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EDUCATION EXHIBITS 1915

Hypervascular Subepi-
thelial Gastrointestinal
Masses: CT-Pathologic
Correlation1
Nam Kyung Lee, MD • Suk Kim, MD • Gwang Ha Kim, MD • Tae Yong
ONLINE-ONLY
CME Jeon, MD • Dae Hwan Kim, MD • Ho Jin Jang, MD • Do Youn Park, MD
See www.rsna
.org/education Although the vast majority of gastrointestinal (GI) masses are epi-
/rg_cme.html thelial neoplasms, a variety of subepithelial masses are infrequently
encountered during endoscopic or radiologic examination. A subepi-
LEARNING thelial mass, which was previously called a submucosal mass, is de-
OBJECTIVES fined as a mass covered with normal-appearing mucosa, whether the
After reading this underlying process is intramural or extramural in origin. At contrast
article and taking
the test, the reader material–enhanced computed tomography (CT), hypervascular sub-
will be able to: epithelial masses are usually detected more easily than isoattenuating
■■Describe the vari-
ous types of hyper-
or hypovascular masses. Entities that appear as intramural hypervas-
vascular subepitheli- cular subepithelial lesions include neuroendocrine tumors, GI stromal
al masses that occur
in the GI tract.
tumor, glomus tumor, hemangioma, angiosarcoma, Kaposi sarcoma,
■■List the CT fea- nerve sheath tumors, hypervascular metastases, heterotopic tissues,
tures of intramural and vascular structures. Entities that appear as extramural hypervas-
hypervascular sub-
epithelial masses in cular subepithelial lesions include Castleman disease, solitary fibrous
the GI tract. tumor, inflammatory myofibroblastic tumor, and actinomycosis. Some
■■Discuss potential rare gastric cancers resemble subepithelial tumors. In comparison
pitfalls in CT diag-
nosis of intramural with endoscopic ultrasonography, CT is of limited value in differen-
hypervascular sub- tiating the layers of the GI wall and determining the origin of mass
epithelial masses in
the GI tract. lesions. However, recent advances in multidetector CT with multi-
planar reformation allow one to determine whether a GI mass is of
epithelial, intramural subepithelial, or extramural subepithelial origin.
TEACHING
POINTS Furthermore, the full extent of tumors can be delineated, and local
See last page invasion and distant metastases can be identified. Familiarity with the
characteristic CT appearances of hypervascular subepithelial masses
of the GI tract will help radiologists make a more confident diagnosis.
©
RSNA, 2010 • radiographics.rsna.org

Abbreviations: AIDS = acquired immunodeficiency syndrome, GI = gastrointestinal, GIST = GI stromal tumor, SFT = solitary fibrous tumor

RadioGraphics 2010; 30:1915–1934 • Published online 10.1148/rg.307105028 • Content Codes:

1
From the Departments of Radiology (N.K.L., S.K.), Internal Medicine (G.H.K.), Surgery (T.Y.J., D.H.K.), and Pathology (D.Y.P.), Pusan National
University Hospital, Pusan National University School of Medicine and Medical Research Institute, Pusan National University, 1-10 Ami-Dong,
Seo-Gu, Busan 602-739, Republic of Korea; and Department of Obstetrics and Gynecology, Armed Forces Seoul Hospital, Seoul, Republic of
Korea (H.J.J.). Recipient of a Cum Laude award for an education exhibit at the 2009 RSNA Annual Meeting. Received February 22, 2010; revision
requested April 28 and received May 26; accepted June 2. Supported by a grant from the National R&D Program for Cancer Control, Ministry for
Health, Welfare and Family Affairs, Republic of Korea, and a 2010 Pusan National University Research Grant. For this CME activity, the authors,
editors, and reviewers have no relevant relationships to disclose. Address correspondence to S.K. (e-mail: kimsuk@medimail.co.kr).
©
RSNA, 2010
1916 November-December 2010 radiographics.rsna.org

Introduction masses. Identification of prominent feeding blood

A subepithelial mass, which was previously called vessels adjacent to tumor foci may help improve
a submucosal mass, is defined as a mass covered the detection of small hypervascular subepithelial
with normal-appearing mucosa. The term sub- masses (Fig 2) (4).
epithelial has come to be favored over submucosal Definitive diagnosis of hypervascular subepi-
because lesions in this category do not necessar- thelial masses requires histologic examinations
ily arise from the submucosa, but can also arise and, more important, immunohistochemical
from any layer of the gastrointestinal (GI) wall studies. C-kit protein (CD117) is highly sensitive
other than the submucosa (intramural) or from and specific for GISTs. Approximately 95% of
extrinsic compression of the wall by a number of GISTs are c-kit positive. Platelet-derived growth
normal or abnormal intraabdominal structures factor receptor–α is a helpful marker for diag-
(extramural) (1,2). Most subepithelial masses nosing c-kit–negative GISTs and distinguishing
are incidentally discovered during endoscopy, them from other mesenchymal tumors. Positive
radiologic examinations, or laparotomy. However, staining for one or more neuroendocrine mark-
lesions that are large or ulcerated may cause ab- ers, such as chromogranin A or synaptophysin,
dominal pain, GI bleeding, or obstructive symp- is needed to diagnose neuroendocrine tumors.
toms (1–3). Positive staining for S100 and glial fibrillary
Endoscopy is the initial diagnostic modal- acidic protein suggests schwannomas, while the
ity for detection and evaluation of subepithelial presence of smooth muscle actin and vimentin
masses. However, endoscopy alone does not suggests glomus tumors (1).
allow accurate differentiation between intramural In this article, we review ways to distinguish
and extramural lesions. Therefore, further exami- intramural subepithelial masses from extramu-
nations are required when subepithelial lesions ral subepithelial masses in the GI tract. We also
are suspected during endoscopy. Endoscopic present the CT features of a variety of intramural
ultrasonography (US) permits determination of hypervascular subepithelial masses or mass-
the layer of tumor origin and differentiation of like lesions, including neuroendocrine tumors,
intramural lesions from extramural compression mesenchymal tumors, hypervascular metastases,
and is considered the best method for making a and heterotopic tissues. Finally, the CT features
diagnosis or for differential diagnosis of subepi- of extramural subepithelial masses or masslike
thelial masses (Fig 1). lesions are briefly described.
Computed tomography (CT) and magnetic
resonance imaging are of limited value due to Determination of Mass
their inability to allow differentiation of GI wall Origin in the GI Wall with CT
layers (Fig 1). More recently, however, multide- At contrast-enhanced CT, the normal GI wall
tector CT is being commonly used to evaluate demonstrates layered enhancement: an inner mu-
patients with nonspecific abdominal symptoms or cosal layer with marked enhancement, a middle
those suspected of having an intraabdominal tu- submucosal layer with lower attenuation, and
mor. CT can be helpful in characterizing a tumor an outer muscular-serosal layer with moderate
by using contrast enhancement, in determining enhancement. This layered appearance is more
the site of origin of a mass lesion, in delineating commonly seen during the arterial phase. The
the full extent of a tumor, and in detecting local normal GI wall may also have only a single- or
invasion and distant metastases (1–3). two-layered appearance. The variability in the lay-
Subepithelial masses or masslike lesions have ered appearance of the normal GI wall has been
varying degrees of enhancement. A hypervascular attributed to the rate of contrast material injec-
subepithelial mass demonstrates enhancement tion or to different degrees of distention (5).
to a degree equal to or greater than that of the CT may be helpful in distinguishing between
surrounding mucosa of the GI wall during the epithelial and subepithelial masses. The CT ap-
early phase of dynamic contrast-enhanced CT pearance of epithelial masses, such as adenocar-
(the arterial and portal venous phases). A hy- cinoma of the GI tract, includes focal, eccentric,
pervascular mass is usually detected more easily and asymmetric wall thickening with overlying
at CT than are isoattenuating or hypovascular mucosal destruction or irregularity as well as
hypo-, hyper-, or mixed enhancement compared
with that of the adjacent normal GI wall. In con-
trast, intramural subepithelial masses appear at
RG • Volume 30 Number 7 Lee et al 1917

