T-staging of gastric cancer of air-filling multidetector-row CT: comparison with hydro-multidetector-row CT

Canine regional gastric blood flow measurement using perfusion computed tomography

This study aimed to determine the feasibility of using perfusion computed tomography (CT) to assess blood flow in different regions of the stomach in dogs. Dynamic perfusion CT scans were conducted on five beagle dogs, and blood flow analysis was performed using the maximum slope and Patlak plot methods. The findings revealed significant variations in blood flow among the fundus, body, and pylorus of the stomach. Specifically, the body showed approximately 1.3 times higher blood flow than the fundus and approximately 5 times higher blood flow than the pylorus. There were no significant differences in blood flow between the two analysis algorithms. The findings suggest that gastric perfusion CT can accurately detect variations in blood flow within the stomach. Using the maximum slope method for analysis allows for noninvasive and rapid measurement of gastric blood flow. This technique may have clinical applications in detecting submucosal diseases that are challenging to identify with endoscopies and serve as a valuable noninvasive tool for longitudinal observations in experimental animal studies.

Korean Practice Guidelines for Gastric Cancer 2024: An Evidence-based, Multidisciplinary Approach (Update of 2022 Guideline)

Gastric cancer is one of the most common cancers in both Korea and worldwide. Since 2004, the Korean Practice Guidelines for Gastric Cancer have been regularly updated, with the 4th edition published in 2022. The 4th edition was the result of a collaborative work by an interdisciplinary team, including experts in gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology, and guideline development methodology. The current guideline is the 5th version, an updated version of the 4th edition. In this guideline, 6 key questions (KQs) were updated or proposed after a collaborative review by the working group, and 7 statements were developed, or revised, or discussed based on a systematic review using the MEDLINE, Embase, Cochrane Library, and KoreaMed database. Over the past 2 years, there have been significant changes in systemic treatment, leading to major updates and revisions focused on this area. Additionally, minor modifications have been made in other sections, incorporating recent research findings. The level of evidence and grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation system. Key factors for recommendation included the level of evidence, benefit, harm, and clinical applicability. The working group reviewed and discussed the recommendations to reach a consensus. The structure of this guideline remains similar to the 2022 version. Earlier sections cover general considerations, such as screening, diagnosis, and staging of endoscopy, pathology, radiology, and nuclear medicine. In the latter sections, statements are provided for each KQ based on clinical evidence, with flowcharts supporting these statements through meta-analysis and references. This multidisciplinary, evidence-based gastric cancer guideline aims to support clinicians in providing optimal care for gastric cancer patients.

Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach

Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.

Gastric hydrodistension CT versus CT without gastric distension in preoperative TN staging of gastric carcinoma: analysis of single-center cancer registry

Accurate staging of gastric cancer is essential for the selection and optimization of therapy. Hydrodistension of the stomach is recommended to improve the accuracy of preoperative staging with contrast-enhanced multidetector computed tomography (MDCT). This study compares the performance of contrast-enhanced gastric water distension versus a nondistension MDCT protocol for T and N staging and serosal invasion in comparison to surgical histopathology. After propensity score matching, 86 patients in each group were included for analysis. The overall accuracy of distension versus nondistension group in T staging was 45% (95% CI 35-56) and 55% (95% CI 44-65), respectively (p = 0.29). There was no difference in the sensitivity and specificity in individual T staging and assessment of serosal invasion (all p > 0.41). Individual stage concordance with pathology was not significantly different (all p > 0.41). The overall accuracy of N staging was the same for distension and nondistension groups (51% [95% CI 40-62]). The majority of N0 staging (78-81%) were correctly staged, whereas N3 staging cases (63-68%) were predominantly understaged. In summary, there was no significant difference in the diagnostic performance of individual TN staging and assessment of serosal invasion using MDCT with or without gastric water distension.

Potential key roles of tumour budding: a representative malignant pathological feature of non-small cell lung cancer and a sensitive indicator of prognosis

OBJECTIVES

To investigate the relationship between tumour budding, clinicopathological characteristics of patients and prognosis in non-small cell lung cancer.

STUDY DESIGN

A retrospective study was used.

PARTICIPANTS

We selected 532 patients with non-small cell lung cancer from China, including 380 patients with adenocarcinoma and 152 with squamous cell carcinoma.

