Gastrointestinal Imaging • Original Research

Yu et al.
MRI of Gastrointestinal Stromal Tumors

Gastrointestinal Imaging
Original Research
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MRI Features of Gastrointestinal

Stromal Tumors
Mi Hye Yu1 OBJECTIVE. The purpose of this study was to investigate the MRI features of gastroin-
Jeong Min Lee2 testinal stromal tumors (GISTs) with special emphasis on the dynamic enhancement pattern
Jee Hyun Baek 2 and findings of diffusion restriction.
Joon Koo Han2 MATERIALS AND METHODS. Forty-two patients with pathologically proven GISTs
Byung-Ihn Choi2 who underwent MRI that included dynamic contrast-enhanced and diffusion-weighted imag-
ing (DWI) were included in this study. Two abdominal radiologists analyzed the MR images
Yu MH, Lee JM, Baek JH, Han JK, Choi BI in consensus regarding the morphologic features, enhancement degree and pattern, and find-
ings of diffusion restriction. The mean apparent diffusion coefficient (ADC) values of the tu-
mors were measured by one of the radiologists. The MRI features and mean ADC values were
analyzed with respect to tumor size and malignancy risk.
RESULTS. Small GISTs (≤ 5 cm, n = 25) appeared as round tumors with strong and ho-
mogeneous arterial enhancement and a persistent enhancement pattern. Large GISTs (> 5
cm, n = 17) appeared as lobulated tumors with mild heterogeneous gradual enhancement, and
they frequently exhibited intratumoral cystic change (n = 13). The prevalence of intratumoral
cystic change was higher in the moderate to high risk group than in very low to low risk group
(p < 0.05). There was negative linear correlation between the mean ADC values and the ma-
lignancy risk of GISTs (r = –0.670, p < 0.05).
CONCLUSION. Small GISTs had MRI features different from the well-known imag-
ing features of large GISTs. The presence of intratumoral cystic change and a low mean ADC
value may be helpful for predicting the high malignancy potential of GISTs.

Keywords: diffusion-weighted imaging, gastrointestinal
stromal tumor, GIST, MRI
DOI:10.2214/AJR.13.11667
Received August 3, 2013; accepted after revision
December 31, 2013.
Supported in part by a National Research Foundation of
Korea grant (NRF-2013R1A1A2A10066037) funded by the
Korean government.
1
Department of Radiology, Konkuk University Medical
Center, Seoul, Korea.
2
Department of Radiology and the Institute of Radiation
Medicine, Seoul National University Hospital, Seoul,
101 Daehangno, Jongno-gu, Seoul, 110-744. Address
correspondence to J. M. Lee (jmsh@snu.ac.kr).
AJR 2014; 203:980–991
0361–803X/14/2035–980
© American Roentgen Ray Society
G
astrointestinal stromal tumors
(GISTs) are the most common
mesenchymal tumors of the gas-
trointestinal tract and account
for 1% of all gastrointestinal neoplasms [1,
2]. They can be differentiated from other
mesenchymal tumors, such as leiomyoma,
leiomyosarcoma, and schwannoma, because
they exhibit positive expression of c-kit pro-
tein (CD117), a tyrosine kinase growth factor
receptor that is a specific immunohistochem-
ical marker for GIST [3]. GISTs originate at
any location along the gastrointestinal tract,
although they occur most frequently in the
stomach (60%), followed by the jejunum and
ileum (30%), duodenum (4–5%), rectum
(4%), colon, and esophagus. They also occa-
sionally occur in the omentum, mesentery, or
retroperitoneum [4]. The radiologic features
of GISTs vary depending on their size and
anatomic location. In general, the most well-
known and usual imaging features of GISTs
seen on cross-sectional images are a well-de-
fined exophytically growing heterogeneous
mass with intratumoral hemorrhage, necro-
sis, or cystic change [2, 5–7]. The wide-
spread use of both cross-sectional imaging
and endoscopic examination has resulted in
more frequent detection of small submucosal
tumors of the gastrointestinal tract and there-
fore has created a diagnostic dilemma re-
garding such small submucosal gastrointes-
tinal tumors. Most of the previous studies
have described the CT and MRI features of
large GISTs [2, 5–7], but there have been
only a few studies of the detailed imaging
features of small GISTs [8].
GISTs have malignant potential with
varying degrees of aggressiveness closely
related to their clinical manifestations and
subsequent treatment and prognosis [9]. An-
atomic location, tumor size, and mitotic rate
are the most important factors for predict-
ing malignant potential [1, 9–11]. CT has
had an important role in the detection and
diagnosis of GISTs and for evaluating adja-

980 AJR:203, November 2014

 MRI of Gastrointestinal Stromal Tumors

cent organ invasion, distant metastasis, and
peritoneal seeding. However, MRI is being
used more frequently for the evaluation of
abdominal diseases because of its high soft-
tissue contrast and multiplanar capability,
both of which are helpful for determining
the organ of origin of large tumors and the
relation between the tumor and other organs
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mens Healthcare, n = 1; Magnetom Avanto, Sie-
mens Healthcare, n = 1; Symphony, Siemens
Healthcare, n = 1; Achieva, Philips Healthcare,
n = 1) or a 3-T (Verio, Siemens Healthcare, n =
10; Signa Excite, GE Healthcare, n = 4; Trio, Sie-
mens Healthcare, n = 1; Achieva, Philips Health-
care, n = 1) superconducting system with an eight-
channel (Signa HDx, Excite) or a 12-channel
The MRI examination protocols varied de-
pending on the location of the tumors: liver pro-
tocol (n = 20), hepatobiliary-pancreatic protocol
(n = 17), and rectal-pelvic protocol (n = 5). The
purpose of the MRI examination was to evalu-
ate both the primary tumor and focal liver le-
sions, which were detected on contrast-enhanced
CT scans of 37 patients, and to evaluate the pri-