Figure 2. GI stromal tumor (GIST) of the

Figure 1. Well-differentiated neuroendocrine jejunum in a 53-year-old woman with acute
carcinoma of the duodenum with a metastatic GI bleeding. (a) Contrast-enhanced CT im-
lymph node in the hepatoduodenal ligament in age obtained during the late arterial phase
a 51-year-old woman. (a) Contrast-enhanced shows prominent feeding arteries and drain-
CT image shows a 3-cm, well-defined hypervas- ing veins (arrows) above the mass. (b) Con-
cular mass (arrows) with central necrosis on the trast-enhanced CT image obtained during
medial side of the duodenum. (b) Endoscopic the late arterial phase slightly caudal to a
US image shows the hypoechoic mass with cen- shows a well-defined, exophytic, hypervascular
tral anechoic cystic change (*), an appearance subepithelial mass (arrowheads) in the jejunum.
similar to that in a. Pathologic analysis revealed (c) Image from digital subtraction angiog-
a metastatic lymph node. (c) Endoscopic US raphy shows that the hypervascular mass
image shows another lesion, which appears as (arrows) is fed by branches of the superior
a 1-cm, well-defined hypoechoic subepithelial mesenteric artery (arrowhead).
mass (*) arising from the second layer of the
duodenum; this mass could not be detected at
CT. Pathologic analysis revealed a well-differen-
tiated neuroendocrine tumor.
1918 November-December 2010 radiographics.rsna.org

Figure 3. Growth patterns of intramural

subepithelial masses. Intramural subepithelial
masses tend to grow in an intraluminal (A), ex-
traluminal (B), or mixed (dumbbell-shaped) (C)
pattern.

CT as well-defined smooth-surface masses with

intraluminal or extraluminal growth; the overly-
Figure 4. Well-differentiated neuroendocrine tumor
ing mucosal layer is generally intact, with the
of the small bowel in a 66-year-old man. Coronal
exception of the focal ulcerated area. reformatted contrast-enhanced CT image shows an
Therefore, the identification of mucosal 8-mm intraluminal enhancing mass (arrow) in the ter-
changes such as mucosal ulceration, thickening, minal ileum.
and irregularity at CT may be important in dif-
ferentiating epithelial masses from subepithelial
masses. However, in some cases of intraluminal the mass causes bulging or displacement of the GI
lesions detected at CT, it may be difficult to wall into the lumen with a crescent shape due to
distinguish between subepithelial and epithelial the mass effect, but the contact surface is usually
lesions; in those cases, further investigation with smooth due to preservation of the normal GI wall.
endoscopic US is required (6). Preservation of the fat plane between a mass and
Intramural subepithelial masses tend to the displaced GI wall may be a clue to the extra-
grow in an intraluminal, extraluminal, or mixed mural origin of the mass. In contrast, when an
(dumbbell-shaped) pattern (Fig 3). The intra- intramural mass appears embedded in the GI wall,
luminal growth pattern occurs when a tumor is the contact surface may become irregular and the
completely confined to the bowel lumen without mass deforms the edge of the involved GI wall into
bulging into the extraluminal space. The extralu- a “beak” shape. In such cases, two-dimensional
minal growth pattern occurs when a mass is con- and three-dimensional multiplanar reformation
fined to the extraluminal space without bulging images provide en face and profile views of the GI
into the bowel lumen. A mixed growth pattern wall; such images can be helpful in determining
is seen when a tumor combines features of both the origin of the mass (6).
intraluminal and extraluminal growth (7).
If an intramural subepithelial mass grows CT Technique
larger, it may be difficult to determine the site of Adequate luminal distention and proper admin-
origin because of exophytic growth. When a large istration of intravenous contrast material are
extramural mass compresses the adjacent GI wall, important in CT evaluation of the GI tract (Fig
4). We prefer to use water as an oral contrast
agent because it allows better visualization of
RG • Volume 30 Number 7 Lee et al 1919

