Body Computed Tomography
Computed Tomographic Staging of Malignant Gastric Neoplasms 1 Kyo Rak Lee, M.D., Errol Levine, M.D., Robert E. Moffat, M.D., Lawrence R. Bigongiari, M.D., and Arlo S. Hermreck, M.D.
Eight patients with proved gastric carcinoma and 3 with gastric lymphoma were studied preoperatively with computed tomography. CT accurately Identified abnormal stomach wall thickening and intra-abdominal tumor extension. Mural thickening was seen on the CT scan when a moderately distended stomach had a wall more than 10 mm thick. CT was useful for assessing surgical resectability, evaluating tumor response to chemotherapy or radiotherapy, and detecting postoperative recurrence. Fourteen patients with an abnormal barium study suggesting gastric malignancy were also studied with CT, which correctly demonstrated a normal stomach or identified the reason for the abnormal barium study, such as an unusually placed spleen or a pancreatic carcinoma invading the stomach. Computed tomography. abdomen. 7[01.1211 (Stomach. CT. 7[21.1211). Stomach. neoplasms. 7[2].321; 7[2].340
INDEX TERMS:
Radiology 133: 151-155. October 1979 ACCURATE determination of the extent of tumor is es-
1-\
sential for the proper management of malignant gastric neoplasms (1-3). Preoperative identification of local or regional spread may avert laparotomy in patients with advanced lesions (1). Although arteriography, ultrasonography. and radionuclide imaging have been used (4-7), surgical exploration has thus far been the only reliable method of identifying tumor extension. CT has already been shown to be an accurate method of assessing many abdominal tumors (8-11). However. little information is available regarding the role of CT in evaluating gastric neoplasms and determining local and regional tumor spread. The present study was undertaken to assess the accuracy and usefulness of CT in evaluating the gastric region. particularly intra-abdominal spread of malignant gastric neoplasms. MATERIALS AND METHODS
Twenty-five patients were studied from October 1977 to August 1978. All had an abnormal upper gastrointestinal study. The patients fell into two groups. The first group consisted of 11 patients with malignant gastric neoplasms proved by endoscopy and biopsy, consisting of carcinoma in 8 and lymphoma in 3. Six of the patients with carcinoma had a total gastrectomy following the CT study. The other 2 were not explored. as the CT scans showed extensive intra-abdominal tumor spread; one died a month later and autopsy was performed. Two of the patients with lymphoma were explored surgically following the CT study. The second group consisted of 14 patients who had an abnormal barium study suggesting a gastric malignancy. All were studied by CT. Subsequent endoscopy and biopsy showed normal findings in 11 patients. and this was con-
firmed by follow-up studies. Nonspecific gastritis was found in 2 patients and Menetrier disease in 1. Scans were obtained with a GE CTIT body scanner (4.8-sec. scan. 10-mm slice thickness). Since poor distension or retained gastric contents may give a false impression of mural thickening (12), a special scanning technique was used for the stomach. Patients were allowed only clear liquid by mouth starting at night. Thirty minutes prior to CT examination. 400 ml of 2 % Gastrografin was given orally and a preliminary abdominal localization radiograph obtained. An additional 200 ml of 2 % Gastrografin containing a foaming agent was given immediately prior to scanning. Scans were obtained at 1.0-cm intervals from 2 em above the diaphragm to the umbilicus in the supine position. The scans were then repeated in the prone position following intravenous infusion of 300 ml of 30 % methylglucamine diatrizoate and additional oral Gastrografin with foaming agent. Lateral decubitus scans were obtained when necessary. The scans were analyzed for gastric wall thickness. tumor thickness. direct tumor extension to adjacent organs. regional lymph node involvement. and distant intra-abdominal metastasis. and the CT findings were correlated with the surgical and pathological findings. The widest window. 1,000 H. was used to measure gastric wall thickness, as it provided the most consistent display of the wall. By noting the difference in density between the gastric wall and mesenteric fat, the serosal surface of the anterior and posterior gastric walls could be identified in most cases. Dilute contrast material was essential for identifying the mucosal surface. The measurement was made at the crevices as suggested by Rourke and Tomchik (12). When the stomach was less distended. the rugae became taller. but the wall thickness at the crevices depicted by the
1 From the Departments of Diagnostic Radiology (K.R.L..E.L..R.E.M.. L.R.B.)and Surgery (A.S.H.). University of Kansas Medical Center. Kansas City. Kan. Presented at the Sixty-fourth Scientific Assembly and Annual Meeting of the Radiological Society of North America. Chicago. III.. Nov. 26-Dec. 1. 1978. Received March 5, 1979 and accepted May 25. sjh
151
Kyo
152
RAK
LEE
Fig. 1. CT scan in a patient with Menetrier disease demonstrates normal wall thickness at the crevices (black arrows), although the rugae of the body of the stomach appear tall. The wall of the fundus (white arrows) is demonstrated well by its interface with air in the prone position.