PRIMARY AND SECONDARY OUTCOME MEASURES

Tumour budding was visible using H&E staining as well as pancytokeratin staining. The count data and measurement data were compared using the χ² test and the t-test, respectively. The overall survival rate was the follow-up result. The survival curves were drawn using the Kaplan-Meier method, and the differences between groups were analysed using the log-rank method. The independent prognostic factor of patients with lung cancer was determined using a multivariate Cox proportional hazard model.

RESULTS

In patients with lung adenocarcinoma, there was a correlation between tumour budding and spread through air spaces (OR 36.698; 95% CI 13.925 to 96.715; p<0.001), and in patients with squamous cell carcinoma, tumour budding state was closely related to the peritumoural space (OR 11.667; 95% CI 4.041 to 33.683; p<0.001). On Cox regression analysis, multivariate analysis showed that tumour budding, pleural and vascular invasion, spread through air spaces, tumour size, lymph node metastasis, and tumour node metastasis stage were independent risk factors of prognosis for patients with non-small cell lung cancer.

CONCLUSIONS

As an effective and simple pathological diagnostic index, it is necessary to establish an effective grading system in the clinical diagnosis of lung cancer to verify the value of tumour budding as a prognostic indicator. We hope that this analysis of Chinese patients with non-small cell lung cancer can provide useful reference material for the continued study of tumour budding.

Advanced gastric cancer: CT radiomics prediction and early detection of downstaging with neoadjuvant chemotherapy

OBJECTIVES

To develop and evaluate machine learning models using baseline and restaging computed tomography (CT) for predicting and early detecting pathological downstaging (pDS) with neoadjuvant chemotherapy in advanced gastric cancer (AGC).

METHODS

We collected 292 AGC patients who received neoadjuvant chemotherapy. They were classified into (a) primary cohort (206 patients with 3-4 cycles chemotherapy) for model development and internal validation, (b) testing cohort I (46 patients with 3-4 cycles chemotherapy) for evaluating models' predictive ability before and after the complete course, and (c) testing cohort II (n = 40) for model evaluation on its performance at early treatment. We extracted 1,231 radiomics features from venous phase CT at baseline and restaging. We selected radiomics models based on 28 cross-combination models and measured the areas under the curve (AUC). Our prediction radiomics (PR) model is designed to predict pDS outcomes using baseline CT. Detection radiomics (DR) model is applied to restaging CT for early pDS detection.

RESULTS

PR model achieved promising outcomes in two testing cohorts (AUC 0.750, p = .009 and AUC 0.889, p = .000). DR model also showed a good predictive ability (AUC 0.922, p = .000 and AUC 0.850, p = .000), outperforming the commonly used RECIST method (NRI 39.5% and NRI 35.4%). Furthermore, the improved DR model with averaging outcome scores of PR and DR models showed boosted results in two testing cohorts (AUC 0.961, p = .000 and AUC 0.921, p = .000).

CONCLUSIONS

CT-based radiomics models perform well on prediction and early detection tasks of pDS and can potentially assist surgical decision-making in AGC patients.

KEY POINTS

• Baseline contrast-enhanced computed tomography (CECT)-based radiomics features were predictive of pathological downstaging, allowing accurate identification of non-responders before therapy. • Restaging CECT-based radiomics features were predictive to achieve pDS after and even at an early stage of neoadjuvant chemotherapy. • Combination of baseline and restaging CECT-based radiomics features was promising for early detection and preoperative evaluation of pathological downstaging of AGC.

Diagnosis of gastric cancer by MDCT gastrography: diagnostic characteristics and management potential

Background

Gastric cancer is regarded as the fifth most frequent tumor globally but the third most common fatal illness. As early as possible, we diagnose cancer stomach especially at early stages, the higher the rate of life. Nevertheless, most cases are diagnosed at late cases where surgery is not of the same benefit at early stages because of clinically indefinite symptoms. The prospective study goal is to estimate the role of MDCT in diagnosis and staging of cancer stomach.

Results

In our study, it was found that there was a high relationship between pathological and CT staging by using MPR. CT with MPR was specific and accurate in diagnosis of all stages of gastric cancer with specificity ranged between 93 and 97% and accuracy ranged between 90 and 92.5%. However, it showed lowest sensitivity in diagnosis of stage 1 of gastric cancer. On the other hand, it showed highest sensitivity (90%) in diagnosis of stage IV as well as we found that MPR and VR of MDCT are much more accurate (92.5%) than multi-detector computed tomography axial images (80%) in the diagnosis of all stages of gastric cancer with the difference between the two sequences was significant (P = 0.009).