and major blood vessels [2, 12]. Diffusion- (Verio and Trio) phased-array coil. mary tumor of the rectum or distal ileum in five
weighted MRI (DWI) is helpful for charac-
terizing both the cellularity and the internal
components of solid tumors of the abdomen.
To our knowledge, however, no large stud-
ies of DWI focusing on the MRI appearance
of small GISTs has been conducted to deter-
mine the imaging features predictive of ma-
lignant potential [13–16].
The purposes of this study were to analyze
the MRI features of GISTs, including the de-
gree of enhancement, dynamic enhancement
pattern, and DWI features and to evaluate
whether these features differ according to tu-
mor size. We also attempted to evaluate wheth-
er any of the MRI features correlate with the
risk of malignancy associated with GISTs.

Materials and Methods

Patient Selection
This retrospective study was approved by the
institutional review board at our hospital. The
requirement for written informed consent was
waived because of the retrospective study design.
A B
We searched our institutional pathology and med-
ical records to identify cases of histopathological-
ly proven GIST diagnosed between January 2007
and September 2012. During this study period,
the cases of 364 patients with a diagnosis of GIST
based on findings of endoscopic biopsy or surgical
resection at our institution were identified. Among
them, 42 patients (24 men, 18 women; mean age,
61.8 ± 10.44 years; range, 29–78 years) who met
all of the following inclusion criteria were includ-
ed in this study: stromal tumor originating in the
gastrointestinal tract; MRI examination including
dynamic contrast enhancement within 1 month
before the surgery or biopsy; and GIST recogniz-
able on MR images, that is, having a tumor size
greater than 1 cm in diameter. We excluded GISTs
smaller than 1 cm in diameter and incidentally
detected at pathologic examination because they
were not noticeable on MR images. All GISTs had
positive expression of c-kit protein (CD117) at im-
munohistochemical analysis.

MRI Examination
MRI was performed with either a 1.5-T (Sig-
na Excite, GE Healthcare, n = 12; Signa HDx,
GE Healthcare, n = 10; Magnetom Sonata, Sie-
C D
Fig. 1—73-year-old woman with small gastrointestinal stromal tumor in jejunum.
A–D, Dynamic contrast-enhanced T1-weighted MR images show small round endoluminal mass (arrow) in
proximal jejunum. Mass has homogeneous strong arterial and persistent enhancement. No intratumoral cystic
change or hemorrhage is present in this lesion.
(Fig. 1 continues on next page)

AJR:203, November 2014 981


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E F
Fig. 1 (continued)—73-year-old woman with small gastrointestinal stromal tumor in jejunum.
E and F, Diffusion-weighted image (b = 800 s/mm2) (E) and apparent diffusion coefficient (ADC) map (F) show diffusion restriction of lesion (arrow). Mean ADC value is
1.56 × 10 −3 mm2 /s.
G, Photograph of surgical specimen shows small endoluminal tumor with mitotic index of 1 per 50 high-power fields. Lesion was confirmed as gastrointestinal stromal
tumor with very low malignancy risk.
patients. The liver MRI protocol consisted of a
breath-hold fat-suppressed T2-weighted fast spin-
echo or turbo spin-echo sequence, a breath-hold
T1-weighted dual-echo (in-phase and opposed-
phase) sequence, dynamic fat-suppressed 3D T1-
weighted sequences, and free-breathing DWI with
a single-shot, echo-planar sequence. Gadoxetic
acid (Primovist, Bayer Schering Pharma) at a dose
of 0.025 mmol/kg body weight was administered
IV at an injection rate of 1.5–2 mL/s through a
power injector (Spectris Solaris EP, Medrad) and
was followed by a 25-mL saline flush. Both be-
fore and after contrast administration, dynamic
T1-weighted unenhanced arterial phase (20–35
seconds), portal venous phase (60 seconds), de-
layed phase (3 minutes), and hepatobiliary phase
(20 minutes) images were obtained. The acquisi-
tion delay times were determined with real-time
MR fluoroscopic monitoring.
The hepatobiliary-pancreatic MRI protocol
consisted of a breath-hold T2-weighted single-
shot fast spin-echo or half-Fourier acquisition sin-
gle-shot turbo spin-echo sequence, a T1-weight-
ed dual-echo sequence, respiratory-triggered MR
cholangiography by fast spin-echo or turbo spin-
echo technique, dynamic, fat-suppressed 3D T1-
weighted sequences, and free-breathing DWI. An
injection of 0.1 mmol/kg body weight gadobenate
dimeglumine (MultiHance, Bracco Imaging) was
given at an injection rate of 1 mL/s through a pow-
er injector and followed by a 25-mL saline flush.
982
Yu et al.
Unenhanced, arterial (20–40 seconds), portal ve-
nous (45–65 seconds), and equilibrium (3–5 min-
utes) phase images were obtained both before and
after administration of contrast medium.
In the rectal-pelvic MRI protocol, T2-weight-
ed fast spin-echo images in the axial, sagittal, and
coronal planes, T1-weighted fast spin-echo imag-
es in the axial and sagittal planes, and DW images
were acquired. After administration of gadobena-
te dimeglumine (MultiHance) in the same way as
in the hepatobiliary-pancreatic protocol, dynamic
fat-suppressed T1-weighted images were obtained
with a spoiled gradient-echo sequence (liver ac-
quisition and volume acquisition [LAVA]) in the
arterial (20–40 seconds), portal venous (45–60
seconds), and delayed (3 minutes) phases.
DWI was available for 30 of the 42 patients in
our study. For 20 patients, conventional DWI was
performed by multisection single-shot echo-planar
imaging during free-breathing acquisition with b
values of 0 s/mm2 and 500 s/mm2. All separate im-
ages were acquired with diffusion weighting in the
axial direction and three directional diffusion gra-
dients. The apparent diffusion coefficient (ADC)
values (× 10 −3 mm2 /s) were calculated as follows:
ADC = [1 / (b1 − b0)] In(S0 / S1)
where S1 and S 0 are the signal intensities obtained
with two different gradient factors (b 0 and b1). In
10 patients, intravoxel incoherent motion modeling
DWI was performed with single-shot echo-planar
G
imaging with free breathing. To shorten the echo-
train length, the parallel imaging technique (gen-
eralized autocalibrating partially parallel acquisi-
tions [GRAPPA]) with a twofold acceleration factor
was used. Three perpendicular spatial directions
were encoded with eight b values of 0, 25, 50, 75,
100, 200, 500, and 800 s/mm2. To increase the sig-
nal-to-noise ratio, three averages were performed.
To remove the patient orientation dependence on
the individual DW images, trace-weighted imag-
es were calculated from the three orthogonal dif-
fusion measurements for each b value according to
the following equation:
IT (b) = 3 Ix (b) × Iy (b) × Iz (b)
where I is intensity and T is time. A linear
(least squares) fit between the logarithm of the
eight trace weighted images, that is, ln[I T (b)],
and b was performed on a pixel-by-pixel basis.
The slope of the result (ADC total) was set equal
to the corresponding pixel value of the ADC
map. All sequences were performed in the ax-
ial plane. The detailed imaging parameters for
the four principal MRI systems used are sum-
marized in Table 1.
Image Analysis
Two abdominal radiologists (9 and 7 years of
clinical experience interpreting abdominal MR
images) analyzed the MR images and reached
a consensus for each case. The image review
AJR:203, November 2014
 MRI of Gastrointestinal Stromal Tumors