the normal GI wall and the detection of subtle gastric and rectal disease has increased due to
disease. Water (500 mL) is given approximately increased endoscopic surveillance (9,10).
15 minutes before CT, and an additional 500 mL Some neuroendocrine tumors release vasoac-
is given immediately before the study. Water as an tive amines, and the liver effectively metabolizes
oral neutral agent provides excellent distention in and inactivates these substances. Carcinoid syn-
the upper GI tract. drome occurs in less than 10% of patients with
However, water is rapidly resorbed within the small bowel neuroendocrine tumors and occurs
GI mucosa, leading to insufficient distention in almost exclusively in the presence of a liver me-
the distal parts of the small bowel. Dilute 0.1% tastasis. Classic carcinoid syndrome (eg, cutane-
barium sulfate (Volumen; E-Z-Em, Lake Success, ous flushing and diarrhea) does not generally oc-
NY) or polyethylene glycol electrolyte solution cur in the absence of hepatic metastases, because
is an available neutral agent that can distend vasoactive substances released by the hepatic
the small bowel better than water (8). Nonionic metastasis enter the systemic circulation directly,
intravenous contrast material is administered thus avoiding hepatic inactivation (9–12).
simultaneously and enhances the GI walls. Dy- According to the most recent classification
namic contrast-enhanced imaging, including the of the World Health Organization, neuroendo-
late arterial and portal venous phases, is usually crine neoplasms are classified into three gen-
performed. eral categories based on histologic features and
In many patients, conventional CT is limited malignant potential: well-differentiated neuroen-
by poor distention of the small and large bowels. docrine tumors (typical carcinoid tumors), which
Therefore, CT enteroclysis has been introduced are low-grade malignancies; well-differentiated
to overcome the disadvantages of both CT and neuroendocrine carcinomas (atypical carcinoid
conventional enteroclysis in evaluation of the tumors), which are more aggressive because of
small bowel. CT enteroclysis is performed after the presence of metastases; and poorly differenti-
placement of a nasojejunal tube in conjunction ated neuroendocrine carcinomas, which are high-
with large volumes of ingested neutral enteric grade malignancies with a poor prognosis (9,11).
contrast material. This technique permits vi- At endoscopy, neuroendocrine tumors usu-
sualization of the small bowel wall and lumen, ally appear as subepithelial lesions that resemble
improving the depiction and characterization of other more common subepithelial tumors, be-
small bowel diseases. Neutral agents (water) or cause neuroendocrine tumors usually arise from
negative agents (air) administered via a rectal enteroendocrine cells, which are usually located
tube can provide excellent contrast for colonic relatively deep in the mucosal layer of the GI
imaging; however, CT enteroclysis and the rectal wall (Fig 5). The diagnosis is based on results of
administration of water or air are not performed histologic analysis with immunohistochemical
routinely at our institution. staining. However, the histologic features may
not allow prediction of the tendency for aggres-
Neuroendocrine Tumors sive behavior. The presence of metastasis or local
Enteroendocrine cells (enterochromaffin cells) spread to adjacent organs establishes the malig-
are located throughout the GI tract, pancreatico- nant nature of the tumor. The risk of metastasis is
biliary tract, and lung. The most common loca- related to tumor size. The main sites of metastasis
tion for neuroendocrine tumors in the GI tract are the lymph nodes, liver, peritoneum, lung,
is the appendix, followed by the small bowel, and, less frequently, bone (9–12).
rectum, colon, and stomach. Recently, the preva-
lence of appendiceal neuroendocrine tumors
has decreased, while the apparent prevalence of
1920 November-December 2010 radiographics.rsna.org

Figure 5. Well-differentiated neuroendocrine tumor of the

stomach in a 69-year-old woman. (a) Contrast-enhanced
CT image obtained during the late arterial phase shows a
1.2-cm hypervascular intramural mass (arrow) in the lesser
curvature of the gastric body. However, the intact mucosa
overlying the mass is not well depicted. (b) Contrast-
enhanced CT image obtained during the portal venous
phase shows less prominent enhancement of the mass (ar-
row) than in a. (c) Endoscopic image shows the subepi-
thelial lesion (*) with intact mucosa in the stomach.

CT is the modality used most commonly to

identify and localize primary neuroendocrine
tumors and to predict the tendency for aggres-
sive behavior by demonstrating local invasion and
distant metastases not apparent at histologic ex- tric neuroendocrine carcinoma may appear as a
amination. However, CT is not very sensitive for large ulceroinfiltrative mass that mimics advanced
detection of a primary tumor, particularly small gastric carcinoma (Fig 6).
neuroendocrine tumors smaller than 1 cm (Fig Small bowel neuroendocrine tumors behave
1). CT findings of neuroendocrine tumors in the aggressively and may undergo transmural exten-
GI tract vary with size and location. GI neuroen- sion and metastasize to mesenteric lymph nodes
docrine tumors are generally more prominent in (Figs 7, 8). Mesenteric metastases enlarge and
the arterial phase and consequently less promi- form a mesenteric mass that often exceeds the
nent in the portal venous and equilibrium phases, primary mass in size and is accompanied by
as most are hypervascular tumors (Fig 5) (9–12). fibrosis and desmoplasia, producing the so-called
Most gastric neuroendocrine tumors manifest sunburst appearance at CT (Fig 7). Up to 70%
as one or more small intraluminal subepithelial of mesenteric masses contain calcifications.
masses with avid enhancement in the early phase Asymmetric or concentric mural thickening may
of dynamic contrast-enhanced CT (Fig 5). Gas- also be seen secondary to an infiltrating tumor
and bowel ischemia (Fig 7). Because 30% of
small bowel neuroendocrine tumors are mul-
ticentric, the entire bowel should be examined
carefully for other tumors (Fig 8). CT enteroclysis
RG • Volume 30 Number 7 Lee et al 1921

Figure 6. Poorly differentiated neuroendocrine

carcinoma of the stomach with liver metastases in a
52-year-old woman. Contrast-enhanced CT image
obtained during the late arterial phase shows an infil-
trative mass with heterogeneous enhancement (black
arrows) in the lesser curvature of the gastric body, find-
ings that mimic those of advanced gastric carcinoma.
Note the multiple liver metastases with peripheral rim
enhancement (arrowheads) and the metastatic lymph-
adenopathy (white arrow) in the left gastric area.

Figure 8. Well-differentiated neuroendocrine carci-

noma of the duodenum and jejunum with multiple he-
patic metastases in a 60-year-old woman. (a) Contrast-
enhanced CT image obtained during the late arterial
phase shows multiple enhancing liver masses with cys-
tic change (*) and a hypervascular intraluminal mass
(arrow) in the duodenum. (b) Contrast-enhanced CT
image obtained during the late arterial phase slightly
caudal to a shows an additional hypervascular intralu-
minal mass in the proximal jejunum (arrows). Note the
hypervascular hepatic metastasis (*).

Figure 7. Well-differentiated neuroendocrine tumor

of the small bowel in a 66-year-old man. Coronal re-
formatted contrast-enhanced CT image shows a spicu-
lated mesenteric mass (arrow) with a small amount
of calcification. Note the concentric mural thickening
with suboptimal enhancement (arrowheads) of the ad-
jacent small bowel loop, a finding due to proved isch-
emia. (Courtesy of J. Y. Oh, MD, Dong-A University
Hospital, Busan, Korea.)
1922 November-December 2010 radiographics.rsna.org

may provide very good small bowel distention,

which improves the detection rate of even small
neuroendocrine tumors in the small bowel.
Most neuroendocrine tumors of the appendix
and rectum are asymptomatic and are discovered
incidentally. CT does not frequently depict the
primary tumor at these locations or may show
focal asymmetric wall thickening or small intra-
mural lesions (Fig 9) (9–12).

