases, the body of the stomach in six cases, the body
and antrum in two cases, and the gastric fundus and body in one case. CT showed an
exogastric mass with a variable degree of internal low density or necrosis in all 20
cases. Thickening of the gastric wall adjacent to the mass appeared to be a specific
finding of exogastric adenocarcinoma (n = 14); it was not seen in reported cases of
Ieiomyosarcoma. Gastric outlet obstruction was seen in four cases, and ulcer was
detected in eight cases. The degree of low density or necrosis within the mass was
minimal in eight cases, moderate in seven cases, and severe in five cases.
CONCLUSION. Our results suggest that CT findings of thickening of the gastric
wall adjacent to an exogastric mass, representing spread of cancer to adjacent gas-
Inc wall, and/or gastric outlet obstruction are typical of exophytic adenocarcinoma of
the stomach and allow distinction between it and gastric leiomyosarcoma.

AJR 1994;163:77-80
Received November 22, 1993; accepted after
revision February 3, 1994.
1 Department of Diagnostic Radiology, Kyung Gastric cancer arises in the mucosa and spreads through the gastric wall, caus-
Hee University Hospital, 1 , Hoeki-dong, Dongdae- ing the characteristic CT finding of gastric wall thickening or an intraluminal mass
mun-ku Seoul 130-702, Korea. Address correspon-
dence to D. H. Lee.
[1-3]. Exophytic growth of gastric carcinoma is rare [4]. If a mass arising from the
gastric wall grows exophytically, it is usually considered to be a submucosal
2Department of Radiology, College of Medicine,
Seoul National University, 28, Yeongun-dong, tumor. When the mass is huge and has internal necrosis, gastric leiomyosarcoma
Chongro-ku, Seoul 110-744, Korea. is often diagnosed. However, the CT appearances of exophytic adenocarcinoma
3Department of Diagnostic Radiology, Asan of the stomach and gastric leiomyosarcoma are similar [5, 6]. Because the prog-
Medical Center, Ulsan University Medical College,
nosis of gastric adenocarcinoma is poorer than that of gastric leiomyosarcoma, it
388-i, Poongnap-dong, Songpa-ku, Seoul 138-
040, Korea. is important to distinguish one from the other [1].
4Department of Radiology, Korea University, Several authors commented on exophytic adenocarcinoma of the stomach in
Guro Hospital, 80, Guro-dong, Guro-ku, Seoul 152- the differential diagnosis of exogastric tumor [4-6], but no studies of the CT find-
050, Korea.
ings of exophytic adenocarcinoma of the stomach have been reported.
address: Department of Diagnostic
Accordingly, we analyzed the CT findings in 20 cases of exophytic adenocarci-
Radiology, Samsung Medical Center, 50, llwon-
dong, Kangnam-ku, Seoul 135-230, Korea. noma of the stomach. The purpose of this study was to assess the CT findings of
0361-803X/94/1631-0077
exophytic adenocarcinoma of the stomach and to determine their value in distin-
© American Roentgen Ray Society guishing this tumor from gastric leiomyosarcoma.
 78 LEE ET AL. AJR:i63, July 1994

Materials and Methods more than two thirds of the whole mass showed low density or
necrosis, we graded the necrosis as severe. Thickening of the gas-
We reviewed the records of four different hospitals and found 20
tric wall adjacent to the mass was judged to be present when the
patients (i 6 men, four women; 34-76 years old; mean age, 58
adjacent gastric wall was more than i 0 mm thick and enhanced
years) with exophytic adenocarcinomas of the stomach diagnosed
after administration of contrast medium.
between January i989 and December i99i Exophytic adenocarci-.

noma of the stomach was diagnosed when a mass protruded out-

ward from the stomach, was continuous with the gastric wall, and Results
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was proved to be carcinoma by biopsy or surgery. Cases in which