TABLE 1: MRI Acquisition Parameters

Fat-Suppressed T2-Weighted Dynamic 3D T1-Weighted Diffusion-Weighted
Slice Slice Slice
MRI Flip Thickness Flip Thickness Flip Thickness
System TR/TE Angle (mm) FOV Matrix TR/TE Angle (mm) FOV Matrix TR/TE Angle (mm) FOV Matrix
1 7500/87.8 90° 7 350 × 350 320 × 224 5/2.2 12° 4.8 380 × 380 384 × 192 5025/67.2 90° 7 380 × 380 128 × 128
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2 2000–8500 / 90° 7 350 × 350 384 × 226 4.6/2.2 12° 5 360 × 360 320 × 192 4000–6000 / 90° 7 400 × 400 128 × 128
84–105 58–105
3 800/144 90° 5 4000 × 400 384 × 307 3.4/1.2 11° 3 380 × 380 384 × 307 5000/54 90° 7 380 × 380 128 × 128
4 2350/99.2 90° 5 240 × 240 384 × 224 3.4/1.6 12° 4 300 × 300 224 × 160 8025/101.3 90° 5 300 × 300 160 × 160
Note—System 1 = Signa Excite 1.5 T (GE Healthcare), system 2 = Signa HDx 1.5 T (GE Healthcare), system 3 = Verio 3 T (Siemens Healthcare), system 4 = Signa Excite 1.5 T
(GE Healthcare) rectal MRI protocol.

was performed with PACS software (Maroview TABLE 2: Clinical and Pathologic Findings of Gastrointestinal Stromal Tumors
5.4, Infinitt) running on a computer workstation
(XW6200, Hewlett-Packard) and with monitors Tumor Size (cm)
with a spatial resolution of 1600 × 1200. The re- Finding ≤2 2–5 5–10 > 10 Total
viewers were blinded to the histopathologic diag-
No of patients 3 22 6 11 42
nosis of the tumors, although they were aware that
all patients had a presumptive diagnosis of GIST. Mean age (y) 64 ± 9 61.45 ± 10.6 64.5 ± 9.18 60.5 ± 12.04 61.8 ± 10.44
The following morphologic features of the tu- Male-to-female ratio 2:1 5:6 5:1 7:4 4:3
mor [17–19] were analyzed on MR images in Mean size (cm) 1.6 ± 0.36 3.65 ± 0.81 6.72 ± 1.77 12.75 ± 3.42 6.33 ± 4.5
this study: maximum tumor diameter; location
Anatomic location
(stomach, duodenum, jejunum and ileum, or rec-
tum); margins (well-defined or ill-defined); shape Stomach 0 8 3 8 19
(round, lobulated, or irregular); growth pattern Duodenum 0 12 2 2 16
(endoluminal, mixed, or exophytic); presence of Jejunum and ileum 1 1 1 1 4
mucosal ulceration, intratumoral hemorrhage, in-
Rectum 2 1 0 0 3
tratumoral cystic change, or calcification; pres-
ence of lymphadenopathy and metastasis; signal Metastasis 0 2 3 7 12
intensity on T1- and T2-weighted images; degree Treatment
of enhancement of the tumor (poor, mild, strong); Excision 1 5 0 0 6
dynamic contrast enhancement pattern (homo-
Resection 1 13 3 3 20
geneous arterial and persistent enhancement,
peripheral to central progressive enhancement, Pylorus-preserving 0 3 1 1 5
pancreaticoduodenectomy
heterogeneous gradual enhancement); and the
presence of diffusion restriction. Low anterior resection 1 0 0 0 1
The presence of intratumoral hemorrhage Imatinib mesylate therapy 0 1 2 7 10
was defined as high signal intensity on unen- Preoperative diagnosis
hanced T1-weighted images and as low sig-
Gastrointestinal stromal tumor 1 17 5 10 33
nal intensity on T2-weighted images. The sig-
nal intensity characteristics were compared with Neuroendocrine tumor 1 3 0 1 5
the surrounding signal intensity of muscle. The Solid pseudopapillary tumor 0 1 0 0 1
presence of intratumoral cystic change in the tu- Neurogenic tumor 0 1 0 0 1
mor was defined as high signal intensity simi-
Castleman’s disease 0 0 1 0 1
lar to that of CSF on T2-weighted images with-
out enhancement. The degree of enhancement Incidental detection 1 0 0 0 1
of the tumor was graded in comparison with Malignancy risk
the surrounding muscle and vessels. Poor en- High 1 5 1 6 13
hancement was defined as less enhancement than
Moderate 0 2 1 0 3
muscle; mild enhancement indicated greater en-
hancement than muscle but less than vessels; and Low 1 7 1 0 9
strong enhancement was defined as equal to that Very low 1 7 0 0 8
of the vessels [18]. Insufficient data 0 0 1 0 1
A radiologist (7 years of clinical experience
Not available 0 1 2 5 8
interpreting abdominal MR images) performed

