Esophageal Metastases and Lymphoma

Published on 19/07/2015 by admin

Filed under Radiology

Last modified 22/04/2025

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 Dysphagia, weight loss, hematemesis, or asymptomatic

• Esophageal metastases

image Direct, lymphatic, or hematogenous spread
image Direct invasion most common route: Gastric and lung cancer most common primary tumors
• Complications

image GI bleeding, perforation, obstruction
• Treatment

image Chemotherapy; radiation therapy
image Surgical resection of complicating lesions (obstruction, upper GI bleed)
image Endoluminal stent for obstructing lesions
• Prognosis

image Usually poor

DIAGNOSTIC CHECKLIST

• Check for history of primary extraesophageal cancer; biopsy required
• Overlapping radiographic features of esophageal metastases, lymphoma, and primary carcinoma
image
(Left) In this 60-year-old woman with lung cancer and progressive dysphagia, 2 views from an esophagram show extrinsic or intramural narrowing of the mid esophagus image, but intact mucosal folds, representing invasion by her lung cancer.

image
(Right) Esophagram in a man with known lung cancer and dysphagia shows a broad shelf-like indentation image along the anterior wall of the mid esophagus.
image
(Left) In this 62-year-old man, a spot film of the distal esophagus shows a distal stricture and mucosal irregularity image that mimics primary esophageal cancer. However, other views (not shown) showed nodular thickened folds in the gastric fundus.

image
(Right) CT in the same patient shows a mass image within the wall of the fundus with extension into the perigastric tissues and nodes. Endoscopy confirmed a primary gastric carcinoma.

TERMINOLOGY

Definitions

• Metastases from primary cancer of other sites
• Lymphoma: Malignant tumor of lymphocytes

IMAGING

General Features

• Best diagnostic clue

image From gastric cancer: Ulcerated/polypoid mass of gastric cardia extending into distal esophagus
image From lung cancer: Extrinsic indentation of upper esophagus from primary cancer or malignant adenopathy

Radiographic Findings

• Fluoroscopic-guided double-contrast barium study

image Direct invasion, gastric carcinoma: Distal esophagus

– Ulcerated/polypoid mass of cardia/fundus
– Irregular or smooth, tapered narrowing of distal esophagus ± discrete mass
image 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
image Contiguous involvement by mediastinal nodes (breast, lung cancer): Mid esophagus

– Smooth, lobulated esophageal indentation or ulceration at level of carina
image 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
image Lymphoma, usually non-Hodgkin (NHL)

– Often involves stomach as well
– May be part of widespread lymphadenopathy
image 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

image 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

image Round/ovoid filling defect, outlined by barium
image Borders form right or obtuse angles with wall
image Extrinsic compression, no wall invasion
image 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

image Esophageal metastases

– Direct, lymphatic, or hematogenous spread

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

image Dysphagia, weight loss, hematemesis

Demographics

• Epidemiology

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

DIAGNOSTIC CHECKLIST

Consider

• Check for history of primary extraesophageal cancer;  biopsy required

Image Interpretation Pearls

• Overlapping radiographic features of esophageal metastases, lymphoma, and primary carcinoma
• Imaging important to identify and stage malignancy
image
Esophagram shows innumerable submucosal nodules, 3-10 mm in size, due to lymphoma. (Courtesy M. Levine, MD.)

image
Esophagram shows smooth stricture of the mid esophagus due to direct invasion by lung cancer.
image
Axial CECT shows gastric carcinoma in the fundus image extending cephalad into the esophagus image.
image
Upper GI series shows a mass image in the gastric fundus extending cephalad into the esophagus image in this patient with gastric carcinoma.

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