Esophageal Metastases and Lymphoma

[level-membership-for-radiology-category] Dysphagia, weight loss, hematemesis, or asymptomatic

• Esophageal metastases

 Direct, lymphatic, or hematogenous spread

 Direct invasion most common route: Gastric and lung cancer most common primary tumors

• Complications

 GI bleeding, perforation, obstruction

• Treatment

 Chemotherapy; radiation therapy

 Surgical resection of complicating lesions (obstruction, upper GI bleed)

 Endoluminal stent for obstructing lesions

• Prognosis

 Usually poor

IMAGING

General Features

• Best diagnostic clue

 From gastric cancer: Ulcerated/polypoid mass of gastric cardia extending into distal esophagus

 From lung cancer: Extrinsic indentation of upper esophagus from primary cancer or malignant adenopathy

Radiographic Findings

• Fluoroscopic-guided double-contrast barium study

 Direct invasion, gastric carcinoma: Distal esophagus

– Ulcerated/polypoid mass of cardia/fundus

– Irregular or smooth, tapered narrowing of distal esophagus ± discrete mass

 Direct invasion of cancer of larynx, pharynx, thyroid, lung: Cervical or thoracic esophagus

– Smooth or slightly irregular esophageal wall, soft tissue mass in adjacent neck/mediastinum

– Serrated, scalloped, or nodular esophageal wall → narrowing/obstruction

– Thyroid cancer: Expansile intraluminal mass

 Contiguous involvement by mediastinal nodes (breast, lung cancer): Mid esophagus

– Smooth, lobulated esophageal indentation or ulceration at level of carina

 Hematogenous spread: Mid esophagus

– Melanoma and breast are most common

– Breast cancer: Short/eccentric strictures

– Malignant melanoma (rare): Submucosal masses, centrally ulcerated “bull’s-eye” lesions

 Lymphoma, usually non-Hodgkin (NHL)

– Often involves stomach as well

– May be part of widespread lymphadenopathy

 Primary intrinsic esophageal lymphoma (very rare)

– Polypoid mass/stricture

– Nodular “folds” mimicking varices

– Submucosal mass may simulate leiomyoma or other benign mural lesions

CT Findings

• Visualize primary tumor, esophageal extension

• Detect mediastinal lymphadenopathy and extent

Ultrasonographic Findings

• Grayscale ultrasound

 Endoscopic ultrasonography (EUS)

– Hypoechoic mass disrupting normal wall layers

– Selective/diffusely thickened echogenic wall layers

DIFFERENTIAL DIAGNOSIS

Esophageal Intramural Benign Tumor

• Submucosal lesions arising within esophageal wall

• Leiomyoma

 Round/ovoid filling defect, outlined by barium

 Borders form right or obtuse angles with wall

 Extrinsic compression, no wall invasion

 Mass lobulation/ulceration suggests malignancy

Esophageal Carcinoma

• Polypoid, ulcerated, infiltrative types

• Narrows lumen, abrupt borders (“rat tail”)

• Periesophageal and distal spread may be seen

• Diagnosis: Endoscopy and biopsy

Esophageal Varices

• Serpiginous, longitudinal radiolucent filling defects

• Easily distinguished from tumor by CT in most cases

PATHOLOGY

General Features

• Associated abnormalities

 Esophageal metastases

– Direct, lymphatic, or hematogenous spread

 Direct invasion most common: From stomach (> 50%) and lung most often

 Lymphoma; generalized adenopathy, AIDS

Gross Pathologic & Surgical Features

• Solitary/multiple, polypoid/ulcerated masses, stricture

Microscopic Features

• Metastases: Varies based on primary cancer

• Lymphoma: Lymphoepithelial lesions

CLINICAL ISSUES

Presentation

• Most common signs/symptoms

 Dysphagia, weight loss, hematemesis

Demographics

• Epidemiology

 Usually in older adults (same demographics as for primary extraesophageal cancer)

 Esophageal lymphoma

– Least common site within GI tract (1% of cases)

– Usually NHL, less commonly Hodgkin

– Secondary lymphoma (90%) > > primary (10%)

– Primary esophageal lymphoma seen in AIDS

Natural History & Prognosis

• Complications: GI bleeding, perforation, obstruction

• Prognosis: Usually poor

Treatment

• Chemotherapy; radiation therapy

• Endoluminal stent for obstructing lesions

[/level-membership-for-radiology-category][not-level-membership-for-radiology-category] Dysphagia, weight loss, hematemesis, or asymptomatic

• Esophageal metastases

 Direct, lymphatic, or hematogenous spread

 Direct invasion most common route: Gastric and lung cancer most common primary tumors

• Complications

 GI bleeding, perforation, obstruction

• Treatment

 Chemotherapy; radiation therapy

 Surgical resection of complicating lesions (obstruction, upper GI bleed)

 Endoluminal stent for obstructing lesions

• Prognosis

 Usually poor

IMAGING

General Features

• Best diagnostic clue

 From gastric cancer: Ulcerated/polypoid mass of gastric cardia extending into distal esophagus

 From lung cancer: Extrinsic indentation of upper esophagus from primary cancer or malignant adenopathy

Radiographic Findings

• Fluoroscopic-guided double-contrast barium study

 Direct invasion, gastric carcinoma: Distal esophagus

– Ulcerated/polypoid mass of cardia/fundus

– Irregular or smooth, tapered narrowing of distal esophagus ± discrete mass

 Direct invasion of cancer of larynx, pharynx, thyroid, lung: Cervical or thoracic esophagus

– Smooth or slightly irregular esophageal wall, soft tissue mass in adjacent neck/mediastinum

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Diagnostic Imaging_ Gastrointes - Michael P Federle