Mesenchymal Tumors

Gastrointestinal Stromal Tumor

GISTs are thought to originate from interstitial
cells of Cajal, which are pacemaker cells for gut
movement. GISTs usually arise from the muscu-
laris propria in the GI wall because the density of
Figure 9. Well-differentiated neuroendocrine
interstitial cells of Cajal is greatest in the muscu- tumor of the rectum in a 54-year-old man. Con-
laris propria, particularly around the myenteric trast-enhanced CT image shows a 1.7-cm, well-
plexus (13). GISTs arise most commonly from defined hypervascular intraluminal mass (arrow)
the stomach (60%–70% of cases) and small bowel in the rectum.
(30%) and rarely from the rectum, esophagus,
colon, and appendix. Occasionally, GISTs origi-
nate outside the GI tract, such as in the mesen- When a hypervascular intramural subepithelial
tery or omentum. mass larger than 3 cm is encountered at contrast-
Primary GISTs are usually solitary rather than enhanced CT, GIST should be considered first in
multiple (14–16). All GISTs are considered po- the differential diagnosis. GIST is the most com-
tentially malignant. When GISTs have recurred, mon subepithelial tumor involving the GI tract,
metastasized, or invaded adjacent organs, they and other intramural subepithelial masses such
are malignant GISTs. Recently, staging criteria as carcinoid tumor, glomus tumor, or ectopic
for GISTs are based on tumor size, dissemination pancreas usually manifest as intraluminal masses,
status, and mitotic rate (16). smaller than 3 cm, with stronger enhancement
Typically, GISTs grow as well-defined, endo- than GIST. However, the CT features of GISTs
or exophytic intramural subepithelial masses. CT smaller than 3 cm overlap with those of other
is more useful than endoscopy for investigating intramural subepithelial masses.
tumor size and local extension because it allows Malignant GISTs commonly metastasize to
assessment of intraluminal and extraluminal tu- the liver or peritoneum, whereas metastases to
mor components. The CT features of GISTs vary the lymph nodes and extraabdominal metastases
greatly depending on the size and aggressiveness are rare. The CT features of metastatic lesions
of the tumor. from GISTs are similar to those of the primary
Small tumors less than 3 cm in diameter tumor. A metastatic mass is likely to be hetero-
are less aggressive and typically appear as well- geneous with central necrosis and a peripherally
defined, homogeneous, soft-tissue attenuation enhancing portion (Fig 12) (13–15).
masses with variable degrees of enhancement
(Figs 2, 10, 11). Large tumors tend to have ir- Vascular Tumors
regular lobulated margins, mucosal ulceration,
central necrosis, cavitation, and heterogeneous Glomus Tumor.—Glomus tumors are rare, be-
enhancement (Fig 12). These CT features are nign, vascular tumors that originate from glomus
considered to denote aggressiveness. Tumor ves- bodies. The glomus body is a unique arteriove-
sels can often be seen in the tumors. Calcification nous shunt, which is believed to regulate temper-
is an unusual feature of GISTs (13–15). ature. Glomus bodies are most abundant in the
soft tissue of the extremities. Although glomus tu-
mors are usually found in this region, particularly
RG • Volume 30 Number 7 Lee et al 1923

Figure 10. GIST of the stomach in a 44-year-old man. (a) Coronal reformatted contrast-
enhanced CT image shows a 1.8-cm, well-defined hypervascular intraluminal mass (arrow) with
central ulceration in the lesser curvature of the gastric body. However, the intact mucosa overlying
the mass is not well depicted. (b) Endoscopic US image shows the 1.8-cm, well-defined, homoge-
neous hypoechoic subepithelial mass (*) with central ulceration arising from the second and third
layers of the stomach.

Figure 12. Malignant GIST of the stomach with a

liver metastasis in a 59-year-old man. Coronal refor-
matted contrast-enhanced CT image shows a large,
Figure 11. GIST of the jejunum with intussuscep- lobulated, exophytic mass (arrows) with heterogeneous
tion in a 62-year-old woman. Coronal reformatted enhancement and central necrosis in the greater cur-
contrast-enhanced CT image shows a jejunojejunal vature of the gastric body. Note the liver metastasis
intussusception secondary to a 1.5-cm, well-defined, (arrowhead) with central necrosis and a peripherally
homogeneously enhancing, polypoid mass (arrow) in enhancing portion.
the jejunum.

a solitary, intraluminal, intramural subepithelial

beneath the fingernails, they have been described mass in the stomach, particularly the antrum, and
in virtually every organ system (17–19). are usually smaller than 3 cm in diameter. Non-
In the GI tract, glomus tumors occur almost enhanced CT reveals a well-defined subepithelial
exclusively in the stomach. Gastric glomus mass with homogeneous attenuation located in
tumors are rare and constitute about 2% of all
benign gastric tumors. Typically, they appear as
1924 November-December 2010 radiographics.rsna.org

Figure 13. Glomus tumor of the stomach in a 56-year-old woman. (a) Contrast-enhanced CT image
obtained during the late arterial phase shows a 2.5-cm, well-defined, intra- and extraluminal subepithe-
lial mass (arrow) with homogeneous strong enhancement in the gastric antrum. Note the liver hemangi-
oma (*). (b) Contrast-enhanced CT image obtained during the hepatic venous phase shows prolonged
enhancement of the mass (arrow). * = liver hemangioma.