Conclusion

Our results demonstrate that preoperative MDCT with contrast filling technique for abdomen and pelvis evaluates the local disease process of gastric cancer as well as the potential areas of spread. This information is vital in choosing between palliative or radical surgery. MPR and VR help in the assessment of tumor extension and considered as a highly representative prognostic value. Making it the imaging modality of choice in diagnosis and staging of gastric cancers.

Radiologic serosal invasion sign as a new criterion of T4a gastric cancer on computed tomography: diagnostic performance and prognostic significance in patients with advanced gastric cancer

PURPOSE

To investigate the diagnostic performance and prognostic significance of a new criterion for radiologic T4a staging on computed tomography (CT) in patients with advanced gastric cancer (AGC).

METHODS

Between January 2010 and April 2019, 101 patients with pathologically confirmed gastric cancer were collected. Among them, 53 patients with pathologic T3 and T4a cancers were included in this study. Three reviewers assessed preoperative CT scans for radiologic T staging in two sessions, independently and in consensus at a 2-week interval, while blinded about the pathologic T stage. The radiologic serosal invasion sign was defined as a nodular extension from the outer gastric wall reaching beyond the perigastric vascular plane and adopted as a new CT criterion for T4a cancer. We evaluated the diagnostic performance, interobserver agreement, and prognostic significance of this sign for the postoperative recurrence.

RESULTS

There were 46 pathologic T3 cancers (86.7%) and seven pathologic T4a cancers (13.2%). The diagnostic performance of the radiologic serosal invasion sign in the differentiation between T3 and T4a cancers was as follows: sensitivity, 91.3%; specificity, 71.43%; and accuracy, 88.68% for R1 and sensitivity, 78.26%; specificity, 85.71%; and accuracy, 79.25% for R2. The k-value was 0.64. Among the clinical and pathologic variables, radiologic T4a sign [hazard ratio (HR): 7.96; 95% confidence interval (CI) 2.36-26.86, p = 0.001], pathologic T4a (HR 9.82, 95% CI 2.35-40.95, p = 0.002), tumor size (HR 1.18, 95% CI 1.02-1.35, p = 0.026), and lymphovascular invasion (HR 6.39, 95% CI 1.42-28.75, p = 0.015) were the significant factors for postoperative recurrence.

CONCLUSIONS

Radiologic serosal invasion sign is reliable as a new CT criterion for T4a cancer staging in patients with advanced gastric cancer, demonstrating 80% to 88% accuracy. Radiologic serosal invasion sign can also serve as a prognostic factor for postoperative recurrence as well as pathologic T4a stage.

Performance of a machine learning-based decision model to help clinicians decide the extent of lymphadenectomy (D1 vs. D2) in gastric cancer before surgical resection

BACKGROUND

Controversy still exists on the optimal surgical resection for potentially curable gastric cancer (GC). Use of radiologic evaluation and machine learning algorithms might predict extent of lymphadenectomy to limit unnecessary surgical treatment. We purposed to design a machine learning-based clinical decision-support model for predicting extent of lymphadenectomy (D1 vs. D2) in local advanced GC.

METHODS

Clinicoradiologic features available from routine clinical assignments in 557 patients with GCs were retrospectively interpreted by an expert panel blinded to all histopathologic information. All patients underwent surgery using standard D2 resection. Decision models were developed with a logistic regression (LR), support vector machine (SVM) and auto-encoder (AE) algorithm in 371 training and tested in 186 test data, respectively. The primary end point was to measure diagnostic performance of decision model and a Japanese gastric cancer treatment guideline version 4th (JPN 4th) criteria for discriminate D1 (pT1 + pN0) versus D2 (≥ pT1 + ≥ pN1) lymphadenectomy.

RESULTS

The decision model with AE analysis produced highest area under ROC curve (train: 0.965, 95% confidence interval (CI) 0.948-0.978; test: 0.946, 95% CI 0.925-0.978), followed by SVM (train: 0.925, 95% CI 0.902-0.944; test: 0.942, 95% CI 0.922-0.973) and LR (train: 0.886, 95% CI 0.858-0.910; test: 0.891, 95% CI 0.891-0.952). By this improvement, overtreatment was reduced from 21.7% (121/557) by treat-all pattern, to 15.1% (84/557) by JPN 4th criteria, and to 0.7-0.9% (4-5/557) by the new approach.