AJR:203, November 2014 983

 Yu et al.

ADC quantification of the tumors on DW im-
ages of 30 patients. The ADC maps were auto-
matically generated by the system. With conven-
tional images as a reference, three circular ROIs
on b = 0 s/mm 2 images were carefully positioned
to avoid intratumoral hemorrhage and cystic por-
tions and to exclude blood vessels and artifacts.
The ROIs were transported onto the ADC maps
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in a copy-and-paste procedure. The average of
the results was the mean ADC value of the tumor
and was expressed as × 10 –3 mm 2 /s.
Pathologic Assessment of the Malignancy Risk
of Gastrointestinal Stromal Tumors
The risk of malignancy of GISTs was defined
as high, moderate, low, or very low on the basis of
mitotic index, size, and anatomic location, accord-
ing to the 2010 National Comprehensive Cancer
Network guidelines [20].
Statistical Analysis
Considering the size criteria (2, 5, and 10 cm)
used in the 2010 National Comprehensive Can-
cer Network guidelines, we divided the GISTs

A B C

D E F
Fig. 2—69-year-old man with large gastrointestinal stromal tumor in stomach.
A–D, T1-weighted images show large lobulated exophytic mass (arrow) high in body of stomach. Lesion has mild degree of heterogeneous gradual enhancement. Area
of high signal intensity (arrowhead, A) is evident on unenhanced T1-weighted image without enhancement on unenhanced image (A) and on dynamic contrast-enhanced
images (B–D), which suggests intratumoral hemorrhage.
E, T2-weighted image shows intratumoral cystic portion with hemorrhagic fluid (arrowhead) within large mass.
F, Because small hepatic metastatic lesion (arrow) on contrast-enhanced T1-weighted image exhibits peripheral enhancement in liver segment VI, this patient underwent
endoscopic biopsy and imatinib mesylate therapy. Stomach mass was confirmed to be gastrointestinal stromal tumor, but malignancy risk was not evaluated.
(Fig. 2 continues on next page)

984 AJR:203, November 2014

 MRI of Gastrointestinal Stromal Tumors

Results
Clinical Features
Detailed demographic and clinical data re-
garding the GISTs are shown in Table 2. The
mean diameter of the GISTs was 6.33 ± 4.50
cm (range, 1.3–22 cm). Three GISTs mea-
sured 2 cm or less; 22, 2 to less than 5 cm; six,
5–10 cm; and 11 more than 10 cm. Most of the
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tumors were located in the stomach and duo-

denum. Thirty-two patients underwent cura-
tive or palliative surgery, most often gastric
wedge resection and small-bowel resection.
The other 10 patients underwent endoscopic
biopsy and imatinib mesylate (Gleevec, No-
vartis) treatment of liver metastasis or perito-
neal seeding. Three of these patients under-
went gastric wedge resection after imatinib
mesylate treatment. Liver metastasis (n = 9),
peritoneal seeding (n = 1), or both (n = 2)
were found in 12 patients. Most of the GISTs
were correctly diagnosed after MRI exami-
G H nation. As a differential diagnosis, pancreatic
Fig. 2 (continued)—69-year-old man with large gastrointestinal stromal tumor in stomach. neuroendocrine tumor, solid pseudopapillary
G and H, Diffusion-weighted image (b = 800 s/mm2) (G) and apparent diffusion coefficient (ADC) map (H) show tumor, and neurogenic tumor of retroperito-
diffusion restriction of peripheral solid portion of huge gastrointestinal stromal tumor. Mean ADC value of neal origin were commonly reported. At path-
tumor is 0.57 × 10 −3 mm2 /s.
ologic assessment of the malignancy risk of
into two groups, that is, small (≤ 5 cm in diam- was performed to determine the optimal cutoff GISTs, 13 tumors were considered high risk,
eter) and large (> 5 cm in diameter). The cat- value of the ADC for differentiating moderate- three moderate risk, nine low risk, and eight
egoric variables were compared by chi-square to high-risk GISTs from very low– to low-risk very low risk. One GIST had insufficient data;
test or Fisher exact test between the small and GISTs. The optimal cutoff point was defined duodenal origin, tumor size of 5.5 cm, and mi-
large GISTs and between the moderate to high as the value at which the sum of the sensitiv- totic index of 3 per 50 high-power fields were
and very low to low malignancy risk GISTs. ity and specificity was maximized. A value of known [20]. The malignancy risk assessment
One-way ANOVA was used to investigate the p < 0.05 was considered statistically signifi- of GISTs was not available for eight patients
differences in the mean ADC values among the cant. All analyses were performed with SPSS who underwent endoscopic biopsy because
four risk groups. Linear correlation was used (version 19.0, IBM SPSS) and MedCalc (version the tissue of the specimen was insufficient to
to analyze the correlation between ADC values 11.3.0.0, MedCalc Software) software for Mi- allow microscopic evaluation of the mitotic
and the malignancy risk of GIST. ROC analysis crosoft Windows. count on 50 high-power fields.