the antrum. Mucosal ulceration and tiny flecks of

calcification within the mass can be detected.
At dynamic contrast-enhanced CT, the tu-
mor demonstrates strong peripheral nodular or
homogeneous enhancement in the arterial and
portal phases and prolonged enhancement in
the delayed phase (Fig 13). Prominent vascular
channels may explain the strong enhancement of
this tumor at contrast-enhanced CT. The en-
hancement pattern is similar to that of the portal
vein, inferior vena cava, or even the descending
aorta and indicates that the lesion is composed of
vascular tissue.
In the stomach, glomus tumors are often
confused with other hypervascular subepithe-
lial masses or masslike lesions, such as GISTs,
neuroendocrine tumors, or ectopic pancreas, at
Figure 14. Hemangioma of the rectum in a
endoscopy, endoscopic US, and CT. However,
38-year-old woman. Contrast-enhanced CT im-
the characteristic enhancement pattern and loca- age shows homogeneously enhanced transmural
tion can be useful for distinguishing glomus tu- bowel wall thickening containing phleboliths
mors from other intramural subepithelial tumors (arrow) along with phleboliths in the perirectal
(18,19). space (arrowheads). (Courtesy of J. H. Cho,
MD, Dong-A University Hospital, Busan,
Hemangioma.—GI hemangiomas are unusual Korea.)
vascular tumors that may occur anywhere in the
GI tract and may be single or multiple. They are
commonly associated with a cutaneous he- syndromes such as Maffucci syndrome, Klippel-
mangioma. Multiple lesions are associated with Trénaunay syndrome, or blue rubber-bleb nevus
syndrome. GI hemangiomas manifest at any age;
however, they are commonly seen during infancy
RG • Volume 30 Number 7 Lee et al 1925

Figure 15. Angiosarcoma of the jejunum in a 55-year-old man. (a) Contrast-enhanced CT im-
age obtained during the late arterial phase shows an asymmetric circumferential mass (arrow)
with slightly heterogeneous enhancement in the jejunum. Note the prominent vessels around the
mass and the bizarre enhancing foci within the inhomogeneous mass. (b) Intraoperative photo-
graph shows blood-filled jejunal tumors (arrows) directly invading the adjacent jejunum.

or early childhood and involute during childhood. Angiosarcoma.—Angiosarcomas are rare, aggres-
Most patients present with hemorrhage, abdomi- sive, malignant vascular tumors that are ex-
nal pain, and intussusception (20,21). tremely rare in the GI tract. Although the precise
Histologically, hemangiomas may be classi- cause of these tumors remains unclear, factors
fied as cavernous, capillary, or mixed. Cavern- that have been implicated in their pathogen-
ous hemangiomas are large blood-filled vascular esis include trauma; exposure to vinyl chloride,
channels with an endothelial lining. Capillary thorium dioxide (Thorotrast), or arsenic com-
hemangiomas are a proliferation of small capillar- pounds; long-standing lymphedema; and radiation
ies usually with a hyperplastic endothelium. Most therapy. The presenting symptoms of small bowel
GI hemangiomas arise from the submucosal angiosarcomas are nonspecific and include GI
vascular plexus and often form a polypoid, intra- hemorrhage and anemia, perforation, and pain
luminal subepithelial mass, although they may (22).
occasionally appear as a diffuse infiltrating mass In our experience, the CT findings of an-
(hemangiomatosis) extending to the surrounding giosarcomas do not differ from those of other
connective tissue (20,21). malignant epithelial and malignant intramural
CT reveals different radiologic features ac- subepithelial masses of the small bowel. Contrast-
cording to the gross appearance: an intramural enhanced CT demonstrates irregular, asymmetric
subepithelial mass with an intraluminal growth wall thickening with heterogeneous enhancement
pattern or transmural circumferential bowel wall (Fig 15). The prominent vessels around the mass
thickening extending into surrounding tissue and the bizarre enhancing portions within the
(Fig 14). Dynamic contrast-enhanced CT images inhomogeneous mass, which reflect increased
demonstrate slow diffuse enhancement, which is vascularity, help identify the vascular origin of the
similar to that seen in hemangiomas elsewhere, mass (22).
and vascular engorgement within the adjacent
mesentery around mass lesions, which reflects Kaposi Sarcoma.—Kaposi sarcomas of the GI
increased lesion vascularity. In addition, CT may tract are common in patients with acquired
reveal phleboliths caused by calcified thrombi immunodeficiency syndrome (AIDS) but also
within the tumor vascular channels, a finding that occur in patients without AIDS. GI involvement
is virtually pathognomonic for a GI hemangioma
(Fig 14) (20,21).
1926 November-December 2010 radiographics.rsna.org

Figure 16. Disseminated AIDS-related Kaposi sarcoma in a 55-year-old man with gastric
compromise. (a) Contrast-enhanced CT image shows a flat polypoid subepithelial mass
(arrow) with increased enhancement in the gastric body. (b) Endoscopic image shows mul-
tiple polypoid lesions with a cherry-red appearance.

Figure 17. Schwannoma of the stomach in a 54-year-old woman. (a) Contrast-enhanced

CT image obtained during the late arterial phase shows a 2-cm homogeneous extraluminal
mass (arrow) in the gastric antrum with minimal enhancement. (b) On a contrast-enhanced
CT image obtained during the hepatic venous phase, the mass (arrow) demonstrates stron-
ger enhancement than in a.

occurs in 40%–50% of AIDS-related Kaposi copy and biopsy. The typical endoscopic findings
sarcomas and is almost always associated with include an ulcerated subepithelial mass or masses
cutaneous disease. Kaposi sarcomas are thought with a reddish appearance.
to originate from the endothelial cells of lym- At CT, GI Kaposi sarcomas occasionally ap-
phatic or blood vessels in response to infection pear as one or more small (0.5–3 cm in diameter)
with human herpesvirus 8; this origin explains polypoid subepithelial masses or as irregular fold
the multiplicity of the tumor. The diagnosis of GI thickening (Fig 16). Central ulceration is also
Kaposi sarcomas is usually made by using endos- common, resulting in the appearance of “bull’s-
eye” or “target” lesions in barium studies. At
contrast-enhanced CT, the enhancement of the
masses is greater than that of the adjacent mu-
RG • Volume 30 Number 7 Lee et al 1927

Figure 18. Paraganglioma of the perirectal space in a 67-year-old woman. (a) Contrast-enhanced
CT image shows a well-defined, lobulated, heterogeneous mass with avid enhancement (arrows)
that displaces the rectum. The mass mimics an intramural subepithelial mass of the rectum. Note
the prominent feeding and draining vessels (arrowhead) adjacent to the mass. (b) Photograph of the
resected gross specimen shows the 5.5-cm tumor replacing the left perirectal space and infiltrating
the adjacent rectal wall. Scale is in centimeters. (Case courtesy of J. Y. Oh, MD, Dong-A University
Hospital, Busan, Korea.)

