CT findings of tumors and tumor-like conditions of small intestine.

Transcription

1 CT findings of tumors and tumor-like conditions of small intestine. Poster No.: C-1100 Congress: ECR 2012 Type: Educational Exhibit Authors: T. Tsuda, M. Takechi, H. Tanaka, T. Mochizuki; Ehime/ Keywords: Neoplasia, Contrast agent-oral, Computer Applications-3D, CT, Small bowel, Gastrointestinal tract, Abdomen DOI: /ecr2012/C-1100 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 28

2 Learning objectives To demonstrate CT findings of tumors and tumor-like conditions of small intestine in comparion with the endoscopic findings and surgical specimen. It would be better understanding for the diseases of small intestine. Page 2 of 28

3 Background Small intestinal tumors had not been found until the tumors were large enough to show the symtomps because of the difficulties of the examination. Recently, #e had have more opportunities to evaluate small intestinal lesions by MDCT because of the development of endoscopy, such as capsule endoscopy and double-balloon endoscopy. Moreover, routine image viewers equipped with capablity of multi-planar reconstruction (MPR) have allowed us to detect small intestinal lesions incidentally. Page 3 of 28

4 Imaging findings OR Procedure details Intravenous contrast enhanced CT is preffered. Enhancement peak of small intetinal mucosa is reported to be 50 seconds after the intravenous bolus injection of contrast material. The delineation of small intestinal tumor would be better by dynamic contrast enhanced-ct. 3D CT enterography (3D CT-E) is reconsructed. Negative oral contrast material is often administered in US and Western countries. Adequate luminal distension is necessary for CT enterography. However, we do not use negative oral contrast material because of discomfort of intubation. We use high concentration Gastrografin (20~30%) as a positive contrast agent for 3DCTE. High concentration Gastrogrfin induced water from intestinal mucosa and adequate distension of small intestine is attained very easily. Positive contrast agent makes it possible to create very precise VR images of 3D-CTE. Intraveous contrast enhancement is not performed when positive oral contrast material is administered. Patients with the symptom with bowel obstruction is good indication for 3D CT-E. Page 4 of 28

5 Fig. 1: VR image of 3D CT-enterography This is the same case of Case 3. Coronal view is important for the evaluation of small intestine. It is sometimes difficult to tracking the small intestinal loops in axial images alone. Coronal images are very helpful for tracking them. We use image viewer capable of multi-planar reconstruction routinely. We have found small intestinal tumors incidentally since the introduction of the image viewer. Page 5 of 28

6 Fig. 2: Coronal image of patients with malignant lymphoma. Large mass involved both small intestine and colon. Gastrografin was administered orally. Case Presntation I. Epithlial tumors 1. Adenocarcinoma of small inetestine Adenocarcinoma of small intestine is reratively rare. It is hard to detect the tumors by routine endoscopy. Page 6 of 28

7 Most of tumors of small intestine is not found until the patients develop the symptoms, such as bowel obstruction and GI bleeding. Symptomatic tumors are usually advanced cases. Most of the carcinoma of small intestine are found either the proximal jejunum within 60cm of Treitz ligament or terminal ileum within 50cm of Bauhin's valve. CT findings of carcinoma of small intestine is localized wall thickening. Proximal dilatation was frequently accompanied. Lymph node swelling is secondary sign which is easily evaluated by coronal reconstruction. Case 1 Adenocarcinoma 53-year-old woman was referred to a clinic because of nausea and vomiting. She underwent upper and colonic endoscopy. No abnormality was found. She developed the symptom of bowel obstruction and referred to our hospital. Fig. 4: Case 1 Adenocarcinoma A: CT scan shows tumor and dilatation of proximal jejunum of the tumor. B: Double-balloon endoscopic view shows circumferential stenosis. C: Enterography using Gastrografin shows marked stenosis in proximal jejunum at about 50cm from the Treitz ligament. D: The macroscopic view of the resected specimen demonstrates a circumferential ulcerated tumor. Page 7 of 28

