2 major risk factors in USA: Tobacco and alcohol abuse
• Adenocarcinoma
90-100% of cases arise from Barrett mucosa
Increasing in prevalence relative to SCC, especially in USA
• Double-contrast esophagography
Best for detection of early cancer
Usually sessile polyp or flattening of esophageal wall
• Advanced cancer
Luminal constriction (stricture) with nodular or ulcerated mucosa
Polypoid, ulcerative, varicoid, irregular constricting forms
• CT: Useful for staging
Mediastinal and abdominal lymphadenopathy
Liver and other metastases
• PET/CT: Superior to CT in detecting regional and distant metastases
• Endoscopic ultrasonography (EUS)
Best technique for determining locoregional extent of tumor
TOP DIFFERENTIAL DIAGNOSES
• Reflux esophagitis (with stricture)
• Esophageal intramural benign tumors
• Esophageal metastases and lymphoma
• Radiation esophagitis
• Foreign body, esophagus
CLINICAL ISSUES
• Dramatic change from squamous cell to adenocarcinoma prevalence in USA within past 20 years
• Early cancer: 5-year survival = 90%
• Treatment
Surgery, radiation (pre- and postoperative radiation)
Esophagectomy with gastric interposition is most common
(Left) Graphic shows a sessile polypoid mass with an irregular surface that infiltrates the esophageal wall and narrows the lumen, a typical appearance of an esophageal carcinoma.
(Right) Spot film from an esophagram shows a polypoid mass of the distal esophagus with an irregular surface and luminal narrowing. This was a squamous cell carcinoma.
(Left) The initial 2 films from a barium esophagram (not shown) looked normal. However, a repeat film, with emphasis on suspended deep inspiration and Valsalva maneuver, demonstrates nodular thickened folds in the distal esophagus.
(Right) Another spot film in the same patient with deep inspiration and Valsalva demonstrates nodular thickened folds and luminal narrowing in the distal esophagus. Biopsy confirmed adenocarcinoma.
TERMINOLOGY
Definitions
• Squamous cell carcinoma (SCC): Malignant transformation of squamous epithelium
• Adenocarcinoma: Malignant dysplasia in columnar metaplasia (Barrett mucosa)
IMAGING
General Features
• Best diagnostic clue
Fixed irregular narrowing of esophageal lumen with destroyed mucosal pattern