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Gastrointestinal ❯ Staging of Gastric Adenocarcinoma

CT Protocol for Staging of Gastric Adenocarcinoma

ProblemStaging of gastric adenocarcinoma. CT findings suggestive of gastric cancer are asymmetric enhancement, diffuse or localized thickening of the gastric wall, a protruding ulcerous or polypoid mass, and lack of distensibility of the viscera (eg, linitis plastica)
Protocol"The currently recommended multiphasic approach includes the unenhanced CT phase, the late arterial phase (40 seconds after the injection of intravenous contrast media), the portal venous phase (70 seconds after), and the delayed phase (180 seconds after). An unenhanced CT phase of the upper abdomen is usually recommended to assess the degree of stomach distention before contrast media administration. During the late arterial phase, the entire gastric volume should be covered, and in the portal venous phase, the thorax and abdomen-pelvis should be covered to detect nodal and distant metastases. The late arterial phase currently is considered the most important phase to evaluate the clinical T stage in EGC, in both diffuse and intestinal histotypes The delayed phase could be acquired because of the peak enhancement of undifferentiated tumors occurring at this phaseand to have extra details in the deep mural invasion." suspicion of gastric tumor or GI bleed the study is done with dual phase acquisition. (arterial and venous)
The potential of CT in clinical staging is strictly linked to an appropriate CT protocol, which consists of the three fundamentals: fasting for at least 6 hours, gastric lumen distention, and a multiphasic contrast-enhanced approach . Gastric lumen distention can be achieved through the oral administration of 800-1000 mL of water immediately before the scan or 4-7 g of effervescent tablets within 80-100 mL of water 3 minutes prior to the scan. Imaging is performed in a supine position before and after administration of intravenous contrast media. The thorax and abdomen-pelvis should be covered. There are no consensus guidelines regarding the amount of contrast media or rate of injection.
Pearls1. This recommendation is based on a recent article in RadioGraphics for staging of gastric cancer.
Staging of Gastric Cancer: CT Patterns and Correlation with Pathologic Findings
Francesca Di Gregorio et al.
RadioGraphics 2025; 45(8):e240186. The statements are from the article.
2. "Gastric cancer is one of the most common cancers worldwide-fifth in incidence in 2020-with a high mortality rate. The numbers are escalating because of increases in both risk factors and the population's average age. In general, the incidence of gastric cancer is rising, even in young patients 40 years of age or older (6.2% in the United States), because of elements of the modern lifestyle and hereditary diffuse gastric cancer syndrome. The incidence is twice as high in men than in women, and the highest number of cases are in Eastern Asia, Eastern Europe, and Andean Latin America."
3. "The gastric wall distention before examination is essential to smooth out the normal folds and to detect any abnormal wall thickening. Usually, the rugal fold is more prominent in the greater curvature and the fundus. The submucosa appears as a hypoattenuation line, with varying thickness, covered by the outer layer, which has a slighter lower attenuation than the mucosa.
The thickness usually is about 5 mm but it is site-specific. The antrum generally exceeds 5 mm and, depending on the grade of distention, up to 10 mm."
4. "Distinguishing T3 from T4a at CT may be difficult, considering the serosa is not visible on CT images and the amount of subserosal adipose tissue is different from one person to another. The nodular or irregular appearance of the outer surface, haziness of the perigastric fat, and the hyperattenuating serosa sign, typical of serosal invasion, are findings that differentiate T3 from T4a gastric cancer. Furthermore, hyperattenuating serosa sign may be considered an independent predicting factor in identifying T4a gastric cancer with a good positive predictive value. The invasion of adjacent organs from gastric cancer (T4b) may be evident as a direct extension into an adjacent organ or as anobliteration of the interspersed adipose tissue, between the gastric mass and adjacent organs. Direct invasion by contiguity most frequently involves the liver, gallbladder, biliarytract, spleen, pancreas, and colon."
5. Currently, CT is the first option in the evaluation of peritoneal implants because of its availability and robustness; however, sensitivity and specificity are not excellent (66% and 77%, respectively) and are mainly related to the region of the abdomen and the diameter of the lesions. CT findings suggesting peritoneal metastasis include ascites, soft-tissue nodules or plaques on the peritoneal surface, small bowel wall thickening and nodularity, intra-abdominal fat stranding, and peritoneal thickening and/or hyperenhancement . The presence of ascites on CT images could be indicative of peritoneal involvement, but minimal ascites (<50 mL) without other findings are rarely associated with peritoneal metastasis."
6. "CT findings suggestive of gastric cancer are asymmetric enhancement, diffuse or localized thickening of the gastric wall, a protruding ulcerous or polypoid mass, and lack of distensibility of the viscera (eg, linitis plastica)."

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