8 A: CT scan shows tumor and dilatation of proximal jejunum of the tumor.b: Double-balloon endoscopic view shows circumferential stenosis.c: Enterography using Gastrografin shows marked stenosis in proximal jejunum at about 50cm from the Treitz ligament.d: The macroscopic view of the resected specimen demonstrates a circumferential ulcerated tumor. Case 2 Adenocarcinoma 48-year-old woman was referred to our hospital because of tarry stool and severe anemia. Initial upper endoscopy could not show any abnormal findings. Fig. 5: Case 2. Adenocarcinoma of jejunum A: Double-balloon endoscopy shows circumferential ulcerated tumor. B: Barium follow-through study showed stricture of proximal jejunum which is typical finding of carcinoma of small intestine. C: Contrast enhanced-ct shows wall thickening of the ileum and lymph nodes A: Double-balloon endoscopy shows circumferential ulcerated tumor. Page 8 of 28

9 B: Barium follow-through study showed stricture of proximal jejunum which is typical finding of carcinoma of small intestine. C: Contrast enhanced-ct shows wall thickening of the ileum and lymph nodes Case 3 Adenocarcinoma 82-year-old woman was referred to our hospital because of fecal occult blood and anemia. Initial upper endoscopy and colonoscopy could not show any abnormal findings. Capsule endoscopy detected tumor of small intestine. Fig. 6: Case 3 Adenocarcinoma of jejunum A: Double balloon endoscopy shows ulcerated tumor. B: 3D CT-enterography using Gastrografin shows the ulcerated lesion similar to the endoscopic findings. C: Axial CT scan shows the eccentric wall thickening. D: Macroscopic view of the resected specimen shows ulcerated tumor surrounded by nodular elevation. A:Double balloon endoscopy shows ulcerated tumor. Page 9 of 28

10 B:3D CT-enterography using Gastrografin shows the ulcerated lesion similar to the endoscopic findings. C:Axial CT scan shows the eccentric wall thickening. D:Macroscopic view of the resected specimen shows ulcerated tumor surrounded by nodular elevation. 2. Neuroendocrine tumor (Carcinoid) Carcinoid is defined as low grade neuroendocrine tumor (NET G1) in latest WHO classification. NETs occur predominantly in the small intestine. Most frequent site of small intestine is ileum. NETs are well enhanced in the arterial phase. NETs are frequently well enhanced because of hyper vascular nature. Case 4 Carinoid tumor (NET G1) of duodenum 76-year-old man underwent upper endoscopy because of epigastric discomfort. Polypoid lesion of duodenal bulb was incidentally found. Page 10 of 28

11 Fig. 7: Case 4 Carcinoid of duodenal bulb A: Submucoal tumor of duodenal bulb with central depression was incidentally found. Histological examination of biopsy specimen revealed carcinoid tumor. B: Contrast-enhanced CT of arterial phase shows marked enhancement of the elevated lesion of duodenal bulb. C: Macroscopic view of the resected specimen shows submucosal tumor with central depression in the bulb. Histological examination revealed tumor is well-differentiated NET (G1). A:Submucoal tumor of duodenal bulb with central depression was incidentally found. Histological examination of biopsy specimen revealed carcinoid tumor. B:Contrast-enhanced CT of arterial phase shows marked enhancement of the elevated lesion of duodenal bulb. C: Macroscopic view of the resected specimen showssubmucosal tumor with central depression in the bulb. Histological examination revealed tumor is well-differentiated NET (G1). II. Secondary tumors Recent advances of cancer chemotherapy and imaging technique allows us to detect metastatic tumor of small intestine in the routine work up for the metastasis. Primary site of metastatic tumor of small intestine are reported that lung cancer is most frequent in Japan. Large cell carcinoma of the lung is the most frequent cancer among the lung cancers. Malignant melanoma is the most common secondary tumor of small intestine in US and Western countries. Small intestinal metastases cause non-specific symptoms, such as obstruction, perforation, GI bleeding. Metastatic tumors of small intestine may cause bowel obstruction, bleeding and perforation. Jejunum is the most common site of metastasis. Metastatic tumor shows protruded tumor or submucosal tumor, which is different from adenocarcinoma. Case 5 Metastatic tumor from the large cell carcinoma of lumg 70-year-old man was admitted our hospital because of bowel obstruction. Anemia and fecal occult blood were seen. His chest X-ray image on admission showed round tumor in the upper right lung field. He underwent contrast-enhanced CT which showed that tumor protruded into the lumen of ileum. Both lung tumor and small intestinal tumor were surgically resected. Pathological examination revealed that both tumor had similar findings. Tumor of small intestine was determined as metastatic tumor from the lung cancer. Page 11 of 28