contrast material remained unchanged. Supine and prone scans permitted evaluation of the anterior and posterior walls, outlined alternately by air and contrast material (Fig. 1). Abnormal wall thickening was diagnosed when the thickness exceeded 1 em ( 12). RESULTS
Carcinoma: The final staging was proved by surgery or autopsy in 7 of 8 patients with carcinoma. Two early neoplasms were confined to the inner layers, without regional or distant extension, and were called Stage AI according
AND
OTHERS
October 1979
to the clinical classification (1). Five patients had an advanced tumor which extended directly to adjacent structures. One patient had no distant metastasis (Stage Bill), but the other 4 had metastases to the liver, peritoneum, pleura, and/or distant lymph nodes (Stage CIII). CT was negative in the 2 cases of early carcinoma. In all 5 advanced cases, the primary tumors were identified by wall thickening ranging from 13 to 45 mm. The tumor had a localized or diffuse irregular outer margin and poor distension, suggesting rigidity of the wall (Fig. 2). The structures involved by direct extension in these cases were the esophagus in 2, pancreas in 3, liver in 2, spleen in 1, transverse colon in 1, hepatogastric ligament in 2, and gastrocolic ligament in 1. CT correctly identified these regions of extension (Fig. 3). One case of liver involvement and one case of hepatogastric ligament extension were missed by CT. Adjacent lymph nodes were involved in all 5 cases; however, CT was unable to detect them, since separation of enlarged nodes from the primary tumors was impossible in most cases. CT accurately identified distant metastases in the liver, pleura, peritoneum, and distant lymph nodes (Fig. 2, a). Six months after surgery, CT demonstrated enlarged mesenteric and para-aortic lymph nodes in the patient with Stage Bill cancer. Lymphoma: CT revealed extensive involvement of the stomach, kidneys, and mesenteric and para-aortic lymph nodes in one case. CT clearly demonstrated the ulcerated gastric lesion perforating the pancreas (Fig. 4). and the findings were confirmed at surgery. In 2 cases CT identified localized involvement of the stomach (Fig. 5, a). Three months after combined radiotherapy and chemotherapy, CT showed complete resolution of the gastric lesion in one case (Fig. 5, b). Suspected Cancer: CT identified an enlarged or abnormally shaped spleen extrinsically compressing the stomach in 3 of 11 patients with a proved normal stomach.
2a,b
Fig. 2. Primary tumors demonstrated by CT. a. Large fungating carcinoma. CT reveals diffuse thickening of the gastric wall by extensive carcinomatous involvement. The thickest portion measures 3.5 cm (arrow). Notice the irregular serosal surface and small gastric lumen. The liver contains multiple metastases. b. Scirrhous carcinoma. The stomach shows diffuse mural thickening (arrows) and lack of distension.
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Body Computed Tomography
Fig. 3. Direct tumor extension to adjacent structures. a. Esophageal involvement. demonstrated by thickening of the wall (arrow). b. Extension to the liver and spleen, demonstrated by a large area of decreased density in the left lobe of the liver (black arrow) and spleen (white arrow). c. Extension to the pancreas (arrows). d. Extension to the gastrocolic ligament and transverse colon. The lumen of the colon (open arrow) is partially obliterated by tumor (arrows).