A B C
Fig. 3—52-year-old man with high-malignancy-risk gastrointestinal stromal tumor in stomach.
A, Huge exophytic mass (arrowhead) in left subphrenic space displaces stomach on T2-weighted image. Large cystic cavity (asterisk) is present within mass.
B and C, Diffusion-weighted image (b = 800 s/mm2) (B) and apparent diffusion coefficient (ADC) map (C) show diffusion restriction of mass. Mean ADC value of this tumor
is 0.92 × 10 −3 mm2 /s.
(Fig. 3 continues on next page)

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D E
G H
MRI Features
The MRI features of GISTs are summa-
rized in Table 3. There were several signifi-
cant differences between small (≤ 5 cm) and
large (> 5 cm) GISTs with respect to MRI
features, including the degree and pattern
of enhancement and the presence of intratu-
moral cystic change. In terms of degree of en-
hancement and pattern of the primary tumor,
small GISTs had rather strong, homogeneous
arterial and persistent enhancement, whereas
large GISTs had mild, inhomogeneous gradu-
al enhancement (p < 0.05). Intratumoral cys-
tic change and mucosal ulceration were also
more frequently associated with large GISTs
than with small GISTs (p < 0.05).
The most prevalent imaging features of
small GISTs were round shape (56% [n =
14]) with a strong degree of enhancement
(80% [n = 20]), and a homogeneous arteri-
al and persistent enhancement pattern (32%
[n = 8]) (Fig. 1). However, large GISTs had
a lobulated shape (76% [n = 13]), mild de-
986
Yu et al.
gree of enhancement (65% [n = 11]), hetero-
geneous gradual enhancement pattern (88%
[n = 15]), and intratumoral cystic change
(76% [n = 13]) (Figs. 2 and 3).
Most of the conventional MRI features of
GISTs, except for intratumoral cystic change,
did not correlate with the malignancy risk of
GISTs (Table 4). The prevalence of intratu-
moral cystic change was significantly higher
in the moderate to high risk group than in the
very low to low risk group (p < 0.05) (Figs. 3
and 4). The intratumoral cystic change seen
on MR images (n = 20) correlated with tu-
mor necrosis (n = 2), hemorrhage (n = 4), and
both of these factors (n = 5) at pathologic ex-
amination, except in nine patients who under-
went endoscopic biopsy (n = 8) or in whom we
could not find remarks about cystic changes in
the gross or the pathologic specimen (n = 1).
Diffusion-Weighted Imaging
The mean ADC value in the high-risk
group was 0.93 ± 0.18 × 10 −3 mm2 /s; mod-
F
Fig. 3 (continued)—52-year-old man with high-
malignancy-risk gastrointestinal stromal tumor in
stomach.
D, Photograph of surgical specimen shows
huge mass with large central cystic cavity and
intratumoral hemorrhage. Mitotic index of tumor is
40 per 50 high-power fields. Tumor was confirmed
to be gastrointestinal stromal tumor with high
malignancy risk.
E–H, Unenhanced (E) and dynamic contrast-
enhanced T1-weighted images (F–H) show peripheral
solid portion of huge mass with mild heterogeneous
gradual enhancement pattern.
erate risk, 1.14 ± 0.11 × 10 −3 mm2 /s; low
risk, 1.19 ± 0.27 × 10 −3 mm2 /s; and very low
risk, 1.38 ± 0.17 × 10 −3 mm2 /s. The differ-
ence between mean ADC values in the four
risk groups was statistically significant (p <
0.05). In subgroup analysis, the difference
between the high and very low risk groups
was statistically significant (p < 0.05). There
was negative linear correlation between the
ADC values and the malignancy risk of
GISTs (r = –0.670, p < 0.05). When the cut-
off ADC value was set at 1.10 × 10 −3 mm2 /s
in the ROC curve analysis for differentiat-
ing moderate to high risk GISTs from very
low to low risk GISTs, sensitivity of 76.9%,
specificity of 83.3%, and AUC of 0.833 were
found. For small GISTs, when the cutoff
ADC value was set at 1.10 × 10 −3 mm2 /s,
the diagnostic performance for differentiat-
ing moderate to high risk GISTs from very
low to low risk GISTs was maximized with
a sensitivity of 100%, specificity of 90.9%,
and AUC of 0.939.
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 MRI of Gastrointestinal Stromal Tumors

TABLE 3: MRI Features of Gastrointestinal Stromal Tumors

Small (≤ 5 cm) Large (> 5 cm)
Feature ≤ 2 cm 2–5 cm Total 5–10 cm > 10 cm Total pa
No. of patients 3 22 25 6 11 17
Anatomic location 0.655
Stomach 0 8 8 3 8 12
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Duodenum 0 12 12 2 2 4
Jejunum and ileum 1 1 2 1 1 2
Rectum 2 1 3 0 0 0
Margins NA
Well-defined 3 22 25 6 11 17
Ill-defined 0 0 0 0 0 0
Shape 0.001
Round 3 11 14 0 0 0
Lobulated 0 9 9 6 7 13
Irregular 0 2 2 0 4 4
Growth pattern 0.065
Exophytic 2 14 16 5 11 16
Mixed 0 5 5 0 0 0
Endoluminal 1 3 4 1 0 1
Presence of ulceration 0 2 2 2 4 6 0.045
Presence of hemorrhage 0 5 5 1 7 8 0.092
Presence of cystic change 0 7 7 4 9 13 0.002
Presence of calcification 0 2 2 1 1 2 0.683
Presence of lymphadenopathy 0 0 0 0 2 2 0.079
T1 signal intensity 0.622
Similar 3 3 6 2 1 3
Low 0 19 19 4 10 14
T2 signal intensity 0.404
High 2 22 24 6 11 17
Similar 1 0 1 0 0 0
Enhancement degree 0.003
Poor 0 0 0 0 0 0
Mild 1 4 5 2 9 11
Strong 2 18 20 4 2 6
Enhancement pattern 0.005
Homogeneous arterial, persistent 2 6 8 1 1 2
Peripheral to central 0 7 7 0 0 0
Heterogeneous, gradual 1 9 10 5 10 15
Diffusion restriction 3 14 17 5 8 13 NA
Note—Diffusion-weighted imaging was available for 30 patients. Bold type indicates statistically significant difference. NA = not available.
aCalculated with chi-square test or Fisher exact test between small and large gastrointestinal stromal tumors.

