AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Multimedia
• References

Background

Cancer of the esophagus remains a devastating disease because it is usually not detected until it has progressed to an advanced incurable stage. Modern imaging techniques, including barium esophagraphy, contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI), endoscopic ultrasonography (EUS), and positron-emission tomography (PET), are powerful tools in the detection, diagnosis, and staging of this malignancy. Early detection remains the elusive but essential goal of research. Only surgical resection at a very early stage has been shown to improve survival rates in patients with this disease.

Pathophysiology

The most common types of esophageal carcinoma are squamous cell carcinoma and adenocarcinoma.

Squamous cell carcinoma

The normal esophagus is lined by stratified squamous nonkeratinizing epithelium. Squamous cell carcinoma arises from this epithelial layer in apparent response to chronic toxic irritation. Alcohol, tobacco, and certain nitrogen compounds have been identified as carcinogenic irritants.

Alcohol and tobacco use are the principal modifiable risk factors for esophageal squamous cell carcinoma. According to the American Cancer Society, the combination of long-term alcohol ingestion and tobacco use is the most substantial risk factor. Nitrosamines and other nitrosyl compounds are found in pickled vegetables, smoked meats, and the water supply of certain geographic regions where the incidence of esophageal squamous cell carcinoma is high. In regions in which the soil is deficient in molybdenum and zinc, plants are impaired in their ability to metabolize nitrites to ammonia. This impairment permits potentially toxic nitrogen compounds to accumulate within plants that enter the human food supply.

Anecdotal associations have been made between esophageal squamous cell carcinoma and chronic consumption of hot liquids, betel nuts, asbestos, air pollution, and diets high in spice content. Conversely, consumption of a diet high in fruits and vegetables has a protective effect.

Certain medical conditions predispose patients to the development of esophageal squamous cell carcinoma. These include achalasia, lye strictures, head and neck tumors, celiac disease, Plummer-Vinson syndrome, tylosis, and prior exposure to radiation. Squamous cell carcinoma may arise in the setting of achalasia, typically after a period of 20 or more years, and it is believed to result from long-standing irritation by retained material. Of patients with strictures caused by lye ingestion, 3% develop squamous carcinomas after 20-40 years. The association of head and neck tumors with squamous cell carcinoma of the esophagus is explained best by the common risk factors of alcohol and tobacco use.

Plummer-Vinson syndrome consists of dysphagia, iron-deficiency anemia, and esophageal webs. Patients with this syndrome have an increased incidence of postcricoid squamous cell carcinoma. Squamous cell carcinoma of the esophagus occurs in almost all patients with tylosis, a rare autosomal dominant disorder characterized by esophageal papillomas and hyperkeratosis of the palms and soles.

Infection with human papillomavirus, particularly subtypes 16 and 18, has been implicated in the pathogenesis of esophageal squamous cell carcinoma.

Adenocarcinoma

Adenocarcinoma, which is most common in the mid and distal esophagus, arises from abnormal esophageal mucosa in a well-characterized sequence. In reaction to chronic gastroesophageal reflux, metaplasia of the normal stratified squamous epithelium of the distal esophagus occurs, resulting in a specialized intestinal glandular epithelium containing goblet cells called Barrett epithelium. Further genetic alterations in this epithelium lead to dysplasia, which may progress from low-grade to high-grade dysplasia and, ultimately, to adenocarcinoma.

Gastroesophageal reflux disease (GERD) is the most important factor in the development of Barrett epithelium. Of patients with GERD, 10% develop Barrett epithelium. Of patients with Barrett epithelium, 1% develop esophageal adenocarcinoma, a risk that is 30-40 times higher than in the population without Barrett epithelium. Therefore, patients with Barrett epithelium are advised to undergo periodic surveillance esophageal endoscopy with biopsy.

Although alcohol use has not been strongly linked to the development of esophageal adenocarcinoma, smoking has been identified as a risk factor. Scleroderma and other motor disorders of the esophagus that predispose patients to GERD increase risk accordingly. Obesity, certain medications and environmental exposures, and diet and nutritional habits have been implicated as additional risk factors.