In the remaining 8 patients, CT was negative. The normal gastric wall thickness ranged from 2 to 7 mm on CT (average, 5 mm). In 1 of 2 patients with nonspecific gastritis shown by endoscopic biopsy, CT identified a tumor of the head of the pancreas invading the stomach. In the remaining patient, CT showed a small, contracted stomach without mural thickening. An enlarged liver and spleen were also demonstrated, and tertiary syphilis involving the central nervous system was proved later. CT was negative in a patient with Menetrier disease (Fig. 1). DISCUSSION
CT is not the primary diagnostic modality for detecting malignant lesions of the stomach. In most instances the diagnosis is established by a combination of barium study and endoscopy. However, CT may provide valuable additional information regarding intra-abdominal extent when
a lesion is detected by either or both studies. This information is useful for staging the lesion, assessing the surgical resectability, and evaluating the tumor's response to therapy (11). In our study, CT was crucial in avoiding laparotomy in 2 patients with advanced carcinoma. CT provided significant information for planning surgery in a patient with lymphoma by demonstrating a large, ulcerated gastric lesion perforating the pancreas (Fig. 4). It was also useful for documenting the results of chemotherapy and radiotherapy in another patient with lymphoma (Fig. 5) and in detecting recurrence in a patient with postoperative carcinoma and helped to shorten the clinical workup in some patients with suspected gastric tumor by demonstrating a pancreatic carcinoma invading the stomach in one case and an enlarged spleen causing the abnormal barium study in others. Most normal stomachs had a wall 2-7 mm thick (average, 5 mm). These data correspond closely to those de-
Kyo
154
RAK LEE AND OTHERS
October 1979
4a,b
4c,d
Fig. 4. Large ulcerated lymphoma. a. Conventional barium study demonstrates a large ulcer along the lesser curvature. band c. CT scans reveal extensive lymphomatous involvement of the stomach. para-aortic lymph nodes. and both kidneys. as well as perforation of the pancreas by the ulcer (arrow). d. The surgical specimen shows the site of perforation (arrow) and marked thickening of the stomach wall.
5a,b
Fig. 5. Tumor response to therapy. a. CT scan shows localized thickening of the anterior gastric wall by lymphoma (arrow). This was proved by surgery. b. Three months after chemotherapy and radiation therapy, CT scan shows normal wall thickness at the previous tumor site (arrow). suggesting excellent response to therapy.
Vol. 133
155
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rived from conventional roentgenographic measurement of the barium-filled stomach (12). The cardiac portion was the most difficult area to evaluate; it appeared to be thicker and measured up to 10 mm in some cases, possibly due to the distal esophagus inserting obliquely into the stomach. The prone scans have proved to be very useful for evaluating the cardia and fundus (Fig. 1). A normal gastric wall may appear thickened due to poor gastric distension, food contents, or hiatus hernia associated with omental herniation. In thin patients lacking mesenteric fat it may not be possible to evaluate the gastric wall adequately. The thickness of the primary tumors evaluated by CT correlated well with the surgical and pathological findings. Two early carcinomas which penetrated only the inner layers as proved by pathology were less than 1 cm on CT. All 5 advanced lesions, which extended to the serosa, were more than 1 cm thick on CT (Fig. 2). Three lymphomas were more than 2 cm thick (Figs. 4 and 5). Thus mural thickening may be suspected when a moderately distended stomach has a wall more than 10 mm thick. Rourke and Tomchik (12) and Ferrucci and Janower (13) have suggested the same criteria for abnormal wall thickening. Abdominal CT is frequently used for staging lymphoma or detecting an unknown primary tumor in patients with known metastatic adenocarcinoma. Therefore, careful evaluation of the stomach may demonstrate unsuspected gastric involvement by lymphoma or gastric carcinoma in such cases. The surgical resectability of gastric carcinomas at the time of diagnosis depends on the tumor size, direct invasion, and distant metastases, including peritoneal implants (1). Needle or open biopsy, cytological study of ascitic fluid, or radiological studies including radionuclide scanning, sonography and arteriography have been used for tumor staging (1, 3-7). Our preliminary results indicate that CT is a valuable method for the preoperative workup of patients with malignant gastric neoplasms.