cosa secondary to the high tumor vascularity (Fig Paragangliomas are extremely rare neoplasms
16). CT can also demonstrate other evidence of that may be identified anywhere within or around
Kaposi sarcomas, such as lung nodules, highly the GI tract (Fig 18) (26).
enhanced lymph nodes, or splenomegaly (23).
Hypervascular Metastases
Nerve Sheath Tumors The mechanism of GI metastases includes direct
GI schwannomas are rare mesenchymal tumors extension from a contiguous or noncontiguous
arising from the Schwann cells of the neural primary malignant tumor, peritoneal carcinoma-
plexus within the GI wall. The most common tosis with serosal implants, and embolic metas-
site is the stomach (60%–70% of cases), followed tases with intramural subepithelial masses. GI
by the colon and rectum. Gastric schwannomas metastases closely resemble the primary tumors;
account for only 0.2% of all gastric tumors and therefore, the radiologic appearance of GI metas-
occur most frequently in the 3rd to 5th decades tases depends mainly on the histologic character-
of life. They are usually solitary tumors and istics of the primary or secondary lesions, such
principally involve the submucosa and muscularis as the degree of vascularity relative to the growth
propria. These tumors are usually discovered in- rate.
cidentally during endoscopic evaluation, although GI metastases are further classified as hypo-
larger tumors may occasionally manifest as upper vascular or hypervascular (27). Hypervascular
GI bleeding, abdominal pain, or discomfort. embolic GI metastases are often multifocal and are
Schwannomas are benign, and malignant trans- most frequently seen in patients with malignant
formation is extremely rare. melanoma or breast cancer. Uncommon hyper-
The most consistent CT feature of GI schwan- vascular GI metastases include those from renal
nomas is homogeneous attenuation for their cell carcinoma, choriocarcinoma, neuroendocrine
relatively large size. Although large tumors may carcinoma, and mesenchymal sarcoma (28).
undergo cystic degeneration, they rarely appear CT can be useful in detecting metastatic
cystic. Calcification is uncommon. Nonenhanced lesions, in determining the growth patterns of
CT shows low attenuation due to the dense metastasis (eg, intramural subepithelial lesions
spindle cell composition. Contrast-enhanced CT with intraluminal or extraluminal growth, which
may show no or minimal enhancement during are frequent in embolic metastasis, or extramural
the arterial phase but delayed enhancement dur- lesions, which are common in peritoneal carcino-
ing the equilibrium phase (Fig 17). Therefore, matosis with serosal implants), and in evaluating
a hypervascular mass may not be a common
feature of GI schwannomas at CT (24,25).
1928 November-December 2010 radiographics.rsna.org

Figure 19. Small bowel metastases from malignant melanoma in a 70-year-old woman. (a) Coronal refor-
matted contrast-enhanced CT image shows multiple hypervascular intraluminal polypoid masses (arrows) in
the ileum. (b) Image from a small bowel follow-through study shows multiple nodular filling defects (arrows)
in the ileum. (Case courtesy of J. Y. Oh, MD, Dong-A University Hospital, Busan, Korea.)

Figures 20, 21. (20) Heterotopic pancreas of the stomach in a 47-year-old woman. Contrast-
enhanced CT image shows a 3-cm, ill-defined, ovoid intraluminal subepithelial mass (arrow) in
the gastric antrum. The lesion has homogeneous enhancement similar to that of the pancreas.
(21) Heterotopic pancreas of the jejunum in a 46-year-old woman. Contrast-enhanced CT image
shows a 2.8-cm, ill-defined, lobulated mass (arrow) in the jejunum. The mass demonstrates en-
hancement similar to that of the orthotopic pancreas (*). The ascites in the peritoneal cavity is due
to recent surgery.

complications secondary to metastatic lesions whereas primary malignant melanomas of the GI

such as intussusception or obstruction (27,28). tract are extremely rare. Most GI melanomas are
Most GI melanomas result from embolic me- likely to metastasize to the small bowel, and the
tastases in patients with cutaneous melanomas, rate of metastasis ranges from 35% to 70% in pa-
tients with melanoma. Although CT allows better
visualization of bowel loops than does conven-
RG • Volume 30 Number 7 Lee et al 1929

Heterotopic Tissues
Heterotopic pancreas is pancreatic tissue in aber-
rant sites that lacks a vascular and ductal connec-
tion to the main pancreatic body. The reported
prevalence at autopsy ranges from 1% to 15%.
Since heterotopic pancreas arises as a detach-
ment of one or more branching buds during
embryonic rotation and results in fusion of the
dorsal and ventral pancreatic buds, heterotopic
pancreas is most often found in the upper part
of the GI tract (90% of cases) near the pancreas,
particularly in the prepyloric region of the stom-
ach along the greater curvature (7,31–33).
Heterotopic pancreas is usually located in the
submucosa or muscularis propria and appears as
an intramural subepithelial nodule less than 3 cm
Figure 22. Heterotopic gastric tissue in a in diameter, usually with central umbilication that
Meckel diverticulum in a 20-year-old man. Con- represents a rudimentary pancreatic duct and its
trast-enhanced CT image shows a 2-cm, well-de- orifice. Heterotopic pancreas is usually asympto-
fined, hypervascular intraluminal masslike lesion matic, but patients may occasionally present with
(arrows) in a blind-ending tubular structure (*). abdominal pain, GI bleeding, and obstruction.
Pathologic analysis demonstrated heterotopic
Complications that can occur in the pancreas can
gastric tissue in a Meckel diverticulum.
also develop in the heterotopic pancreas, including
pancreatitis, pseudocysts, cystic dystrophy, insu-
tional barium fluoroscopy and permits detection linomas, and malignant transformation, although
of extraluminal abnormalities in patients with these are rare (7,31–33).
intestinal melanoma, the sensitivity of CT for de- Contrast-enhanced CT usually demonstrates
tection of intestinal melanoma is only 60%–70%. a homogeneously enhancing mass with attenua-
The use of CT enteroclysis or multidetector CT tion similar to that of the pancreas (Figs 20, 21).
with multiplanar visualization is likely to improve However, some instances of heterotopic pancreas
the detection rate of small bowel melanomas. enhance poorly; this finding is mainly attributed
Typically, metastatic melanomas manifest to ductal tissue with surrounding hypertrophied
as one or more small intramural subepithelial muscle but with the pancreatic acini as only a
nodules and polypoid masses in the GI tract with minor component (31,32). Differentiation of
increased enhancement at contrast-enhanced heterotopic pancreas from other subepithelial
CT (Fig 19). Embolic metastases are localized to masses is crucial to avoid unnecessary resection.
one wall of the bowel, usually the antimesenteric The typical location (prepyloric antrum), flat-
border; this pattern is related to the intramural ovoid shape, intraluminal growth, and irregular
ramifications of the vasa recta toward the submu- border of heterotopic pancreas are important for
cosal plexus in the antimesenteric border. Central differentiation from other subepithelial masses
ulceration is especially common because metas- (Fig 20) (7,33).
tases tend to outgrow their blood supply, leading Heterotopic gastric mucosa may be found
to the appearance of bull’s-eye or target lesions in in many parts of the GI tract, including the
barium studies (Fig 19). A larger lesion may ap- esophagus, duodenum, small bowel, and Meckel
pear more complex due to necrosis, hemorrhage, diverticulum and in duplication cysts. Although
and degenerative change (28–30). heterotopic gastric mucosa is not a subepithe-
Hematogenous metastases from breast cancer lial lesion but an epithelial lesion, heterotopic
occur in the stomach, small bowel, and colon and gastric mucosa in the Meckel diverticulum
manifest as localized eccentric bowel wall thick- may appear as a nodular or polypoid intralu-
ening or as a diffuse irregular circumferential minal mass at contrast-enhanced CT (Fig 22);
stricture. At contrast-enhanced CT, GI metas- this mass can be mistaken for other common
tases from breast cancer may appear as diffuse subepithelial masses such as carcinoid tumors or
irregular wall thickening with increased attenua- GISTs (34,35).
tion, producing a linitis plastica–like appearance
(28).
1930 November-December 2010 radiographics.rsna.org