the origin of the mass was not clear were excluded. CT and endos- CT findings in all 20 cases included an exogastric mass
copy were performed in all 20 cases, and upper gastrointestinal with a variable degree of internal necrosis or low density.
series were performed in ii cases. The initial diagnosis based on The size of the exogastric mass varied from 5 to 1 4 cm, with
CT findings was exophytic gastric carcinoma in ii cases, gastric lei- a mean of 9 cm. The mass was in the gastric antrum in ii
omyosarcoma in six cases, gastric leiomyoma in two cases, and cases, the body of the stomach in six cases, the body and
gastric lymphoma in one case. But endoscopic findings of these antrum in two cases, and the gastric fundus and body in one
cases included the characteristic patterns of gastric carcinoma, and
case. In five cases in which the tumor was resected, the low
adenocarcinoma was confirmed in all 20 cases by endoscopic
density within the mass was confirmed to be caused by
biopsy (n = ii) or surgery (n = 9). The histologic pattern by the
World Health Organization’s system [7] was poorly differentiated in tumor necrosis. The degree of low density or necrosis was
seven cases, moderately differentiated in seven cases, papillary in minimal in eight cases, moderate in seven cases, and
two cases, well differentiated in one case, and signet-ring cell type severe in five cases.
in one case. In two patients, the histologic findings were not deter- Fourteen cases (70%) showed thickening of the gastric
mined. Surgical resection was possible in five patients, but the wall adjacent to the mass. The mass was resected in three
remaining four patients had only palliative surgery because of of those cases. Correlation with the pathologic specimen
spread of the tumor to the pancreas or omentum. showed that the thickening of the wall adjacent to the mass
CT was performed with a GE 9800 scanner or equivalent third- represented adenocarcinoma within the adjacent gastric
generation scanners. All patients were examined after administration
wall. The 10 cases initially diagnosed as exophytic gastric
of oral and IV contrast material. A total of 700 ml of 1.5% water-solu-
cancer on the basis of initial CT findings had focal thickening
ble contrast material was administered orally 2 hr before scanning,
and a further 350 ml of contrast material was administered orally of the gastric wall adjacent to the exogastric mass (Fig. 1 In ).

immediately before scanning. Contrast-enhanced images were one case without thickening of the gastric wall, gastric outlet
obtained after bolus injection of i 50 ml of iodinated contrast medium obstruction allowed a correct diagnosis. Three cases initially
(iodine content, 28%). Most images were obtained during the equilib- and incorrectly diagnosed as gastric leiomyosarcoma had
rium stage. Continuous scans with 5-iO mm collimation at 7- to iO- focal thickening of the gastric wall adjacent to the mass at
mm intervals were obtained. the time of the retrospective review (Fig. 2). Two cases mi-
CT findings in the 20 patients were analyzed retrospectively by tially and incorrectly diagnosed as gastric leiomyoma had
three gastrointestinal radiologists. CT scans were assessed for the neither wall thickening nor gastric outlet obstruction, so the
size, location, and character of the mass and the presence of thick-
distinction between leiomyoma and adenocarcinoma was
ening of the adjacent gastric wall and gastric outlet obstruction. The
impossible (Fig. 3). One case initially and incorrectly diag-
degree of low density or necrosis within the mass was classified into
nosed as gastric lymphoma had focal thickening of the gas-
one of three groups. When less than one third of the whole mass
showed low density or necrosis, we graded the necrosis as minimal. tric wall adjacent to the mass at the time of retrospective
When between one third and two thirds of the whole mass showed review, too. Gastric obstruction was seen in four cases (Fig.
low density or necrosis, we graded the necrosis as moderate. When 4), and ulcer was detected in eight cases.

Fig. 1.-56-year-old man with exophytic ado-

nocarclnoma of stomach.
A, CT scan of upper part of abdomen shows
a well-demarcated, low-density mass at body of
stomach with ulceration. Gastric wall anterior
to mass is thickened (arrows).
B, CT scan 1.5 cm caudal to A shows exo-
gastric growth of mass invading body of pan-
cress. At surgery, hepatic mass was found to be
a hemangioma, but gastric mass was not totally
resected because tumor had invaded pancreas
and lesser omentum.
 AJR:i63, July 1994 CT OF EXOPHYTIC ADENOCARCINOMA OF STOMACH 79

Fig. 2.-58-year-old woman with initial diag-

nosis of gastric leiomyosarcoma.
A, CT scan of mid abdomen shows large
mass with irregular margins protruding from
posterior wall of gastric antrum. Mass has inter-
nal necrosis. Gastric leiomyosarcoma was mi-
tially diagnosed on the basis of CTfindings, but
exophytic adenocarcinoma of stomach was
confirmed when mass was surgically resected.
On retrospective review, anterior wall of gastric
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antrum appears to be thickened and continu-

ous with exogastric mass (arrows). Thickened
wall is enhanced by contrast medium because
of spread of cancer.
B, CT scan 4 cm caudal to A shows massive
necrosis of tumor. Tumor mass is nearly re-
placed by necrotic fluid with thin capsule. At
surgery, tumor was found to contain massive
hemorrhagic necrosis.

Fig. 3.-48-year-old woman with initial diagnosis of gastric leiomyoma.