Body Computed Tomography
REFERENCES 1. Hoerr SO: Carcinoma of the stomach. [In] NyhusLM, WasteII C, ed: Surgery of the Stomach and Duodenum. Boston, Little, Brown, 3d Ed, 1977, Chapt 25, pp 649-672 2. Frik W: Neoplastic diseasesof the stomach. [In I MargulisAR, Burhenne HJ, ed: Alimentary Tract Roentgenology. St. Louis, Mo., Mosby, 2d Ed, 1973, Vol 1, pp 662-709 3. FriedlandGW: Stomach. [In] Steckel RJ. Kagan AR: Diagnosis and Staging of Cancer. A Radiologic Approach. Philadelphia, Saunders, 1976, Chapt 7, pp 129-155 4. Baum S: Angiography of localized gastric lesions. Semin Roentgenol 6:207-219. Apr 1971 5. Efsen F, Fischerman K: Angiography in gastric tumours. Acta Radiol[Diagn] 15:193-197, Mar 1974 6. Walls WJ: The evaluation of malignant gastric neoplasms by ultrasonic B-scanning. Radiology 118:159-163. Jan 1976 7. Marsden OS, AlexanderCH, YeungPK, et al: The use of 99mrc to detect gastric malignancy. Am J Gastroenterol 59:410-415, May 1973 8. Redman HC. Glatstein E, Castellino RA. et al: Computed tomography as an adjunct in the staging of Hodgkin's disease and nonHodgkin's lymphomas. Radiology 124:381-385. Aug 1977 9. Seidelmann FE, Cohen WN, Bryan PJ, et al: Accuracy of CT staging of bladder neoplasms using the gas-filled method: report of 21 patients with surgical confirmation. Am J Roentgenol 130:735-739, Apr 1978 10. Boldt OW, Reilly BJ: Computed tomography of abdominal mass lesions in children. Initial experience. Radiology 124:371-378, Aug 1977 11. Kressel HY, Callen PW. Montagne J-P, et al: Computed tomographic evaluation of disorders affecting the alimentary tract. Radiology 129:451-455, Nov 1978 12. Rourke JA, Tomchik FS: Diffuse gastric abnormality-benign or malignant? Am J Roentgenol 96:400-407, Feb 1966 13. Ferrucci JT Jr, Janower ML: Localized infiltrating lesions of the stomach. Semin RoentgenoI6:168-181, Apr 1971
Department of Diagnostic Radiology University of Kansas Medical Center Rainbow Blvd. at 39th St. Kansas City, Kan. 66103
Computed Tomographic Staging of Malignant Gastric Neoplasms 1 Kyo Rak Lee, M.D., Errol Levine, M.D., Robert E. Moffat, M.D., Lawrence R. Bigongiari, M.D., and Arlo S. Hermreck, M.D.
Eight patients with proved gastric carcinoma and 3 with gastric lymphoma were studied preoperatively with computed tomography. CT accurately Identified abnormal stomach wall thickening and intra-abdominal tumor extension. Mural thickening was seen on the CT scan when a moderately distended stomach had a wall more than 10 mm thick. CT was useful for assessing surgical resectability, evaluating tumor response to chemotherapy or radiotherapy, and detecting postoperative recurrence. Fourteen patients with an abnormal barium study suggesting gastric malignancy were also studied with CT, which correctly demonstrated a normal stomach or identified the reason for the abnormal barium study, such as an unusually placed spleen or a pancreatic carcinoma invading the stomach. Computed tomography. abdomen. 7[01.1211 (Stomach. CT. 7[21.1211). Stomach. neoplasms. 7[2].321; 7[2].340
INDEX TERMS:
Radiology 133: 151-155. October 1979 ACCURATE determination of the extent of tumor is es-
1-\
sential for the proper management of malignant gastric neoplasms (1-3). Preoperative identification of local or regional spread may avert laparotomy in patients with advanced lesions (1). Although arteriography, ultrasonography. and radionuclide imaging have been used (4-7), surgical exploration has thus far been the only reliable method of identifying tumor extension. CT has already been shown to be an accurate method of assessing many abdominal tumors (8-11). However. little information is available regarding the role of CT in evaluating gastric neoplasms and determining local and regional tumor spread. The present study was undertaken to assess the accuracy and usefulness of CT in evaluating the gastric region. particularly intra-abdominal spread of malignant gastric neoplasms. MATERIALS AND METHODS
Twenty-five patients were studied from October 1977 to August 1978. All had an abnormal upper gastrointestinal study. The patients fell into two groups. The first group consisted of 11 patients with malignant gastric neoplasms proved by endoscopy and biopsy, consisting of carcinoma in 8 and lymphoma in 3. Six of the patients with carcinoma had a total gastrectomy following the CT study. The other 2 were not explored. as the CT scans showed extensive intra-abdominal tumor spread; one died a month later and autopsy was performed. Two of the patients with lymphoma were explored surgically following the CT study. The second group consisted of 14 patients who had an abnormal barium study suggesting a gastric malignancy. All were studied by CT. Subsequent endoscopy and biopsy showed normal findings in 11 patients. and this was con-