Miscellaneous Masses

Vascular Structures
Vascular structures may produce focal submuco-
sal abnormalities. Varices are occasionally seen as
masslike polypoid lesions or as tortuous elevation
of the mucosa at endoscopy. The diagnosis of
varices is usually made with endoscopy. However,
it may be difficult to distinguish between varices
and subepithelial mass lesions at endoscopy. The
vascular nature of varices may not be evident
during endoscopy because of thick overlying
rugal folds.
CT can be helpful in detecting varices and
identifying the underlying cause, such as portal
hypertension. Varices appear as enhanced tubular
vessels at CT. Because they are veins, they will Figure 23. Duodenal varices in a 62-year-old
enhance during the portal venous phase (Fig 23). man with occult GI bleeding. Contrast-enhanced
CT can demonstrate communications of the vari- CT image shows varices (arrows) in the poste-
ces, such as afferent and efferent veins, and other rior wall of the third part of the duodenum.
collateral vessels in patients with portal hyperten-
sion (36).

Extramural Subepithelial Masses

Many hypervascular extramural subepithelial
masses are seen at contrast-enhanced CT. Most
are caused by extrinsic compression by masses
adjacent to the GI tract. Rarely, these masses
secondarily involve the GI tract by eroding or
invading the GI wall. These conditions include
Castleman disease, solitary fibrous tumor (SFT),
inflammatory myofibroblastic tumor, and actino-
mycosis. GISTs arising from the mesentery and
omentum are also included.
Castleman disease (angiofollicular lymph
node hyperplasia) is a rare lymphproliferative
disorder. Although it usually involves the medias-
tinal lymph nodes, it may occur in other regions
where lymph nodes are normally found, such as Figure 24. Castleman disease (hyaline vascular
the abdomen, including both intraperitoneal and type) in a 49-year-old woman. Coronal reformat-
retroperitoneal regions. Abdominal Castleman ted contrast-enhanced CT image shows a well-
disease causes enlargement of single or multiple defined, homogeneously enhancing mass (arrow)
abutting the duodenum. Note the preservation
lymph nodes; the enlarged nodes may result in
of the fat plane between the mass and the duo-
extrinsic compression of the adjacent bowel.
denum, a finding indicative of an extramural
Castleman disease is categorized into three subepithelial mass. (Courtesy of J. H. Cho, MD,
major histologic types: the more commonly Dong-A University Hospital, Busan, Korea.)
identified hyaline vascular type, the less common
plasma cell type, and a mixed type. There are also
two clinical variants: the localized form and the of the localized form are the hyaline vascular
disseminated form. Approximately 95% of cases type, which has a good prognosis. The dissemi-
nated form is strongly associated with human
herpesvirus 8 and has more complicated systemic
manifestations.
RG • Volume 30 Number 7 Lee et al 1931

demonstrate homogeneous and marked enhance-

ment, which reflects the hypervascularity of the
lesion (Fig 24). Larger tumors demonstrate het-
erogeneous enhancement with low attenuation,
which reflects fibrosis, necrosis, or degeneration;
10%–15% of these lesions may have calcification.
When disseminated from the abdominopelvic
cavity, Castleman disease manifests as diffuse
lymphadenopathy, hepatosplenomegaly, and
ascites (37,38).
SFTs are rare, distinct mesenchymal neo-
plasms, which were initially thought to originate
only from the serosal membranes. More recently,
SFTs have been found to occur in almost ev-
ery site throughout the body. SFTs are usually
benign, although malignant behavior may be seen
Figure 25. SFT of the perineum in a 67-year- histologically, and such tumors can recur or me-
old woman. Contrast-enhanced CT image shows tastasize. SFTs sometimes manifest as compres-
a well-circumscribed, lobulated, large hetero- sive symptoms and rarely as systemic symptoms.
geneous mass (arrows) with avid enhancement SFTs have a wide spectrum of histologic
abutting and displacing the rectum. features, ranging from a fibrous form to a cellular
form. The cellular form of SFT resembles what
was previously called hemangiopericytoma. At CT,
SFTs are usually described as a well-defined mass
with solid and cystic portions and with varying
degrees of enhancement, which may be related
to the varying cellularity (Fig 25). A prominent
rich vascular structure enhances early, whereas a
high fibrous content with hypocellularity results in
delayed progressive enhancement (39,40).
Inflammatory myofibroblastic tumors, also
known as inflammatory pseudotumors, are rare
reactive lesions. They occur in nearly every site in
the body and occasionally involve the peritoneal
cavity. The CT appearance of inflammatory myo-
fibroblastic tumors is variable and nonspecific.
Lesions may appear as infiltrative or well-defined
masses at CT. Enhancement usually occurs in
a variety of patterns, including early peripheral
Figure 26. Inflammatory myofibroblastic tu- enhancement with delayed central filling, target-
mor in a 48-year-old woman. Contrast-enhanced like heterogeneous enhancement, homogeneous
CT image shows a slightly lobulated, homoge- enhancement, or no enhancement (Fig 26) (41).
neously enhancing mass (arrows) in the right Infectious diseases such as actinomycosis ap-
paracolic gutter. Abdominal wall invasion by the
pear as infiltrative hypervascular extramural soft-
mass is suspected. (Courtesy of S. H. Kim, MD,
Daegu Fatima Hospital, Daegu, Korea.) tissue masslike lesions with or without involve-
ment of adjacent bowel at contrast-enhanced CT.
These lesions mimic other subepithelial masses
At contrast-enhanced CT, localized Castleman or masslike lesions (42).
disease in the abdominopelvic cavity manifests as
(a) a solitary well-circumscribed mass, (b) a domi-
nant infiltrative mass with involvement of contig-
uous structures, or (c) matted lymphadenopathy
without a dominant mass. Smaller lesions tend to
1932 November-December 2010 radiographics.rsna.org