12 Fig. 8: Case 5 Metastatic tumor from the large cell carcinoma of lung A: Double balloon endoscopy shows protruded tumor which is composed of submucosal component and necrotic tissue, which is typical finding of secondary tumor. B: Contrast-enhanced CT showed that well-enhanced tumor protruded into the lumen of ileum. C: Coronal images showed that the density of mesentery increased around the feeding vessels of the tumor, which indicated invasion or inflammation. A:Double balloon endoscopy shows protruded tumor which is composed of submucosal component and necrotic tissue, which is typical finding of secondary tumor. B:Contrast-enhanced CT showed that well-enhanced tumor protruded into the lumen of ileum. C:Coronal images showed that the density of mesentery increased around the feeding vessels of the tumor, which indicated invasion or inflammation. D:Resected specimen shows both protrusion into the lumen and serosal invasion through the muscular layer. Page 12 of 28

13 Case 6 Metastatic tumor from anal malignant melanoma 43-year-old woman treated by anal melanoma five months ago. She developed anemia. Fig. 9: Case 6 Metastatic tumor from anal melanoma A: Endoscopy of stomach showed multiple submucosal tumor with central depression which showed dark color. Histological finding of biopsy specimen revealed metastatic melanoma. B: CT shows large tumor invades jejunal loop which was thought to be metastatic tumor. C: Coronal image of equilibrium phase CT helps the relationship between tumor and jejunal loops. A: Endoscopy of stomach shows multiple submucosal tumors with central depression which show dark color. Histological finding of biopsy specimen revealed metastatic melanoma. B: Axial image of arterial phase CT shows large tumor invased jejunal loop which was thought to be metastatic tumor. C: Coronal image of equilibrium phase CT helps the relationship between tumor and jejunal loops. Page 13 of 28

14 III. Mesenchymal tumors 1. Gastrointestinal stromal tumor (GIST) Gastrointestinal stromal tumors are most common mesenchymal tumor of gastrointestinal tracts. Small intestine and duodenum are second most frequent site of GIST following gastric GISTs. GISTs express c-kit and CD34, which is different from other mesenchymal tumor. Tumor size is important factor of predicting malignancy. Small GISTs of small intestine are not usually found because small tumors do not show any symptoms. GIST showing symtomps, such as abdominal mass, bleeding, bowel obstruction and tumor rupture, tend to be large and malignant GIST. Common metastatic pattern of GISTs of small intestine are peritoneal dissemination and liver metastasis. Growth pattern of GISTs are variable. Eccentric wall thickening or tumor adjacent to the small intestine indicate GIST. GISTs of small intestitine frequently show marked enhancement which may be a sign of malignant tumor. FDG uptake of tumor also indicates malignant tumor. Case 7 GIST of duodenum 71-year-old man was admitted our hospital because of colon cancer. Preoperative CT scan incidentally detected tumor of jujunum. Duodenal tumor was resected at the surgery of colon cancer. Immunohistological examination revealed the tumor was positive for both c-kit and CD34, which indicated the tumor was GIST. Both low mitotic rate and MIB-1 index (3%) indicated the tumor was low risk. Page 14 of 28