firmed by follow-up studies. Nonspecific gastritis was found in 2 patients and Menetrier disease in 1. Scans were obtained with a GE CTIT body scanner (4.8-sec. scan. 10-mm slice thickness). Since poor distension or retained gastric contents may give a false impression of mural thickening (12), a special scanning technique was used for the stomach. Patients were allowed only clear liquid by mouth starting at night. Thirty minutes prior to CT examination. 400 ml of 2 % Gastrografin was given orally and a preliminary abdominal localization radiograph obtained. An additional 200 ml of 2 % Gastrografin containing a foaming agent was given immediately prior to scanning. Scans were obtained at 1.0-cm intervals from 2 em above the diaphragm to the umbilicus in the supine position. The scans were then repeated in the prone position following intravenous infusion of 300 ml of 30 % methylglucamine diatrizoate and additional oral Gastrografin with foaming agent. Lateral decubitus scans were obtained when necessary. The scans were analyzed for gastric wall thickness. tumor thickness. direct tumor extension to adjacent organs. regional lymph node involvement. and distant intra-abdominal metastasis. and the CT findings were correlated with the surgical and pathological findings. The widest window. 1,000 H. was used to measure gastric wall thickness, as it provided the most consistent display of the wall. By noting the difference in density between the gastric wall and mesenteric fat, the serosal surface of the anterior and posterior gastric walls could be identified in most cases. Dilute contrast material was essential for identifying the mucosal surface. The measurement was made at the crevices as suggested by Rourke and Tomchik (12). When the stomach was less distended. the rugae became taller. but the wall thickness at the crevices depicted by the
1 From the Departments of Diagnostic Radiology (K.R.L..E.L..R.E.M.. L.R.B.)and Surgery (A.S.H.). University of Kansas Medical Center. Kansas City. Kan. Presented at the Sixty-fourth Scientific Assembly and Annual Meeting of the Radiological Society of North America. Chicago. III.. Nov. 26-Dec. 1. 1978. Received March 5, 1979 and accepted May 25. sjh
151
Kyo
152
RAK
LEE
Fig. 1. CT scan in a patient with Menetrier disease demonstrates normal wall thickness at the crevices (black arrows), although the rugae of the body of the stomach appear tall. The wall of the fundus (white arrows) is demonstrated well by its interface with air in the prone position.
contrast material remained unchanged. Supine and prone scans permitted evaluation of the anterior and posterior walls, outlined alternately by air and contrast material (Fig. 1). Abnormal wall thickening was diagnosed when the thickness exceeded 1 em ( 12). RESULTS
Carcinoma: The final staging was proved by surgery or autopsy in 7 of 8 patients with carcinoma. Two early neoplasms were confined to the inner layers, without regional or distant extension, and were called Stage AI according
AND
OTHERS
October 1979
to the clinical classification (1). Five patients had an advanced tumor which extended directly to adjacent structures. One patient had no distant metastasis (Stage Bill), but the other 4 had metastases to the liver, peritoneum, pleura, and/or distant lymph nodes (Stage CIII). CT was negative in the 2 cases of early carcinoma. In all 5 advanced cases, the primary tumors were identified by wall thickening ranging from 13 to 45 mm. The tumor had a localized or diffuse irregular outer margin and poor distension, suggesting rigidity of the wall (Fig. 2). The structures involved by direct extension in these cases were the esophagus in 2, pancreas in 3, liver in 2, spleen in 1, transverse colon in 1, hepatogastric ligament in 2, and gastrocolic ligament in 1. CT correctly identified these regions of extension (Fig. 3). One case of liver involvement and one case of hepatogastric ligament extension were missed by CT. Adjacent lymph nodes were involved in all 5 cases; however, CT was unable to detect them, since separation of enlarged nodes from the primary tumors was impossible in most cases. CT accurately identified distant metastases in the liver, pleura, peritoneum, and distant lymph nodes (Fig. 2, a). Six months after surgery, CT demonstrated enlarged mesenteric and para-aortic lymph nodes in the patient with Stage Bill cancer. Lymphoma: CT revealed extensive involvement of the stomach, kidneys, and mesenteric and para-aortic lymph nodes in one case. CT clearly demonstrated the ulcerated gastric lesion perforating the pancreas (Fig. 4). and the findings were confirmed at surgery. In 2 cases CT identified localized involvement of the stomach (Fig. 5, a). Three months after combined radiotherapy and chemotherapy, CT showed complete resolution of the gastric lesion in one case (Fig. 5, b). Suspected Cancer: CT identified an enlarged or abnormally shaped spleen extrinsically compressing the stomach in 3 of 11 patients with a proved normal stomach.