Figure 27. Mucinous carcinoma of the stomach mimicking a subepithelial mass in a

69-year-old man. (a) Contrast-enhanced CT image shows a large subepithelial mass lesion
in the gastric cardia that contains large mucin pools (*) and enhancing solid portions (ar-
row). The mass lesion is generally covered with normal mucosa, with the exception of an
ulcer (arrowhead) at the top of the tumor. (b) Endoscopic image shows jellylike mucin leak-
ing from the subepithelial mass.

Epithelial Tumors tumor. Hypervascular intramural subepithelial

Resembling Subepithelial Lesions masses are not uncommonly seen at contrast-
Gastric cancers resembling subepithelial tumors enhanced CT. CT can be helpful in detecting
are very rare. They appear as polypoid lesions hypervascular intramural subepithelial masses
that are generally covered with normal mucosa, or masslike lesions, delineating the full extent
with the exception of an ulcer at the top of the of tumors, identifying local invasion and distant
tumor (Fig 27). The ulcer is due to prominent metastases, and following up the masses or mass-
cancer infiltration into the submucosal layer or like lesions.
sometimes to deeper invasion into the gastric In comparison with endoscopic US, CT is of
wall. limited value in differentiating the layers of the
At endoscopy, gastric cancers resembling sub- GI wall and determining the origin of mass le-
epithelial tumors can appear similar to intramural sions. However, familiarity with the CT features
subepithelial tumors. The postulated mechanisms of hypervascular subepithelial masses or masslike
for the resemblance of these gastric cancers to lesions and with the various diseases that may
subepithelial tumors include (a) the tendency of cause them will help radiologists make a more
poorly differentiated adenocarcinomas to invade confident diagnosis (Table).
the deeper layer early, (b) large amounts of mucin
produced by a mucinous adenocarcinoma, or References
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RG • Volume 30 Number 7 Lee et al 1933

Hypervascular Subepithelial Masses and Masslike Lesions in the GI Tract

Type of Lesion Clinical and CT Features
Intramural origin
Neuroendocrine tumor
   Well-differentiated neuroendocrine tumor Small intraluminal polypoid mass with avid enhancement
  Neuroendocrine carcinoma Ulcerative tumor similar to adenocarcinoma; has metastases
Mesenchymal tumor
  GIST Small GISTs are well-defined with homogeneous attenu-
ation; large GISTs have an irregular margin and central
necrosis with heterogeneous enhancement
  Glomus tumor Typically in the gastric antrum; strong enhancement in
the arterial phase and prolonged enhancement in the
delayed phase
  Hemangioma Phleboliths
  Angiosarcoma Similar to other malignant epithelial or subepithelial
masses of the GI tract
  Kaposi sarcoma Polypoid mass with ulceration (bull’s-eye appearance);
common in patients with AIDS
  Schwannoma Relatively homogeneous; minimal enhancement in the arte-
rial phase and delayed enhancement in the delayed phase
Hypervascular metastases History of a hypervascular primary malignancy
Heterotopic pancreas Typically in the gastric antrum; shows intraluminal growth,
an irregular border, and enhancement similar to that of
the pancreas
Extramural origin
Castleman disease, SFT, inflammatory myofibro- Preservation of the fat plane between the extramural mass
blastic tumor, actinomycosis and the displaced GI wall

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This article meets the criteria for 1.0 AMA PRA Category 1 Credit TM. See www.rsna.org/education/rg_cme.html.
Teaching Points November-December Issue 2010

Hypervascular Subepithelial Gastrointestinal Masses: CT-Pathologic Corre-

lation
Nam Kyung Lee, MD • Suk Kim, MD • Gwang Ha Kim, MD • Tae Yong Jeon, MD • Dae Hwan Kim, MD •
Ho Jin Jang, MD • Do Youn Park, MD
RadioGraphics 2010; 30:1915–1934 • Published online 10.1148/rg.307105028 • Content Codes:

Page 1916
A subepithelial mass, which was previously called a submucosal mass, is defined as a mass covered with
normal-appearing mucosa. The term subepithelial has come to be favored over submucosal because lesions
in this category do not necessarily arise from the submucosa, but can also arise from any layer of the gas-
trointestinal (GI) wall other than the submucosa (intramural) or from extrinsic compression of the wall
by a number of normal or abnormal intraabdominal structures (extramural) (1,2).

Page 1919 (Figure on page 1920)

At endoscopy, neuroendocrine tumors usually appear as subepithelial lesions that resemble other more
common subepithelial tumors, because neuroendocrine tumors usually arise from enteroendocrine cells,
which are usually located relatively deep in the mucosal layer of the GI wall (Fig 5).

Page 1922
When a hypervascular intramural subepithelial mass larger than 3 cm is encountered at contrast-en-
hanced CT, GIST should be considered first in the differential diagnosis. GIST is the most common
subepithelial tumor involving the GI tract, and other intramural subepithelial masses such as carcinoid
tumor, glomus tumor, or ectopic pancreas usually manifest as intraluminal masses, smaller than 3 cm,
with stronger enhancement than GIST. However, the CT features of GISTs smaller than 3 cm overlap
with those of other intramural subepithelial masses.

Page 1927
GI metastases closely resemble the primary tumors; therefore, the radiologic appearance of GI metas-
tases depends mainly on the histologic characteristics of the primary or secondary lesions, such as the
degree of vascularity relative to the growth rate.

Page 1929 (Figure on page 1928)

Differentiation of heterotopic pancreas from other subepithelial masses is crucial to avoid unnecessary
resection. The typical location (prepyloric antrum), flat-ovoid shape, intraluminal growth, and irregular
border of heterotopic pancreas are important for differentiation from other subepithelial masses (Fig 20)
(7,33).