15 Fig. 10: Case 7 GIST of duodenum A: Double-balloon endoscopy shows submucosal tumor protrudes into the bowel lumen B: Axial image of arterial phase shows wellenhanced lesion is seen in the duodenal wall. C: Coronal image of arterial phase shows exact location of tumor. A: Double-baloon endoscopy shows submucal tumor protrudes into the bowel loomen B: Axial image of arterial phase shows well-ehhanced lesion is seen in the duodenall wall. C: Coronal image of arterial phase shows exact location of tumor. Case 8 GIST of duodenum 62-year-old woman underwent abdominal CT because of anemia. CT scan shows abdominal tumor in the upper abdomen. The tumor was resected because the tumor size exceeded 9cm which indicated malignant tumor. Immunohistological examination revealed the tumor was positive for both c-kit and CD34, which indicated the tumor was GIST. High mitotic rate and MIB-1 index (7%) indicated the tumor was malignant. Page 15 of 28

16 Fig. 11: Case 8 GIST of duodenum A: Double-baloon endoscopy shows submucal tumor with small ulcer. B: Axial image of arterial phase shows poorly-ehhanced lesion is adjacent to duodenall wall. C: Coronal image of arterial phase shows close relation between tumor and duodenal wall which indicated the tumor origin was duodenal wall. D: Resected specimen shows the tumor had both internal and extrenal component. A: Double-balloon endoscopy shows submucosal tumor with small ulcer. B: Axial image of arterial phase shows poorly-ehhanced lesion is adjacent to duodenal wall. C: Coronal image of arterial phase shows close relation between tumor and duodenal wall which indicated the tumor origin was duodenal wall. D: Resected specimen shows the tumor had both internal and external component. 2. Other mesenchymal tumors Page 16 of 28

17 Case 9 Hemangioma of jejunum 85-year-old man was admitted our hospital because of colon cancer. Preoperative CT scan incidentally detected well-enhanced tumor of jejunum. Hemangioma was suspected by image findings. Follow up CT showed no interval change. Hemangioma of small intestine is rare. Fig. 12: Case 9 Hemangioma of jejunum A: Double-baloon endoscopy shows submucosal tumor which did not show change of color. B: Axial image of portal phase shows marked enhanced tumor within jejunum. C: Coronal image of portal phase shows the exact location of tumor. D: T2-weighted image shows marked high intensity of the tumor which suggest that the hemangioma. A: Double-balloon endoscopy shows submucosal tumor which did not show change of color. B: Axial image of portal phase shows marked enhanced tumor within jejunum. Page 17 of 28

18 C: Coronal image of portal phase shows the exact location of tumor. D: T2-weighted image shows marked high intensity of the tumor which suggest that the hemangioma. Case 10 Lipoma of duodenum 68-year-old man underwent abdominal CT for the screening. He did not have any symptom. CT scan showed multiple lipomatous lesion in the gastric and duodenal wall which indicated lipoma. Gastrointestinal lipoma occurs especially in the colon. Fig. 13: Case 10 Lipoma of duodenum A: Axial image of CT shows diffuse low density of gastric wall which indicates lipomatous chanege. B: Axial image of CT shows focal fat within duodenum, which indicates lipoma. C: Coronal image of CT also shows multiple focal fat within duodenal wall. A: Axial image of CT shows diffuse low density of gastric wall which indicates lipomatous change. Page 18 of 28

19 B: Axial image of CT shows focal fat within duodenum, which indicates lipoma. C: Coronal image of CT also shows multiple focal fat within duodenal wall. Case 11 Inflammatory fibroid polyp of ileum She underwent colonoscopy and submucosal tumor of terminal ileum was pointed out. Biopsy specimen did not determined the diagnosis. She underwent surgery. Macroscopic finding of the tumor is pedunculated tumor. Immunohistological examination revealed the tumor is inflammatory fibroid polyp (IFP). Fig. 14: Case 11 Inflammatory fibroid polyp A: Axial image of arterial phase shows marginal enhancement of the tumor. B: Macroscopic view of the resected specimen shows typical finding of IFP, such as pedunculated lesion or penis-like shape. C: Coronal image of arterial phase shows well-enhanced mucosa delineates the shape of the tumor. A: Axial image of arterial phase shows marginal enhancement of the tumor. Page 19 of 28

