Esophageal Carcinoma

Published on 19/07/2015 by admin

Filed under Radiology

Last modified 22/04/2025

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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
image Stricture in advanced carcinoma

– Asymmetric contour with abrupt proximal borders of narrowed distal segment (“rat-tail” appearance)

CT Findings

• CT: Staging of esophageal carcinoma

image Stages I and II: Localized wall thickening or small luminal tumor, without mediastinal invasion
image Stage III: Tumor extends beyond esophagus into mediastinal tissues

– Tracheobronchial invasion: Posterior wall indentation/bowing and tracheobronchial displacement/compression; ± collapse of lobes
– Aortic invasion: Uncommon finding (2% of cases)
– Pericardial invasion: Based on obliteration of fat plane or mass effect
– Mediastinal adenopathy: Discrete or confluent with primary tumor
image Stage IV: Extends into mediastinum and distant sites

– Liver, lungs, pleura, adrenals, kidneys, and nodes
– Subdiaphragmatic adenopathy seen in > 2/3 of distal cancers

MR Findings

• Provides similar information as CT

Ultrasonographic Findings

• Grayscale ultrasound

image Endoscopic ultrasonography (EUS)

– Best technique for determining locoregional extent of tumor
– Malignant nodes: Hypoechoic and well defined
– Benign nodes: Hyperechoic; indistinct borders

Nuclear Medicine Findings

• PET

image FDG-18F positron emission tomography (FDG PET)

– More sensitive and superior to CT in detecting regional and distant metastases

Imaging Recommendations

• Double-contrast esophagography for detection
• EUS for locoregional evaluation
• CT and PET for metastases

DIFFERENTIAL DIAGNOSIS

Reflux Esophagitis (With Stricture)

• Concentric, smooth tapering of short distal segment

image Distinguished by normal peristalsis in benign type
image Lack of peristalsis in malignant stricture
• Diagnosis: Endoscopic biopsy and history

Esophageal Intramural Benign Tumors

• Leiomyoma > > gastrointestinal stromal tumor
• Borders form right angles or obtuse angles with wall
• Round or ovoid filling defect, outlined by barium
• Usually have smooth, intact mucosa
• Ulceration of surface mucosa may mimic carcinoma

Esophageal Metastases and Lymphoma

• May invade esophagus directly
• May cause irregular narrowing of lumen
• History and imaging evidence of lung cancer

Radiation Esophagitis

• Irregular stricture of irradiated portion of esophagus
• Check for history of lung, mediastinal, or other thoracic tumor

Foreign Body, Esophagus

• Impacted meat bolus appears as polypoid, irregular filling defect
• Incompletely distended esophagus below impaction may be mistaken for pathologic narrowing
• Esophagram after foreign body removal may show underlying normal esophagus, Schatzki ring, stricture

PATHOLOGY

General Features

• Etiology

image Squamous cell carcinoma

– Smoking, alcohol, achalasia, lye strictures
– Celiac disease, head and neck tumor
– Plummer-Vinson syndrome, radiation, tylosis
– Human papillomavirus, synergistic effect
image Adenocarcinoma

– Barrett esophagus accounts for almost all cases
• Genetics

image Genomic instability in patients with Barrett esophagus may increase risk of adenocarcinoma

Staging, Grading, & Classification

• Spread: Local, lymphatic, hematogenous
• TNM staging

image Stage 0: Carcinoma in situ
image Stage I: Lamina propria or submucosa
image Stage IIA: Muscularis propria and adventitia
image Stage IIB: Lamina propria, submucosa, muscularis propria, and regional lymph nodes
image Stage III: Invades adjacent structures, regional lymph nodes, or any other nodes
image Stage IV: All layers, same and any other nodes, or distant metastases

Gross Pathologic & Surgical Features

• Infiltrating, polypoid, ulcerative, or varicoid lesions

Microscopic Features

• Squamous cell atypia; columnar glands
• Adeno and squamous components

CLINICAL ISSUES

Presentation

• Most common signs/symptoms

image Dysphagia (solids), odynophagia (painful swallowing), anorexia, weight loss, retrosternal pain
• Clinical profile

image Elderly patient with history of difficulty in swallowing solids and weight loss
• Lab data

image ± hypochromic, microcytic anemia
image ± hemoccult-positive stool or decreased albumin
• Diagnosis: Endoscopic biopsy and histology

Demographics

• Age

image Usually > 50 years
• Gender

image M:F = 4:1
• Ethnicity

image African Americans > Caucasians (2:1)
• Epidemiology

image Increased incidence in Turkey, Iran, India, China, South Africa, France, Saudi Arabia
image Dramatic change from squamous cell to adenocarcinoma prevalence in USA within past 20 years

Natural History & Prognosis

• Complications

image Fistula to trachea, bronchi, pericardium
• Prognosis

image Early cancer: 5-year survival = 90%
image Advanced cancer: 5-year survival = < 10%

Treatment

• Curative 

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

– Ivor-Lewis or alternate procedure
• Palliative

image Surgery, radiation, chemotherapy
image Laser treatment, indwelling prosthesis

DIAGNOSTIC CHECKLIST

Consider

• Overlap of imaging findings with inflammatory causes of strictures and mucosal irregularity
• Endoscopic biopsy often required

Image Interpretation Pearls

• Irregular narrowing with nodular/ulcerated mucosa
• Asymmetric contour with abrupt proximal borders of narrowed distal segment (“rat-tail” appearance)

image
(Left) Esophagram shows an “apple core” constricting lesion image of the distal esophagus. There is an abrupt transition, or shoulder, at the proximal end of the tumor as it abuts the normal esophagus. The mucosa through the tumor is destroyed with nodular contours.
image
(Right) Esophagram in the same patient shows nodular thickened folds image in the gastric cardia as well, strongly suggesting gastric extension of the tumor. Alternatively, gastric carcinoma may invade the distal esophagus.
image
(Left) Axial PET/CT shows intense FDG uptake within a primary esophageal cancer image.

image
(Right) Axial, more caudal PET/CT in the same patient shows intense FDG uptake within an aortocaval node image, indicating metastases to the upper abdomen. There is also abnormal uptake within a left renal mass image, which proved to be an unrelated primary renal cell carcinoma. PET/CT is the most effective means of evaluation for the total extent of disease and often affects management decisions.
image
(Left) Endoscopic ultrasound demonstrates an intraluminal mass image that does not penetrate the muscularis propria (T1a adenocarcinoma). Endoluminal sonography is the best method for determining the depth of tumor invasion.

image
(Right) Endoscopic photograph in the same patient shows an irregular polypoid mass image in the distal esophagus. This adenocarcinoma was treated by esophagectomy with gastric interposition in the chest.
image
Esophagrams show a large fungating polypoid mass with acute angle interface with the esophageal wall.

image
Esophagrams demonstrate delayed passage of a barium pill, drawing attention to a stricture with subtle mucosal irregularity. This case proved to be squamous cell carcinoma.
image
Axial CECT shows mural thickening near the gastroesophageal junction due to carcinoma. Note the liver metastasis image.
image
Axial CECT shows extensive lymphadenopathy in the gastrohepatic region due to metastases from distal esophageal carcinoma.

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