A, CT scan of upper part of abdomen shows a well-demarcated, low-density mass at antrum of stomach. Gastric wall adjacent to mass is not thickened.
B, CT scan 1 cm caudal to A shows exophytic growth of tumor. Gallbladder is compressed by mass.
C, CT scan 1 cm caudal to B shows low-density mass. Main portion of mass is located at exogastric area. Gastric leiomyoma was initially diagnosed
on the basis of CT findings, but exophytic adenocarcinoma of stomach was confirmed when mass was surgically resected.

Discussion

The CT features of gastric cancer are well known: focal

thickening of or a mass in the gastric wall [1-3, 8-10]. The
pattern of gastric wall thickening can be localized, circumfer-
ential, or diffuse [1 8]. Sometimes
, ulcer is detected within
the thickened area of the gastric wall or within the mass [1].
Exophytic adenocarcinoma of the stomach is rare. Three
authors mentioned exophytic growth of gastric carcinoma
[4-6]. Cho showed three cases of bulky exophytic adenocar-
cinoma of the stomach to Megibow, but Megibow had not
collected this form of adenocarcinoma of the stomach at his
institution [5]. Megibow described exophytic adenocarci-
noma of the stomach as a differential diagnosis of gastric lei-
omyosarcoma. Lerner et al. [6] reported five cases of gastric
Fig. 4.-69-year-old man with exophytic adenocarcinoma of stomach.
leiomyoblastoma and described exophytic adenocarcinoma
CT scan of mid abdomen shows huge exogastric mass with internal no-
crosis that arises from posterior wall of gastric antrum. Stomach is dis- of the stomach as the differential diagnosis. Herhinger [4]
tended. Antral wall of stomach adjacent to mass is thickened. At surgery, described exophytic adenocarcinoma of the stomach as the
pyloric antrum was found to be obstructed by huge exogastrlc mass aris-
ing from its wall. Palliative surgery was done because of spread of cancer differential diagnosis of exogastric tumor. We know of no
to liver and omentum. other articles. But these articles were neither case reports
 80 LEE ET AL. AJR:163, July 1994

nor papers about exophytic adenocarcinoma of the stomach. wall thickening adjacent to the mass to diagnose exophytic
These three articles merely mentioned exophytic adenocar- adenocarcinoma, we correctly diagnosed 1 0 exophytic ade-
cinoma of the stomach in the differential diagnosis of exo- nocarcinomas of the stomach that mimicked gastric leiomyo-
gastric tumor. Accordingly, we did this study to determine the sarcoma. In the two cases mimicking gastric leiomyoma,
CT findings of exophytic adenocarcinoma of the stomach. neither thickening of the gastric wall nor outlet obstruction
When a patient has a huge mass in the left upper quadrant was seen. Thus we were unable to distinguish adenocarci-
of the abdomen, gastric Ieiomyosarcoma, leiomyoma, leiomy- noma from leiomyoma even on retrospective review. The
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oblastoma, lymphoma, carcinoma, pancreatic pseudocyst, presence of gastric outlet obstruction is another differential
and pancreatic cystadenocarcinoma are considered in the dif- point. Gastric adenocarcinoma tends to involve the more
ferential diagnosis [5, 6]. CT scans show gastric leiomyosar- distal part of the stomach and produces outlet obstruction,
coma as a large exogastnc mass with internal necrosis and whereas gastric leiomyosarcoma rarely produces obstruc-
gastric mural attachment [1 1 0-1 3]. The characteristic
, CT lion [1 2, 14]. In one case without thickening of the gastric
finding of gastric leiomyoma is a smooth, well-marginated, wall adjacent to the mass, we were able to make a correct
bulging mass with uniform density [1 3, ii]. The larger
, diagnosis by detecting the presence of gastric outlet
lesions have increasingly exophytic components. obstruction.
Exophytic growth of gastric carcinoma is rare, and its CT
findings are especially similar to those of gastric Ieiomyosar-
ACKNOWLEDGMENTS
coma [5, 6]. In general, adenocarcinoma produces regional
or circumferential thickening of the gastric wall, tends to The authors thank Alec J. Megibow, New York University Medical
involve the more distal part of the stomach and produce out- Center, for his thoughtful review and correction of this paper and
let obstruction, and commonly shows perigastric lymphaden- Young Ran Park for her secretarial assistance in the preparation of
opathy. In contrast, leiomyosarcoma generally appears as a this manuscript.
large mass arising from the gastric body or cardia and is not
associated with thickening of the gastric wall. Perigastric
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