2a,b
Fig. 2. Primary tumors demonstrated by CT. a. Large fungating carcinoma. CT reveals diffuse thickening of the gastric wall by extensive carcinomatous involvement. The thickest portion measures 3.5 cm (arrow). Notice the irregular serosal surface and small gastric lumen. The liver contains multiple metastases. b. Scirrhous carcinoma. The stomach shows diffuse mural thickening (arrows) and lack of distension.
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Body Computed Tomography
Fig. 3. Direct tumor extension to adjacent structures. a. Esophageal involvement. demonstrated by thickening of the wall (arrow). b. Extension to the liver and spleen, demonstrated by a large area of decreased density in the left lobe of the liver (black arrow) and spleen (white arrow). c. Extension to the pancreas (arrows). d. Extension to the gastrocolic ligament and transverse colon. The lumen of the colon (open arrow) is partially obliterated by tumor (arrows).
In the remaining 8 patients, CT was negative. The normal gastric wall thickness ranged from 2 to 7 mm on CT (average, 5 mm). In 1 of 2 patients with nonspecific gastritis shown by endoscopic biopsy, CT identified a tumor of the head of the pancreas invading the stomach. In the remaining patient, CT showed a small, contracted stomach without mural thickening. An enlarged liver and spleen were also demonstrated, and tertiary syphilis involving the central nervous system was proved later. CT was negative in a patient with Menetrier disease (Fig. 1). DISCUSSION
CT is not the primary diagnostic modality for detecting malignant lesions of the stomach. In most instances the diagnosis is established by a combination of barium study and endoscopy. However, CT may provide valuable additional information regarding intra-abdominal extent when
a lesion is detected by either or both studies. This information is useful for staging the lesion, assessing the surgical resectability, and evaluating the tumor's response to therapy (11). In our study, CT was crucial in avoiding laparotomy in 2 patients with advanced carcinoma. CT provided significant information for planning surgery in a patient with lymphoma by demonstrating a large, ulcerated gastric lesion perforating the pancreas (Fig. 4). It was also useful for documenting the results of chemotherapy and radiotherapy in another patient with lymphoma (Fig. 5) and in detecting recurrence in a patient with postoperative carcinoma and helped to shorten the clinical workup in some patients with suspected gastric tumor by demonstrating a pancreatic carcinoma invading the stomach in one case and an enlarged spleen causing the abnormal barium study in others. Most normal stomachs had a wall 2-7 mm thick (average, 5 mm). These data correspond closely to those de-
Kyo
154
RAK LEE AND OTHERS
October 1979
4a,b
4c,d
Fig. 4. Large ulcerated lymphoma. a. Conventional barium study demonstrates a large ulcer along the lesser curvature. band c. CT scans reveal extensive lymphomatous involvement of the stomach. para-aortic lymph nodes. and both kidneys. as well as perforation of the pancreas by the ulcer (arrow). d. The surgical specimen shows the site of perforation (arrow) and marked thickening of the stomach wall.
5a,b
Fig. 5. Tumor response to therapy. a. CT scan shows localized thickening of the anterior gastric wall by lymphoma (arrow). This was proved by surgery. b. Three months after chemotherapy and radiation therapy, CT scan shows normal wall thickness at the previous tumor site (arrow). suggesting excellent response to therapy.