Discussion
Our study results show that there are dif-
ferences in MRI features between small (≤ 5
cm) and large (> 5 cm) GISTs with respect to
shape, degree of enhancement, dynamic en-
hancement pattern, and heterogeneity with in-
tratumoral cystic change. Small GISTs were
round and had strong homogeneous arte-
rial enhancement. Large GISTs were lobu-
lated and had mild, heterogeneous, gradual
enhancement and heterogeneity with intratu-
moral cystic change. The presence of intra-
tumoral cystic change and mean ADC value
correlated with the malignancy risk of GISTs.
In general, the MRI features of the small and

AJR:203, November 2014 987

 Yu et al.

large GISTs in our study strongly agreed with
those of previous studies conducted with CT
and with the few case reports regarding the
use of MRI [6, 8, 13, 14, 21]. However, to our
knowledge, no large study has focused on
the different MRI features of small and large
GISTs with special emphasis on degree of en-
hancement and the dynamic enhancement
pattern of the tumor. As shown in our study,
the imaging features of small GISTs differed
substantially from the well-known imaging
features of large GISTs.
Because small GISTs appear as round tu-
mors with a strong homogeneous arterial and
persistent enhancement pattern, they can easily

TABLE 4: MRI Features of Gastrointestinal Stromal Tumors and Their Relation to Risk of Malignancy (n = 33)
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Risk
Feature Very Low (n = 8) Low (n = 9) Moderate (n = 3) High (n = 13) pa
Mean size 3.6 ± 1.13 3.3 ± 1.28 5.6 ± 3.92 8.02 ± 5.51
Location 0.485
Stomach 5 1 3 3
Duodenum 2 7 0 5
Jejunum and ileum 1 0 0 3
Rectum 0 1 0 2
Margins NA
Well-defined 8 9 3 13
Ill-defined 0 0 0 0
Shape 0.075
Round 4 5 2 3
Lobulated 4 4 1 6
Irregular 0 0 0 4
Growth pattern 0.115
Exophytic 4 7 2 12
Mixed 2 2 0 0
Endoluminal 2 0 1 1
Presence of ulceration 1 0 0 1 1.000
Presence of hemorrhage 1 2 1 6 0.141
Presence of cystic change 2 1 1 9 0.013
Presence of calcification 1 2 0 0 0.227
Presence of lymphadenopathy 0 0 0 0 NA
T1 signal intensity 1.000
Similar 2 2 2 2
Low 6 7 1 11
T2 signal intensity 1.000
High 8 8 3 13
Similar 0 1 0 0
Enhancement degree 0.141
Poor 0 0 0 0
Mild 2 1 1 6
Strong 6 8 2 7
Enhancement pattern 0.440
Homogeneous arterial and persistent 3 3 0 3
Periphery to center 1 3 1 2
Heterogeneous gradual 4 3 2 9
Diffusion restriction 5 7 3 10 1.000
Note—Diffusion-weighted imaging was available for 25 patients. Bold type indicates statistically significant difference. NA = not available
aCalculated with chi-square test or Fisher exact test between moderate- to high-risk and very low– to low-risk groups.

988 AJR:203, November 2014

 MRI of Gastrointestinal Stromal Tumors

be misdiagnosed as nongastrointestinal submu-
cosal tumors, such as schwannoma, neuroendo-
crine tumor of the pancreas, and other hypervas-
cular tumors [19, 22], especially when they are
located in the stomach and duodenum. There-
fore, awareness of these MRI features of small
GISTs by radiologists could be helpful in the
correct differential diagnosis of small GISTs.
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valuable for radiologists. In our study, we ob-
served a negative correlation between ADC
value and malignant risk of GIST. This result
agrees with that of a study [18] that showed
that ADC value correlated with the malig-
nant risk grade of GIST. Several studies have
shown that diffusion restriction on DW imag-
es reflects the higher cellularity of malignant
[2], the lower ADC value of malignant GISTs
than of benign GISTs could be explained by
their greater cellularity. Even though a statis-
tically significant difference was found only
between the high and very low risk groups in
our study, we believe that a low mean ADC
value can be helpful for predicting high risk
of malignancy of a GIST.