Frequency

United States

Cancer of the esophagus accounts for 7% of gastrointestinal tract cancers in the United States. In 2000, approximately 12,300 new cases of esophageal carcinoma occurred in the United States, and 12,100 deaths resulted from the disease. In the past, squamous cell carcinoma accounted for more than 95% of cases of esophageal cancer. However, by the early 1990s, adenocarcinoma had become the most common cancerous cell type among white Americans, accounting for approximately one half of esophageal malignancies in the United States and Europe. Squamous cell cancers still predominate among African American patients.

International

Worldwide, certain geographic regions have a high incidence of esophageal squamous cell carcinoma. In particular, a band of high incidence extends from the region of the Caspian Sea eastward through Central Asia to northern China.

Mortality/Morbidity

Only early surgical resection improves survival rates in patients with this disease. Of patients with esophageal cancer, 50% present with metastatic disease and most patients with apparent local disease develop metastases despite potentially curative local therapy. An improved 5-year survival rate of approximately 30% is believed to be the result of standardized oncologic practice and attention to complete resection at surgery. The primary cause of death in patients who are treated surgically is local recurrence, compared to other gastrointestinal tract tumors in which metastatic disease is usually the cause.

Prognosis depends on depth of tumor penetration through the esophageal wall and the presence of lymph node metastases. The TNM system is used to classify the extent of disease.

Table 1. TNM Classification of Esophageal Carcinoma

*Metastatic disease from a primary lesion in the lower esophagus is classified as M1a if celiac nodes are involved. M1b designates metastatic disease beyond locoregional and celiac lymph nodes. For a primary lesion in the mid esophagus, the M1a status is not applicable; metastatic disease beyond locoregional lymph nodes is designated M1b. For a primary lesion in the upper esophagus, involvement of cervical lymph nodes is designated M1a; metastatic disease beyond locoregional and cervical lymph nodes is designated M1b.

Staging groups are formed on the basis of the TNM classifications and are used to guide therapy and predict the prognosis and survival.

Table 2. Staging of Esophageal Carcinoma

Race

African Americans are 3 times more likely than whites to develop cancer of the esophagus. Although squamous cell carcinoma is relatively more common in African Americans, adenocarcinoma is more common in white Americans.

Sex

Males are 3 times more likely to develop esophageal carcinoma than females.

Age

Incidence of both squamous cell carcinoma and adenocarcinoma increases with age.

Anatomy

The esophagus is a muscular tube extending from the pharynx to the stomach. Histologically, the esophageal wall contains 4 major layers:

• Mucosa or a mucous membrane composed of the lining epithelium; the lamina propria, a layer of loose connective tissue enriched with capillaries and lymphatics; and the muscularis mucosae, a thin double layer of smooth muscle
• Submucosa, a loose connective tissue layer also rich in capillaries and lymphatics
• Muscularis externa (propria), consisting of 2 layers of muscle, the inner layer deployed circumferentially, and the outer layer arranged longitudinally
• Loose adventitia (unlike other areas of the gastrointestinal tract, which have a true serosa)

Because the esophagus lacks a serosal covering, esophageal carcinoma encounters few anatomic barriers to local invasion.

The cervical esophagus is that portion extending from the inferior aspect of the cricoid cartilage to the thoracic inlet. Caudal to the thoracic inlet, the thoracic esophagus is divided into thirds: The upper third extends from the thoracic inlet to the carina, and the middle and lower thirds are defined as the cranial and caudal halves of the remaining esophagus from the carina to the gastroesophageal junction.

The esophagus is drained by a rich network of lymphatics; therefore, precisely determining the particular draining lymph node chain for a given segment is often difficult. Jump lymph-node metastases occur when a node close to the involved esophageal segment is not diseased, but a more distant node is diseased.

For the cervical esophagus, cervical and supraclavicular lymph nodes are considered local, and mediastinal and upper abdominal lymph nodes are considered distant. For the upper and mid thoracic esophagus, mediastinal lymph nodes are considered local, and involved cervical, supraclavicular, and abdominal lymph nodes are considered distant. For the lower esophagus, mediastinal and perigastric lymph nodes are considered local, whereas involved cervical, supraclavicular, and celiac lymph nodes are considered distant.