CONCLUSIONS

The decision model with machine learning analysis demonstrates high accuracy for identifying patients who are candidates for D1 versus D2 resection. Its approximate 14-20% improvements in overtreatment compared to treat-all pattern and JPN 4th criteria potentially increase the number of patients with local advanced GCs who can safely avoid unnecessary lymphadenectomy.

Magnetic Semiconductor Gd-Doping CuS Nanoparticles as Activatable Nanoprobes for Bimodal Imaging and Targeted Photothermal Therapy of Gastric Tumors

Targeted delivery of enzyme-activatable probes into cancer cells to facilitate accurate imaging and on-demand photothermal therapy (PTT) of cancers with high spatiotemporal precision promises to advance cancer diagnosis and therapy. Here, we report a tumor-targeted and matrix metalloprotease-2 (MMP-2)-activatable nanoprobe (T-MAN) formed by covalent modification of Gd-doping CuS micellar nanoparticles with cRGD and an MMP-2-cleavable fluorescent substrate. T-MAN displays a high r1 relaxivity (∼60.0 mM-1 s-1 per Gd3+ at 1 T) and a large near-infrared (NIR) fluorescence turn-on ratio (∼185-fold) in response to MMP-2, allowing high-spatial-resolution magnetic resonance imaging (MRI) and low-background fluorescence imaging of gastric tumors as well as lymph node (LN) metastasis in living mice. Moreover, T-MAN has a high photothermal conversion efficiency (PCE, ∼70.1%) under 808 nm laser irradiation, endowing it with the ability to efficiently generate heat to kill tumor cells. We demonstrate that T-MAN can accumulate preferentially in gastric tumors (∼23.4% ID%/g at 12 h) after intravenous injection into mice, creating opportunities for fluorescence/MR bimodal imaging-guided PTT of subcutaneous and metastatic gastric tumors. For the first time, accurate detection and laser irradiation-initiated photothermal ablation of orthotopic gastric tumors in intraoperative mice was also achieved. This study highlights the versatility of using a combination of dual biomarker recognition (i.e., αvβ3 and MMP-2) and dual modality imaging (i.e., MRI and NIR fluorescence) to design tumor-targeting and activatable nanoprobes with improved selectivity for cancer theranostics in vivo.

Effect of the degree of gastric filling on the measured thickness of advanced gastric cancer by computed tomography

Imaging of gastric cancer thickness is closely associated with the depth of tumor invasion, which provides guidance for clinical staging and assists the evaluation of the effects of adjuvant therapy. However, it is unclear whether the measurement of thickness is affected by the degree of gastric filling, and its accuracy and reliability are under-reported. The present study aimed to investigate the influence of the degree of gastric filling on the measurement of gastric cancer thickness. A total of 38 patients with advanced gastric cancer who underwent enhanced abdominal computed tomography (CT) scanning at the Department of CT and MR in The Fourth Hospital of Hebei Medical University (Shijiazhuang, China) between July and September 2016 were recruited, consisting of 21 newly diagnosed cases and 17 follow-up cases following non-surgical treatments. Plain scanning (prior to filling) and enhanced scanning in venous phase (following filling) were performed. Axial CT images prior to and following filling of the normal part of gastric wall and the lesions were compared. The same procedure was repeated on these participants 1 month later by the same radiologist, and the results were compared with those obtained previously. Normal gastric wall thickness prior to and following gastric filling was significantly different (all P<0.001) with the most substantial changes observed at the greater curvature. Lesion thickness prior to and following filling was similar in newly diagnosed patients, but significantly different in patients for re-examination (P<0.05). The two thickness measurements in the same patients were consistent. The measured thickness of gastric cancer in newly diagnosed patients was relatively stable, and could be used as an indicator in baseline CT examination. Maintaining a similar degree of gastric filling during re-examination could aid the accurate evaluation of treatment efficacy.

Preoperative tumor restaging and resectability assessment of gastric cancers after chemotherapy: diagnostic accuracy of MDCT using new staging criteria

PURPOSE

To evaluate the diagnostic performance of preoperative MDCT for tumor restaging and determination of resectability in gastric cancers after chemotherapy using new staging criteria.