To our knowledge, no previous correla- tumors in many organs [25–29]. Considering Two previous studies, by Amano et al. [15]
tion has been established between the radi- that, in general, malignant GISTs are larger, and Zhou et al. [18], showed that the degree
ologic appearance and the malignant poten- have greater cellularity, and are more mitot- of enhancement of GISTs correlated with
tial of GISTs on CT images. However, our ically active than their benign counterparts risk of malignancy. However, the degree of
study results suggest that the presence of in-
tratumoral cystic change is frequently seen
in high-risk GISTs. The cystic tumor degen-
eration frequently occurs as a result of the
overgrowth of the tumor. Because tumor size
is one of the most important factors for pre-
dicting the malignant potential of GISTs,
we can assume that the presence of intra-
tumoral cystic change also correlates with
the risk that the tumor is malignant. In pre-
vious studies [23, 24] of the CT findings of
GIST, researchers focused on the low-atten-
uating cystic portion of the tumor for assess-
ing malignant potential. They did not find a
correlation between the low-attenuating cys-
tic portion and the malignant potential of
GISTs because the central low-attenuating
area seen on CT images can indicate various
A
pathologic conditions, including cystic de-
generation, the solid tumor itself, and fluid in
an ulcer [5]. This may, therefore, make it dif-
ficult to predict malignant potential with CT.
MRI performed with various sequences is
more accurate than CT for the characteriza-
tion of tumor components, such as fluid, mu-
cin, and fibrous portion. We believe that our
study results occurred because of the high
soft-tissue contrast of MRI. The presence of
intratumoral cystic change was also observed
in six of the eight patients for whom risk as-
sessment was not available. Even though the
mitotic count was unknown in this study, the
risk of malignancy was estimated as moderate
or high because these patients already had liv-
er metastasis or peritoneal seeding and most
of them (n = 5) had large GISTs (> 10cm).
Therefore, considering this limitation, the ac-
tual prevalence of intratumoral cystic change
in high-risk GISTs may be much higher than
our results suggested. Considering the high
incidence of liver metastases from malignant B C
GISTs and the increasing acceptance of hepa- Fig. 4—76-year-old man with high malignancy risk gastrointestinal stromal tumor in jejunum.
tocyte-specific contrast-enhanced liver MRI A, T2-weighted MR image shows lobulated exophytic mass (arrow) in left upper abdomen abutting proximal
for evaluating small liver metastases because jejunum. Mass has intratumoral cystic change (asterisk). Two hepatic metastatic lesions (arrowheads) of high
T2 signal intensity are also evident in segment VI of liver.
of its high disgnostic performance, knowl- B and C, Diffusion-weighted imaging (b = 800 s/mm2) (B) and apparent diffusion coefficient (ADC) map (C) show
edge of these MRI spectra of GISTs could be diffusion restriction of mass (arrow). Mean ADC value of mass is 1.14 × 10 −3 mm2 /s.
(Fig. 4 continues on next page)

AJR:203, November 2014 989


enhancement seen in our study was not sta-
tistically significantly different among the
malignancy risk groups. On the contrary,
in our study, strong enhancement was more
frequently observed in small GISTs than in
large GISTs (p < 0.05). Basically, this phe-
nomenon can be explained by the tumor size
and neovascularization. As a tumor grows,
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neovascularization also increases. Howev-
D E
F G
Fig. 4 (continued)—76-year-old man with high malignancy risk gastrointestinal stromal tumor in jejunum.
D–G, Unenhanced (D) and dynamic contrast-enhanced T1-weighted images (E–G)show mild heterogeneous
gradual enhancement of this lesion (arrow). Tumor has mitotic index of 30 per 50 high-power fields and was
confirmed to be gastrointestinal stromal tumor with high malignancy risk.
990
Yu et al.
er, when a tumor grows so large that neovas-
cularization does not keep up its metabolic
needs, the blood supply is not sufficient to
cover the large tumor volume. As a result,
enhancement of the large tumor decreases,
and central necrosis can be seen. Accord-
ing to our study results, the degree of en-
hancement does not seem to correlate with
the risk of malignancy of a GIST.
Our study had several limitations. First,
it was a retrospective review of cases col-
lected over 6 years at a single medical insti-
tution. Selection or referral bias is inevita-
ble in such studies, including ours. Second,
MRI is not a routinely used imaging modal-
ity for the preoperative evaluation of GIST.
Our study population underwent MRI for
evaluation of liver metastasis, further dif-
ferential diagnosis, or another research pur-
pose. This may explain why more than one
third of our study population was at high
risk of malignancy and why there was a
high prevalence of GISTs in the duodenum.
Third, MRI protocols vary with equipment
and protocols. We did not use a standard
protocol because the MRI protocols were
determined according to the anatomic lo-
cation of the tumor and the purpose of the
MRI examination. We also did not perform
DWI for all of the study patients, and we
evaluated DWI with a single pair of b val-
ues (0 and 500 s/mm 2) for patients undergo-
ing conventional DWI. Because DWI with
a low b value has a large perfusion effect,
these images can be confounding during at-
tempts to identify true restricted diffusion.
However, the lack of standardization of the
imaging parameters cannot be overcome
in a study population of this retrospective
type. Fourth, even though, to our knowl-
edge, this article presents the largest, radi-
ologic series of GISTs detected with MRI,
the number of patients in our study popula-
tion was not large. This is because MRI is
not routinely performed for the evaluation
of GIST. Further studies with large series of
patients are needed.
Conclusion
Small (≤ 5 cm) GISTs had MRI features
different from the well-known imaging fea-
tures of large GISTs. The small tumors were
round and had strong homogeneous arterial
and persistent enhancement. The presence of
intratumoral cystic change and a low mean
ADC value may be helpful for predicting the
high malignancy potential of a GIST.
Acknowledgment
We thank Bonnie Hami for editorial
­assistance.
References
1. Miettinen M, El-Rifai W, Sobin LH, Lasota J.
Evaluation of malignancy and prognosis of gas-
trointestinal stromal tumors: a review. Hum
Pathol 2002; 33:478–483
AJR:203, November 2014

