Esophageal Carcinoma

Published on 19/07/2015 by admin

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Last modified 19/07/2015

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 2 major risk factors in USA: Tobacco and alcohol abuse

• Adenocarcinoma

image 90-100% of cases arise from Barrett mucosa
image Increasing in prevalence relative to SCC, especially in USA
• Double-contrast esophagography

image Best for detection of early cancer
image Usually sessile polyp or flattening of esophageal wall
• Advanced cancer

image Luminal constriction (stricture) with nodular or ulcerated mucosa
image Polypoid, ulcerative, varicoid, irregular constricting forms
• CT: Useful for staging

image Mediastinal and abdominal lymphadenopathy
image Liver and other metastases
• PET/CT: Superior to CT in detecting regional and distant metastases
• Endoscopic ultrasonography (EUS)

image 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

image Surgery, radiation (pre- and postoperative radiation)
image Esophagectomy with gastric interposition is most common
image
(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.

image
(Right) Spot film from an esophagram shows a polypoid mass image of the distal esophagus with an irregular surface and luminal narrowing. This was a squamous cell carcinoma.
image
(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 image in the distal esophagus.

image
(Right) Another spot film in the same patient with deep inspiration and Valsalva demonstrates nodular thickened folds image 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

image Fixed irregular narrowing of esophageal lumen with destroyed mucosal pattern
• Location

image Middle 1/3 (50%), lower 1/3 (30%), upper 1/3 (20%)
• Morphology

image Classification of advanced esophageal cancer based on gross pathology and radiographic findings

– Infiltrating, polypoid, ulcerative, varicoid lesions
• Other general features

image Carcinoma is most common tumor of esophagus (> 95%)
image Squamous cell cancer (SCC)

– Accounts for about  40% of esophageal cancer in USA and 90% in developing countries

image Decreasing in relative prevalence as adenocarcinoma becomes more common
– Human papillomavirus: Synergistic increased risk factor

image Especially in China and South Africa
– 1% of all cancers and 7% of all gastrointestinal cancers
– 2 major risk factors in USA: Tobacco and alcohol abuse
image Adenocarcinoma

– Accounts for > 60% of esophageal cancer in USA
– Increasing in prevalence relative to SCC
– 90-100% of cases arise from Barrett mucosa

Radiographic Findings

• Radiography

image Chest radiograph (PA and lateral view): Advanced carcinoma

– Hilar, retrohilar, or retrocardiac mass
– Anterior bowing of posterior tracheal wall
– Retrotracheal stripe thickening > 3 mm
• Double-contrast esophagography: En face and profile views

image Early esophageal squamous cell cancer

– Plaque-like lesions: Small, sessile polyps, or depressed lesions
image Early adenocarcinoma in Barrett esophagus

– Plaque-like lesions: Flat, sessile polyps
– Localized area of flattening/stiffening in wall of peptic stricture (common in distal 1/3)
image Advanced esophageal squamous cell cancer

– Infiltrating lesion (most common): Irregular narrowing, luminal constriction (stricture) with nodular or ulcerated mucosa
– Polypoid lesion: Lobulated, fungating intraluminal mass
– Ulcerative lesion: Well-defined meniscoid ulcers with radiolucent rim of tumor surrounding ulcer in profile view
– Varicoid lesion: Thickened, tortuous, serpiginous longitudinal folds due to submucosal spread of tumor, mimicking varices

image Key difference: No change on repeated films
image Advanced adenocarcinoma in Barrett esophagus

– Radiologically indistinguishable from SCC
– Long infiltrating lesion in distal esophagus

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