METHODS

This retrospective study was approved by our institutional review board and the requirement for informed consent was waived. Thirty-seven patients with initially unresectable gastric cancers who had received chemotherapy followed by surgery were included. Two independent radiologists reviewed preoperative MDCT images to determine the TNM staging and rate the overall likelihood of resectability using a 5-point scale (5: definitely unresectable, 1: definitely resectable). New post-chemotherapy MDCT criteria do not use non-enhancing perigastric infiltrations, non-enhancing lymph nodes (LNs), and subtle remaining infiltrations after marked decrease in the size of distant metastases for T, N, and M upstaging, respectively. Discrepancies in TNM staging were resolved by a third reviewer. The diagnostic performances of MDCT were assessed using pathologic results or operation records as reference standards.

RESULTS

For predicting resectability, the areas under the ROC curve were 0.885 and 0.882 (95% CIs 0.737-0.966 and 0.733-0.964) in reviewers 1 and 2, respectively, with substantial inter-reader agreement (weighted κ = 0.689). Sensitivities and specificities of MDCT for tumor restaging on a consensus review were 80.0% (4/5) and 100% (29/29) for T4b, 35.3% (6/17) and 81.3% (13/16) for N-positive, and 63.6% (7/11) and 100% (26/26) for M1, respectively.

CONCLUSIONS

For gastric cancers after chemotherapy, new MDCT criteria demonstrated high specificities for T4b and M-staging and good performances to predict resectability before conversion surgery.

Contribution of diffusion weighted MRI to diagnosis and staging in gastric tumors and comparison with multi-detector computed tomography

Background

Diagnostic performance of Diffusion-Weighted magnetic resonance Imaging (DWI) and Multi-Detector Computed Tomography (MDCT) for TNM (Tumor, Lymph node, Metastasis) staging of gastric cancer was compared.

Patients and methods

We used axial T2-weighted images and DWI (b-0,400 and b-800 s/mm2) protocol on 51 pre-operative patients who had been diagnosed with gastric cancer. We also conducted MDCT examinations on them. We looked for a signal increase in the series of DWI images. The depth of tumor invasion in the stomach wall (tumor (T) staging), the involvement of lymph nodes (nodal (N) staging), and the presence or absence of metastases (metastatic staging) in DWI and CT images according to the TNM staging system were evaluated. In each diagnosis of the tumors, sensitivity, specificity, positive and negative accuracy rates of DWI and MDCT examinations were found through a comparison with the results of the surgical pathology, which is the gold standard method. In addition to the compatibilities of each examination with surgical pathology, kappa statistics were used.

Results

Sensitivity and specificity of DWI and MDCT in lymph node staging were as follows: N1: DWI: 75.0%, 84.6%; MDCT: 66.7%, 82%;N2: DWI: 79.3%, 77.3%; MDCT: 69.0%, 68.2%; N3: DWI: 60.0%, 97.6%; MDCT: 50.0%, 90.2%. The diagnostic tool DWI seemed more compatible with the gold standard method (surgical pathology), especially in the staging of lymph node, when compared to MDCT. On the other hand, in T staging, the results of DWI and MDCT were better than the gold standard when the T stage increased. However, DWI did not demonstrate superiority to MDCT. The sensitivity and specificity of both imaging techniques for detecting distant metastasis were 100%.

Conclusions

The diagnostic accuracy of DWI for TNM staging in gastric cancer before surgery is at a comparable level with MDCT and adding DWI to routine protocol of evaluating lymph nodes metastasis might increase diagnostic accuracy.

Impact of the Cross-Sectional Location of Multidetector Computed Tomography Scans on Prediction of Serosal Exposure in Patients with Advanced Gastric Cancer

BACKGROUND

The extent of serosal exposure varies depending on the cross-section of the stomach that is viewed, affected by the visceral peritoneum of the omentum. Although multidetector computed tomography (MDCT) is the most useful method to predict serosal exposure, the MDCT criteria for such exposure by cross-sectional location remain to be established.

METHODS

The MDCT of gastric cancer patients who underwent surgery, and for whom pathological reports were available, were reviewed by radiologists. The MDCT criteria for invasion depth were divided into five grades: (1) smooth margin; (2) undulating margin; (3) streaky margin within vessels; (4) nodular margin within perigastric vessels; and (5) streaky or nodular margin over the perigastric vessels. The five grades were compared in terms of pathological tumor depth by curvature and wall group.

