ORIGINAL ARTICLE

Incidental diagnosis
of a gastric mass on

chest radiographs

W F C van Gelderen
FCRad(D) SA

Department of Radiology, Masterton Hospital,
Masterton, New Zealand

Abstract
Careful inspection of the infra-
diaphragmatic area on chest radi-
ographs may lead to diagnosis of dif-
ferent conditions such as gastric fun-
dal masses, sub-diaphragmatic free
air, subphrenic abscess, bowel
obstruction, etc. Case histories are
presented for 4 patients in whom the
diagnosis of a gastric tumour was
made on chest X-ray.

The importance of including the
infradiaphragmatic area as a review
area of the chest X-ray is emphasised.

Introduction
Traditional review areas on chest

radiographs (important areas that
should be reviewed after a systematic
examination of the radiographs)
include the lung apices, the hilar
regions, the retrocardiac area and the
costophrenic angles. I The infradi-
aphragmatic area is not a classical
review area, but can easily be added to
the last-named review area as many
important entities may be identified.

Conditions include subdiaphragmatic
free air, bowel obstruction, hepatic or
splenic calcification, signs of previous
surgery, subphrenic abscess and
abnormality of the gastric air bubble.

Over a 20-year period 4 cases of a
mass in the cardia of the stomach
were incidentally detected on chest
radiographs by the author.

Case reports
Casel

A 59-year-old man scheduled for
eye surgery was referred for preopera-
tive chest radiographs (Fig. la). These
revealed signs of chronic obstructive
airways disease, a segmental atelectasis
in the left lower lobe and an oblong air
loculus projecting beyond the left tra-
cheal border. (The latter was due to a
localised traction diverticulum, well
demonstrated on subsequent barium
swallow, and secondary to previous
tuberculosis in the left upper lobe).

A 5.5 x 4.0 cm rounded mass was
identified in the gastric cardia, convex
to lateral and extending into the gas
shadow of the gastric fundus. The
mass was noted to be well-defined,
homogeneous, and apparently entire-
ly intragastric on barium examination
(Fig. lb). The radiological diagnosis
of a leiomyoma was confirmed by
biopsy.

Case2
A 61-year-old woman, a known

30 SA JOURNAL OF RADIOLOGY. August 2003

Fig. 1a. Case 1. Frontal chest radiograph demon-
strates signs of chronic obstructive airways disease,
left basal segmental atelectasis (retrocardiac), an
air loculus projecting beyond the border of the left
side of the trachea due to an oesophageal traction
diverticulum (small arrows). and a gastric mass
arising from the cardia of the stomach (arrow).

Fig. 1b. Case 1. Barium meal confirms mass
(leiomyoma) (arrowheads) arising from the cardia
of the stomach.

asthmatic, presented with acute dysp-
noea and cough and a clinical diagno-
sis of pneumonia was favoured. A
frontal chest radiograph revealed a
large right-sided pneumothorax,
which was treated with an intercostal
drainage tube. Once the right lung
had re-expanded underlying tubercu-
lous infiltration was identified (Fig. 2)
and active tuberculosis was confirmed
clinically. The tuberculosis was treat-
ed effectively,and chest films taken 6



ORIGINAL ARTICLE

Fig. 2. Case 2. Frontal chest X-ray shows signs of
active tuberculous disease in the right upper lobe
and a small rounded mass within the cardia of the
stomach (arrow) (unconfirmed leiomyoma).

months later only demonstrated some
residual fibrotic scarring.

A 2.7 x 2.7 cm mass, quite obvious
as it was well outlined by air, was
noted on all the chest radiographs
within the gastric cardia.

Reviewing the X-rays, a barium
study performed 4 years previously
was discovered in another X-ray pack-
et and demonstrated the mass to be
the same size as the mass on chest
radiographs 4 years later. The surgeon
opted for a conservative approach,
and the radiological diagnosis of a
leiomyoma was not confirmed.

Case3
A 55-year-old woman with known

chronic obstructive airways disease
was referred for chest radiographs. In
addition to the airways disease, a large
rounded mass convex to anterior, with
a semilunar gas shadow within the
stomach in front of it, was demon-
strated on the left lateral film (Fig. 3a).
The frontal film did not reveal the
mass and little gas was seen in the
stomach. A barium meal was recom-
mended and 4 days later the patient

Fig. 3a. Case 3. Lateral chest radiography demon-
strates an apparent mass in the stomach protruding
convex to anterior (arrows) with a semilunar gastric
air shadow anteriorly.