Vol. 133
155
CT STAGING OF MALIGNANT GASTRIC NEOPLASMS
rived from conventional roentgenographic measurement of the barium-filled stomach (12). The cardiac portion was the most difficult area to evaluate; it appeared to be thicker and measured up to 10 mm in some cases, possibly due to the distal esophagus inserting obliquely into the stomach. The prone scans have proved to be very useful for evaluating the cardia and fundus (Fig. 1). A normal gastric wall may appear thickened due to poor gastric distension, food contents, or hiatus hernia associated with omental herniation. In thin patients lacking mesenteric fat it may not be possible to evaluate the gastric wall adequately. The thickness of the primary tumors evaluated by CT correlated well with the surgical and pathological findings. Two early carcinomas which penetrated only the inner layers as proved by pathology were less than 1 cm on CT. All 5 advanced lesions, which extended to the serosa, were more than 1 cm thick on CT (Fig. 2). Three lymphomas were more than 2 cm thick (Figs. 4 and 5). Thus mural thickening may be suspected when a moderately distended stomach has a wall more than 10 mm thick. Rourke and Tomchik (12) and Ferrucci and Janower (13) have suggested the same criteria for abnormal wall thickening. Abdominal CT is frequently used for staging lymphoma or detecting an unknown primary tumor in patients with known metastatic adenocarcinoma. Therefore, careful evaluation of the stomach may demonstrate unsuspected gastric involvement by lymphoma or gastric carcinoma in such cases. The surgical resectability of gastric carcinomas at the time of diagnosis depends on the tumor size, direct invasion, and distant metastases, including peritoneal implants (1). Needle or open biopsy, cytological study of ascitic fluid, or radiological studies including radionuclide scanning, sonography and arteriography have been used for tumor staging (1, 3-7). Our preliminary results indicate that CT is a valuable method for the preoperative workup of patients with malignant gastric neoplasms.
Body Computed Tomography
REFERENCES 1. Hoerr SO: Carcinoma of the stomach. [In] NyhusLM, WasteII C, ed: Surgery of the Stomach and Duodenum. Boston, Little, Brown, 3d Ed, 1977, Chapt 25, pp 649-672 2. Frik W: Neoplastic diseasesof the stomach. [In I MargulisAR, Burhenne HJ, ed: Alimentary Tract Roentgenology. St. Louis, Mo., Mosby, 2d Ed, 1973, Vol 1, pp 662-709 3. FriedlandGW: Stomach. [In] Steckel RJ. Kagan AR: Diagnosis and Staging of Cancer. A Radiologic Approach. Philadelphia, Saunders, 1976, Chapt 7, pp 129-155 4. Baum S: Angiography of localized gastric lesions. Semin Roentgenol 6:207-219. Apr 1971 5. Efsen F, Fischerman K: Angiography in gastric tumours. Acta Radiol[Diagn] 15:193-197, Mar 1974 6. Walls WJ: The evaluation of malignant gastric neoplasms by ultrasonic B-scanning. Radiology 118:159-163. Jan 1976 7. Marsden OS, AlexanderCH, YeungPK, et al: The use of 99mrc to detect gastric malignancy. Am J Gastroenterol 59:410-415, May 1973 8. Redman HC. Glatstein E, Castellino RA. et al: Computed tomography as an adjunct in the staging of Hodgkin's disease and nonHodgkin's lymphomas. Radiology 124:381-385. Aug 1977 9. Seidelmann FE, Cohen WN, Bryan PJ, et al: Accuracy of CT staging of bladder neoplasms using the gas-filled method: report of 21 patients with surgical confirmation. Am J Roentgenol 130:735-739, Apr 1978 10. Boldt OW, Reilly BJ: Computed tomography of abdominal mass lesions in children. Initial experience. Radiology 124:371-378, Aug 1977 11. Kressel HY, Callen PW. Montagne J-P, et al: Computed tomographic evaluation of disorders affecting the alimentary tract. Radiology 129:451-455, Nov 1978 12. Rourke JA, Tomchik FS: Diffuse gastric abnormality-benign or malignant? Am J Roentgenol 96:400-407, Feb 1966 13. Ferrucci JT Jr, Janower ML: Localized infiltrating lesions of the stomach. Semin RoentgenoI6:168-181, Apr 1971
Department of Diagnostic Radiology University of Kansas Medical Center Rainbow Blvd. at 39th St. Kansas City, Kan. 66103