RESULTS

A total of 125 patients of stage ≥ T2 were enrolled. The five MDCT grades correlated with tumor depth (P < 0.001). Exposed serosal lesions of grade 3 (P = 0.031) and 5 (P = 0.030) constituted significantly the largest proportion of wall and curvature cancers, respectively. The accuracy of MDCT in terms of T staging using the five grades was calculated by cross-sectional location. The highest accuracies were associated with curvature- and wall-located tumors (55.1 and 64.3%, respectively) when serosal exposure was graded 5 and 3, respectively. The highest overall accuracy for T staging was 59.2% when the various MDCT criteria were applied by reference to the cross-sectional location.

CONCLUSIONS

The MDCT criteria for serosal exposure vary by the cross-sectional location of the gastric cancer.

Individualized nomogram improves diagnostic accuracy of stage I-II gallbladder cancer in chronic cholecystitis patients with gallbladder wall thickening

BACKGROUND

Early diagnosis of gallbladder cancer (GBC) can remarkably improve the prognosis of patients. This study aimed to develop a nomogram for individualized diagnosis of stage I-II GBC in chronic cholecystitis patients with gallbladder wall thickening.

METHODS

The nomogram was developed using logistic regression analyses based on a retrospective cohort consisting of 89 consecutive patients with stage I-II GBC and 1240 patients with gallbladder wall thickening treated at one biliary surgery center in Shanghai between January 2009 and December 2011. The accuracy of the nomogram was validated by discrimination, calibration and a prospective cohort treated at another center between January 2012 and December 2014 (n=928).

RESULTS

Factors included in the nomogram were advanced age, hazardous alcohol consumption, long-standing diagnosed gallstones, atrophic gallbladder, gallbladder wall calcification, intraluminal polypoid lesion, higher wall thickness ratio and mucosal line disruption. The nomogram had concordance indices of 0.889 and 0.856 for the two cohorts, respectively. Internal and external calibration curves fitted well. The area under the receiver-operating characteristic curves of the nomogram was higher than that of multidetector row computed tomography in diagnosis of stage I-II GBC (P<0.001).

CONCLUSION

The proposed nomogram improves individualized diagnosis of stage I-II GBC in chronic cholecystitis patients with gallbladder wall thickening, especially for those the imaging features alone do not allow to confirm the diagnosis.

Multidetector computed tomography in the preoperative staging of gastric adenocarcinoma

Objective

To evaluate the role of multidetector computed tomography in the preoperative investigation of tumor invasion depth and lymph node and metastatic involvement according to the TNM classification, in patients with gastric adenocarcinoma.

Materials and Methods

Fifty-four patients with biopsy-confirmed gastric cancer underwent preoperative staging with 64-channel multidetector computed tomography. Two independent radiologists analyzed the images and classified the findings. Sensitivity, specificity, accuracy and overall accuracy were calculated for each observer. The interobserver agreement was also evaluated.

Results

The accuracy in the classification of categories T ranged from 74% to 96% for observer 1 and from 80% to 92% for observer 2. The overall accuracy was 70% for both observers. The weighted kappa index was 0.75, consistent with a significant interobserver agreement. The accuracy in the classification of lymph node involvement (category N) ranged from 55% to 79% for observer 1 and from 73% to 82% for observer 2. The evaluation of metastatic involvement showed an overall accuracy of 89.6% for both observers.

Conclusion

64-channel multidetector computed tomography demonstrated clinically relevant accuracy in the preoperative staging of gastric adenocarcinoma as regards invasion depth (T category) and metastatic involvement (M category).

Correlation between CT contrast enhancement ratio and CT perfusion parameters and expression of HER2 in gastric cancer

AIM: To evaluate the correlation between the computed tomography (CT) contrast enhancement ratio (CER) in arterial phase and venous phase, CT perfusion parameters and expression of human epidermal growth factor receptor 2 (HER2) in pathologically proven gastric cancer.

METHODS: A retrospective analysis of triple-phase CER was performed on 105 patients who underwent MSCT. A retrospective analysis of CT perfusion parameters including maximal arterial flow (AF), blood volume (BV), blood flow (BF) and clearance (CL) was performed on 50 patients who underwent 320-detector-row CT perfusion. The expression of HER2 was detected by immunohistochemistry in all the patients. The differences in CER and CT perfusion parameters between the HER2-negative and HER2-positive groups were analyzed.