2. Levy AD, Remotti HE, Thompson WM, Sobin
LH, Miettinen M. Gastrointestinal stromal tu-
mors: radiologic features with pathologic correla-
tion. RadioGraphics 2003; 23:283–304
3. Nishida T, Hirota S. Biological and clinical re-
view of stromal tumors in the gastrointestinal
tract. Histol Histopathol 2000; 15:1293–1301
4. Miettinen M, Lasota J. Gastrointestinal stromal
Downloaded from ajronline.org by 181.176.8.78 on 01/22/24 from IP address 181.176.8.78. Copyright ARRS. For personal use only; all rights reserved
tumors: pathology and prognosis at different sites.
Semin Diagn Pathol 2006; 23:70–83
5. Kim HC, Lee JM, Choi SH, et al. Imaging of gas-
trointestinal stromal tumors. J Comput Assist To-
mogr 2004; 28:596–604
6. Sandrasegaran K, Rajesh A, Rushing DA, Ryd-
berg J, Akisik FM, Henley JD. Gastrointestinal
stromal tumors: CT and MRI findings. Eur Radiol
2005; 15:1407–1414
7. Chourmouzi D, Sinakos E, Papalavrentios L,
Akriviadis E, Drevelegas A. Gastrointestinal stro-
mal tumors: a pictorial review. J Gastrointestin
Liver Dis 2009; 18:379–383
8. Ghanem N, Altehoefer C, Furtwangler A, et al.
Computed tomography in gastrointestinal stromal
tumors. Eur Radiol 2003; 13:1669–1678
9. Dematteo RP, Gold JS, Saran L, et al. Tumor mitotic
rate, size, and location independently predict recur-
rence after resection of primary gastrointestinal stro-
mal tumor (GIST). Cancer 2008; 112:608–615
10. Fletcher CD, Berman JJ, Corless C, et al. Diagno-
sis of gastrointestinal stromal tumors: a consensus
approach. Hum Pathol 2002; 33:459–465
11. Kim HC, Lee JM, Kim KW, et al. Gastrointestinal
stromal tumors of the stomach: CT findings and
prediction of malignancy. AJR 2004; 183:893–898
12. Ponsaing LG, Kiss K, Loft A, Jensen LI, Hansen
AJR:203, November 2014
MRI of Gastrointestinal Stromal Tumors
MB. Diagnostic procedures for submucosal tu-
mors in the gastrointestinal tract. World J Gastro-
enterol 2007; 13:3301–3310
13. Levy AD, Remotti HE, Thompson WM, Sobin
LH, Miettinen M. Anorectal gastrointestinal stro-
mal tumors: CT and MR imaging features with
clinical and pathologic correlation. AJR 2003;
180:1607–1612
14. Caramella T, Schmidt S, Chevallier P, et al. MR
features of gastrointestinal stromal tumors. Clin
Imaging 2005; 29:251–254
15. Amano M, Okuda T, Amano Y, Tajiri T, Kumaza-
ki T. Magnetic resonance imaging of gastrointes-
tinal stromal tumor in the abdomen and pelvis.
Clin Imaging 2006; 30:127–131
16. Kim H, Kim JH, Lim JS, et al. MRI findings of
rectal submucosal tumors. Korean J Radiol 2011;
12:487–498
17. Tateishi U, Miyake M, Maeda T, Arai Y, Seki K,
Hasegawa T. CT and MRI findings in KIT-weak
or KIT-negative atypical gastrointestinal stromal
tumors. Eur Radiol 2006; 16:1537–1543
18. Zhou HY, Zhang XM, Zeng NL, Jian SH, Tang W.
Use of conventional MR imaging and diffusion-
weighted imaging for evaluating the risk grade of
gastrointestinal stromal tumors. J Magn Reson
Imaging 2012; 36:1395–1401
19. Choi JW, Choi D, Kim KM, et al. Small submuco-
sal tumors of the stomach: differentiation of gastric
schwannoma from gastrointestinal stromal tumor
with CT. Korean J Radiol 2012; 13:425–433
20. Demetri GD, von Mehren M, Antonescu CR, et al.
NCCN Task Force report: update on the management
of patients with gastrointestinal stromal tumors. J
Natl Compr Cancer Netw 2010; 8(suppl 2):S1–S41
21. Gong J, Kang W, Zhu J, Xu J. CT and MR imag-
ing of gastrointestinal stromal tumor of stomach:
a pictorial review. Quant Imaging Med Surg 2012;
2:274–279
22. Raman SP, Hruban RH, Cameron JL, Wolfgang
CL, Fishman EK. Pancreatic imaging mimics.
Part 2. Pancreatic neuroendocrine tumors and
their mimics. AJR 2012; 199:309–318
23. Burkill GJ, Badran M, Al-Muderis O, et al. Ma-
lignant gastrointestinal stromal tumor: distribu-
tion, imaging features, and pattern of metastatic
spread. Radiology 2003; 226:527–532
24. Kim HC, Lee JM, Kim SH, et al. Small gastroin-
testinal stromal tumours with focal areas of low
attenuation on CT: pathological correlation. Clin
Radiol 2005; 60:384–388
25. Coolen J, De Keyzer F, Nafteux P, et al. Malignant
pleural disease: diagnosis by using diffusion-weight-
ed and dynamic contrast-enhanced MR imaging—
initial experience. Radiology 2012; 263:884–892
26. Vargas HA, Akin O, Franiel T, et al. Diffusion-
weighted endorectal MR imaging at 3 T for pros-
tate cancer: tumor detection and assessment of
aggressiveness. Radiology 2011; 259:775–784
27. Thoeny HC, Forstner R, De Keyzer F. Genitouri-
nary applications of diffusion-weighted MR im-
aging in the pelvis. Radiology 2012; 263:326–342
28. Padhani AR, Koh DM, Collins DJ. Whole-body
diffusion-weighted MR imaging in cancer: cur-
rent status and research directions. Radiology
2011; 261:700–718
29. Provenzale JM, Mukundan S, Barboriak DP. Diffu-
sion-weighted and perfusion MR imaging for brain
tumor characterization and assessment of treatment
response. Radiology 2006; 239:632–649
991