Fig. 3b. Case 3. Lateral barium meal film confirms
a lobulated mass in the cardia of the stomach (but
found to be Irregular in outline on other views sug-
gestive of a malignant lesion) and confirmed to be
due to a carcinoma.

presented with the request form mak-
ing mention of peptic ulcer syInp-
toms, profound anaemia and occult
blood in the stool. The barium meal
(Fig. 3b) confirmed the 6.0 x 5.5 cm
mass, which was lobulated and
thought to be due to a leiomyoma or
a carcinoma. Gastroscopy demon-

31 SA JOURNAL OF RADIOLOGY. August 2003

strated a polypoid mass with a malig-
nant appearance, confirmed on his-
tology.

Case4
A 72-year-old woman was referred

for a preoperative chest X-ray which
demonstrated an apparently inciden-
tal3.0 x 2.7 cm mass in the gastric car-
dia (Fig. 4a). Previous films were
obtained at a later stage and it became
evident that a gastric carcinoma had
already been diagnosed by endoscopy
and abdominal computed tomogra-
phy (CT) (Fig.4b). The patient had
presented with loss of weight,

Fig. 4a. Case 4. Frontal chest radiography demon-
strates a small looulated mass (arrow) situated in
the cardia of the stomach protruding into the gastric
air bubble convex to lateral.

Fig. 4b. Case 4. Axial CT section shows a small
mass in the cardia of the stomach (arrows) without
extragastric involvement or lymphadenopathy and
due to a well-differentiated adenocarcinoma.



ORIGINAL ARTICLE

anaemia and a central abdominal
mass. CT had demonstrated the mass
in the gastric cardia without extragas-
tric extension or lymphadenopathy. A
well-differentiated adenocarcinoma
was surgically resected.

Discussion
Gas was noted to be present in the

stomach in 500 of 700 normal chest
radiographs.' Absence of gas in the
stomach may occur associated with
oesophageal disease, e.g. carcinoma or
achalasia. The gas shadow of the gas-
tric fundus may be indented by a nor-
mal left lobe of the liver on its medial
aspect or the spleen on its lateral
aspect.' An adjacent mass, such as a
subphrenic abscess, may also indent
the stomach, but other signs such as a
left pleural effusion would usually be
associated with a subphrenic abscess.

Apart from an extrinsic impres-
sion, an intraluminal mass such as a
food bolus or bezoar should be con-
sidered. Previous surgery for hiatus
hernia (fundoplication) can also
deform the gastric fundus and simu-
late a mass: Gastric varices and an
inverted hiatus hernia can likewise
cause a 'mass' in the cardia of the
stomach.

Having excluded an intraluminal
mass and an extrinsic impression, the
third possibility that should always be
excluded relating to any tubular struc-
ture, is disease arising from the wall.
Inthe above case studies, a leiomyoma
(often ovoid or rounded with a well-
defined outline) or a carcinoma (often
less rounded, often lobulated and/or
ill-defined polypoid) was responsible
in each case.

In the cases diagnosed incidentally,

the mass within the stomach was
rounded, of soft tissue density and
clearly outlined by air for at least
half of its circumference. In all these
instances, however, the mass could
have been easily overlooked if the
infradiaphragmatic area had not been
included as one of the review areas.

References
1. Pierce]W, Graigner RG. The normal chest:

techniques. In: Sutton D, ed. A Textbook of
Radiology and Imaging. 3rd ed. Edinburgh:
Churchill Livingstone, 1980: 260.

2. Felson B. A review of over 30 000 normal chest
roentgenograms. In: Felson B, ed. Chest
Roentgenology. Philadelphia: WB Saunders,
1973: 498-499.

3. Chapman AH. The stomach and duodenum.
In: Sutton D, ed. A Textbook of Radiology and
Imaging. 6th ed. Edinburgh: Churchill
Livingstone, 1998: 831-832.

4. Berk RN. The postoperative stomach. In:
Tepliek JG, Haskin ME, eds. Surgical Radiology.
Philadelphia: WB Saunders, 1981: 490.

32 SA JOURNAL OF RADIOLOGY • August 2003