20 B: Macroscopic view of the resected specimen shows typical finding of IFP, such as pedunculated lesion or penis-like shape. C: Coronal image of arterial phase shows well-enhanced mucosa delineates the shape of the tumor. IV. Malignant lymphoma Malignant lymphoma (ML) of gastrointestinal tract is common in both primary and systemic ML. Stomach and terminal ileum is frequently involved. Shape and growth pattern of ML are variable. CT findings of small intestinal ML frequently shows circumferential wall thickening, luminal dilatation, lymphadenopathy. Bowel obstruction is not usually seen even though tumor is very large. Ga scintigraphy and PET may help the diagnosis of ML. Case 12 Malignat lymphoma of jejunum 69-year-old man underwent CT because of compression fracture of lumbar spine. Wall thickening of small intestine was pointed out incidentally. He was referred to our hospital. Histological examination of biopsy specimen revealed the diagnosis as the diffuse large B-cell lymphoma (DLBCL). Page 20 of 28

21 Fig. 15: Case 12. Malignant lymphoma of jejunum A: Double-balloon endoscopy shows the ulcerated lesion which margin is relatively smooth. B: Axial image of unenhanced CT shows circular wall thickening and aneurysmal dilatation of bowel lumen. C: Coronal image shows the exact location of tumor and lymphadenopathy adjacent to the lesion. D: Ga-scintigraphy shows the marked uptake of the lesion, which help the diagnosis of ML. A: Double-balloon endoscopy shows the ulcerated lesion which margin is relatively smooth. B: Axial image of unenhanced CT shows circular wall thickening and aneurysmal dilatation of bowel lumen. C: Coronal image shows the exact location of tumor and lymphadenopathy adjacent to the lesion. D: Ga-scintigraphy shows the marked uptake of the lesion, which help the diagnosis of ML. Page 21 of 28

22 Case 13 Malignant lymphoma of ileum 67-year-old man complained intermittent abdominal pain. Gastric endoscopy and colonoscopy did not show any abnormal finding. He underwent abdominal CT because he developed the symptom of bowel obstruction. Localized wall thickening of ileum was pointed out and referred to our hospital. Colonoscopy at our hospital detected SMT-like lesion. Biopsy specimen of colonic lesion resulted in follicular lymphoma. He underwent resection of both colon tumor and ileal tumor because of bowel stenosis. Fig. 16: Case 13 Malignant lymphoma of ileum A: Axial CT scan using oral positive contrast material shows localized wall thickening and narrowing. Lymphadenopathy adjacent the lesion is seen. B: Coronal image also shows localized wall thickening and stenosis. C: 3D-CT enterography indicated stenosis and loss of Kerckring fold. D: Resected specimen shows ulcerated tumor and thickened fold. A: Axial CT scan using oral positive contrast material shows localized wall thickening and narrowing.lymphadenopathy adjacent the lesion is seen. B: Coronal image also shows localized wall thickening and stenosis. Page 22 of 28

23 C: 3D-CT enterography indicated stenosis and loss of Kerckring fold. D: Resected specimen shows ulcerated tumor and thickened fold. V. Miscellaneous Conditions We have encountered miscellaneous condition of small intestine which mimic the tumor of small intestine. Case 14 Aberrant Pancreas 43-year-old woman underwent contrast enhanced CT for the other reason. Wellenhanced tumor was detected in the arterial phase. Enhancement pattern of the tumor was similar to the normal pancreas and duct-like structure was observed. Aberrant pancreas was suspected. Follow up study showed no interval change. Fig. 3: Case 14 Aberrant pancreas of jejunum A: Axial image of arterial phase shows well-enhanced tumor adjacent to the jejunal loop. B: Sagittal image shows both normal pancreas and suspected aberrant pancreas. Similar enhancement is Page 23 of 28