RESULTS: The triple-phase CER values in the HER2-negative group were 0.65±0.35, 1.18±0.53 and 2.62±1.41, respectively; the corresponding values in the HER2-positive group were 0.78±0.44, 1.47±0.61 and 2.37±1.36. CER in the venous phase was significantly higher in the HER2-positive group than in the HER2-negative group ((P = 0.010), although CER values in the arterial phase and arterial-venous phase were not significantly different ((P = 0.094, 0.597). The perfusion parameters in the HER2-negative group were as follows: AF = 117.15 mL/(100 mL·min) ± 31.56 mL/(100 mL·min), BV = 20.69 mL/100 Ml ± 13.41 mL/100 mL, BF = 6.42 mL/(100 mL·min) ± 4.25 mL/(100 mL·min), and CL = 4.46 1/s ± 2.25 1/s; the corresponding values in the HER2-positive group were 119.08 mL/(100 mL·min) ± 41.97 mL/(100 mL·min), 20.07 mL/100 mL ± 14.46 mL/100 mL, 6.39 mL/(100 mL·min) ± 3.68 mL/(100 mL·min), and 5.63 1/s ± 2.90 1/s. There was no significant difference in AF, BV, BF or CL between the two groups ((P = 0.888, 0.886, 0.979 and 0.123, respectively).

CONCLUSION: The CER in venous phase is significantly higher in the HER2-positive group than in the HER2-negative group, but there is no significant difference in the CT perfusion parameters.

Gastric Carcinoma: Ex Vivo MR Imaging at 7.0 T-Correlation with Histopathologic Findings

PURPOSE

To determine the imaging detail and diagnostic information that can be obtained at 7.0-T magnetic resonance (MR) imaging with a voxel volume of 9.5-14.0 nL as a means of evaluating the depth of mural invasion by gastric carcinomas ex vivo.

MATERIALS AND METHODS

This study was approved by the institutional review board, and written informed consent was obtained from each patient. Twenty gastric specimens containing 20 carcinomas were studied with a 7.0-T MR imaging system equipped with a four-channel surface coil. MR images were obtained with a 50-60 × 25-30 mm field of view, a 512 × 256 matrix, and a 1.0-mm section thickness, resulting in a voxel volume of 0.0095-0.0140 mm(3) (9.5-14.0 nL). The signal intensity of the gastric wall layers, tumor tissue, and fibrosis was described as low, intermediate, or high by comparing it with the signal intensity of the muscularis propria. Depth of invasion initially was assessed by two reviewers independently and then by the two reviewers in consensus. MR images were compared with histopathologic findings.

RESULTS

The 7.0-T T2-weighted MR images clearly depicted the normal gastric wall in all 20 specimens (100%) as consisting of seven layers, which clearly corresponded to the tissue layers of the gastric wall. These MR images enabled clear differentiation between tumor tissue and fibrosis. Reviewers disagreed on the depth of invasion at the initial reading in three (15%) of 20 specimens (between mucosa and submucosa in two specimens and between muscularis propria and subserosa and serosa in one specimen); however, in all 20 gastric carcinomas, the depth of invasion could be accurately determined on T2-weighted images after consensus interpretation.

CONCLUSION

Ex vivo 7.0-T MR imaging enables clear delineation of the gastric wall layers and clear differentiation of tumor tissue from fibrosis and allows one to assess the depth of mural invasion by gastric carcinomas.

The role of three-dimensional multidetector CT gastrography in the preoperative imaging of stomach cancer: emphasis on detection and localization of the tumor

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.

CT volumetry for gastric carcinoma: association with TNM stage

OBJECTIVES

We evaluated the feasibility of performing CT volumetry of gastric carcinoma (GC) and its correlation with TNM stage.

METHODS

This institutional review board-approved retrospective study was performed on 153 patients who underwent a staging CT study for histologically confirmed GC. CT volumetry was performed by drawing regions of interest including abnormal thickening of the stomach wall. Reproducibility of tumour volume (Tvol) between two readers was assessed. Correlation between Tvol and TNM/peritoneal staging derived from histology/surgical findings was evaluated using ROC analysis and compared with CT evaluation of TNM/peritoneal staging.

RESULTS

Tvol was successfully performed in all patients. Reproducibility among readers was excellent (r = 0.97; P = 0.0001). The median Tvol of GC showed an incremental trend with T-stage (T1 = 27 ml; T2 = 32 ml; T3 = 53 ml and T4 = 121 ml, P < 0.01). Tvol predicted with good accuracy T-stage (≥T2:0.95; ≥T3:0.89 and T4:0.83, P = 0.0001), M-stage (0.87, P = 0.0001), peritoneal metastases (0.87, P = 0.0001) and final stage (≥stage 2:0.89; ≥stage 3:0.86 and stage 4:0.87, P = 0.0001), with moderate accuracy for N-stage (≥N1:0.75; ≥N2:0.74 and N3:0.75, P = 0.0001). Tvol was significantly (P < 0.05) more accurate than standard CT staging for prediction of T-stage, N3-stage, M-stage and peritoneal metastases.