24 observed. Suspected tumor has duct-like structure within tumor, which indicates aberrant pancreas. A: Axial image of arterial phase shows well-enhanced tumor adjacent to the jejunal loop. B: Sagittal image shows both normal pancreas and suspected aberrant pancreas. Similar enhancement is observed. Suspected tumor has duct-like structure within tumor, which indicates aberrant pancreas. Case 15 Small Bowel obstrction due to Bezoar 70-year-old man complained nausea and vomiting. CT scan shows small bowel obstruction. Ovoid mass including small air bubble caused bowel obstruction. He underwent gasterectomy decades ago. Small bowel obstruction due to bezoar was suspected. Ileus did not subsided and bezoar was surgically removed. The analysis of bezoar revealed tannin shibuol from persimmons. Page 24 of 28

25 Fig. 17: Case 15 Small bowel obstruction due to bezoar A: Coronal image shows ovoid mass including air bubble at the transitional point of the bowel obstruction. B: Coronal image using Gastrografin several days after the initial CT shows impaction of tumor continue. C: Finally ovoid mass was surgically removed. D: Cut surface of bezoar shows dark brownish color. Analysis of bezoar reveals 98% was tannin shibuol. A: Coronal image shows ovoid mass including air bubble at the transitional point of the bowel obstruction. B: Coronal image using Gastrografin several days after the initial CT shows impaction of tumor continue. C: Finally ovoid mass was surgically removed. D: Cut surface of bezoar shows dark brownish color. Analysis of bezoar reveals 98% was tannin shibuol. Page 25 of 28

26 Conclusion Syptomatic tumors of small intestine usually detected by CT. Coronal images and 3D-CT enterography are useful for the detection and characterization of the tumor. Asymptomatic tumors may be also depicted by current MDCT technique and image viewer. The knowledge of these tumor would be helpful for making correct diagnosis. Page 26 of 28

27 Personal Information Page 27 of 28

28 References 1. Theise ND, M.P. C, S. F, P. H, al. e. Who Classification of Tumours of the Digestive System. 2010: Sebastian T, et al. Multi-Detector Row CT of the Small Bowel: Peak Enhancement Temporal Window-Initial Experience. Radiology 2007; 243: Pilleul F, et al. Possible Small-Bowel Neoplasms: Contrast-enhanced and Water-enhanced Multidetector CT Enteroclysis. Radiology 2006;241: Hong SS, S et al. MDCT of Small-Bowel Disease: Value of 3D Imaging. AJR 2006;187: Borthne AS, et al. Bowel MR imaging with oral Gastrografin: an experimental study with healthy volunteers. Eur Radiol 2003;13: Romono S, et al. Multidetector computed tomography enteroclysis (MDCTE) with neutral and IV contrast enhancement in tumor detection. Eur Radiol 2005;15: Paulsen SR, et al. CT Enterography as a Diagnostic Tool in Evaluating Small Bowel Disorders: Review of Clinical Experience with over 700 Cases. Radiographics 2006; Levy AD, et al.duodenal Carcinoids: Imaging Features with ClinicalPathologic Comparison. Radiology 2005;237: Levy AD, et al. From the Archives of the AFIP: Gastrointestinal Stromal Tumors: Radiologic Features with Pathologic Correlation. Radiographics 2003;23: Kim HC, at al. Gastrointestinal Stromal Tumors of the Stomach: CT Findings and Prediction of Malignancy. 2004;183: Sandrasegaran KS, et al. Case Report: Heterotopic Pancreas: Presentation as Jejunal Tumor. AJR 2006; 187:W Delabrousse E, et al. Small-Bowel Bezoar Versus Small-Bowel Feces: CT Evaluation. AJR 2008;191: Page 28 of 28