CONCLUSION

CT volumetry may provide useful adjunct information for preoperative staging of GC.

KEY POINTS

CT volumetry of gastric carcinoma is feasible and reproducible. Tumour volume <19.4 ml predicts T1-stage gastric cancer with 91% sensitivity and 100% specificity (P = 0.0001). Tumour volume >95.7 ml predicts metastatic gastric cancer with 87% sensitivity and 78.5% specificity (P = 0.0001). CT volumetry may be a useful adjunct for staging gastric carcinoma.

Added value of diffusion-weighted MR imaging to T2-weighted and dynamic contrast-enhanced MR imaging in T staging of gastric cancer

OBJECTIVE

To assess the utilization of diffusion-weighted (DW) magnetic resonance (MR) imaging in T staging of gastric cancer prospectively.

METHODS

Fifty-one patients underwent T2-weighted (T2W), contrast-enhanced (CE) and DW MR imaging. Two radiologists independently interpreted the images for T staging of the tumors.

RESULTS

The overall accuracy of T staging in pT1-4 gastric cancers by T2W+CE+DW (88.2%) was significantly higher than that by T2W+CE and T2W+DW (both 76.5%, P=.031).

CONCLUSION

DW adds useful information to T2W and CE MR imaging in T staging of gastric cancer.

Prospective comparison of 3T MRI with diffusion-weighted imaging and MDCT for the preoperative TNM staging of gastric cancer

PURPOSE

To compare the diagnostic performance of 3T magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI) and multidetector-row computed tomography (MDCT) for the preoperative TNM staging of gastric cancer.

MATERIALS AND METHODS

This prospective study was approved by our Institutional Review Board. Forty-nine consecutive patients with histologically confirmed gastric cancers underwent MDCT and 3T MRI followed by surgery. MRI without DWI, MRI with DWI, and MDCT were reviewed to determine preoperative TNM staging. Using the pathologic stages as the reference standard, the diagnostic performance of each imaging modality was compared.

RESULTS

Diagnostic accuracies of MRI with DWI, MRI without DWI, and MDCT did not show a significant difference (≤T2 vs. ≥T3: 85.1%, 78.7%, and 80.9%; ≤T3 vs. T4: 76.6%, 74.5%, and 72.3%; N-negative vs. N-positive: 76.6%, 66.0%, and 63.8%; M0 vs. M1: all 95.9%, respectively) (P > 0.05). For N staging, MRI with DWI demonstrated higher sensitivity but lower specificity (86.7% and 58.8%, respectively) than MRI without DWI (50.0% and 94.1%) or MDCT (43.3% and 100%) (P < 0.05).

CONCLUSION

The diagnostic accuracy of 3T MRI is comparable to that of MDCT for the preoperative TNM staging of gastric cancer, and for assessing LN metastasis, the addition of DWI to conventional MRI may increase the sensitivity.

Gastric carcinoma: imaging diagnosis, staging and assessment of treatment response

Gastric carcinoma (GC) is one of the most common causes of cancer-related death worldwide. Surgical resection is the only cure available and is dependent on the GC stage at presentation, which incorporates depth of tumor invasion, extent of lymph node and distant metastases. Accurate preoperative staging is therefore essential for optimal surgical management with consideration of preoperative and/or postoperative chemotherapy. Multidetector computed tomography (MDCT) with its ability to assess tumor depth, nodal disease and metastases is the preferred technique for staging GC. Endoscopic ultrasonography is more accurate for assessing the depth of wall invasion in early cancer, but is limited in the assessment of advanced local or stenotic cancer and detection of distant metastases. Magnetic resonance imaging (MRI), although useful for staging, is not proven to be effective. Positron emission tomography (PET) is most useful for detecting and characterizing distant metastases. Both MDCT and PET are useful for assessment of treatment response following preoperative chemotherapy and for detection of recurrence after surgical resection. This review article discusses the usefulness of imaging modalities for detecting, staging and assessing treatment response for GC and the potential role of newer applications including CT volumetry, virtual gastroscopy and perfusion CT in the management of GC.