Clinical Details

At the time of diagnosis, weight loss and dysphagia are the most common symptoms. Dysphagia usually occurs late in the course of the disease when the esophageal lumen has been narrowed by 50-75%. Less commonly, presenting symptoms may be related to local invasion or metastases.

Examples of signs and symptoms include stridor, cough, and aspiration pneumonia as the result of erosion into the tracheobronchial tree; hemoptysis or hematemesis resulting from invasion of a mediastinal vessel; left vocal cord paralysis resulting from recurrent laryngeal nerve involvement by tumor or lymph node metastasis; malignant pleural effusion; and diaphragmatic paralysis. Jaundice and bone pain are systemic manifestations of organ metastases.

Preferred Examination

Barium esophagraphy is a useful initial examination in the evaluation of a patient with esophageal complaints because it allows the assessment of esophageal morphology and motility. Esophageal endoscopy permits direct inspection and biopsy of the esophageal mucosa for histologic diagnosis. For the purpose of staging esophageal carcinoma, EUS, contrast-enhanced CT, and PET each offer unique information.

Limitations of Techniques

Barium esophagraphy has optimal sensitivity for the detection of lesions when a double-contrast technique is used. Such technique requires that the patient be able to stand upright, which may not be possible with patients who are debilitated. For bulkier obstructive lesions, an air-contrast technique may not be possible, and a detailed mucosal examination may not be achieved distal to the obstruction.

A notable limitation of CT in diagnosis involves the characterization of lymph nodes. With CT scans, size criteria are used to determine possible metastatic involvement; however, lymph nodes may be enlarged because of infectious or inflammatory etiologies. Conversely, subcentimeter lymph nodes may harbor metastatic tumor.

Ultrasonographic examinations are highly operator dependent. Limitations of EUS with the standard Olympus diagnostic echo-endoscope (13 mm in diameter) include an inability to pass the malignant stricture with the transducer. This limitation results in an incomplete examination, which occurred in 40% of patients reported by Massari et al. However, the use of a dedicated 8-mm-diameter esophagoprobe for EUS allows complete examination in most patients.

With PET, the resolution and cost remain the primary limitations. Subcentimeter foci of tumor metabolism may not be detected.

DIFFERENTIALS

Section 3 of 11  

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• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
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• Multimedia
• References

Other Problems to be Considered

The differential diagnosis of esophageal carcinoma depends on the morphologic appearance of the lesion. Esophageal strictures, filling defects, fold thickening, and dilatation are abnormal patterns to be considered.

Abnormal narrowing of the esophagus may result from extrinsic compression resulting from vascular structures such as aortic aneurysm, aberrant vascular anatomy (aberrant subclavian artery or vascular ring), and left atrial enlargement. Lymph node enlargement, whether reactive or neoplastic, may cause impressions on the esophageal contour. Primary mediastinal tumors may secondarily invade and narrow the esophagus. Esophageal strictures may be inflammatory or infectious in etiology. Inflammatory causes include epidermolysis, pemphigoid, strictures arising in the setting of GERD, caustic ingestion, or esophageal intubation. Severe infectious esophagitis may lead to stricture formation.

Filling defects within the esophagus may be caused by benign and malignant neoplasms and foreign bodies. Benign neoplasms that may cause an esophageal filling defect include leiomyoma, fibrovascular polyp, duplication cyst, papilloma, fibroma, and hemangioma. Malignant neoplasms include squamous cell carcinoma, adenocarcinoma, carcinosarcoma, small cell carcinoma, lymphoma, and metastases. Esophageal foreign bodies should also be considered in the differential diagnosis.

Thickened esophageal folds may be caused by esophagitis, lymphoma, varicoid carcinoma, or esophageal varices.

A dilated debris-filled esophagus may result from achalasia, scleroderma, Chagas disease, diabetic or alcoholic neuropathy, or bulbar palsy. Alternatively, an obstructing mass lesion or stricture may cause this appearance.

RADIOGRAPH

Section 4 of 11  

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• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Multimedia
• References

Findings

Barium esophagraphy is unique among esophageal studies for assessing both morphology and motility. Barium esophagraphy remains the study of choice for characterization of esophageal strictures. Esophageal carcinoma may demonstrate a variety of appearances on barium esophagrams.

• Lesions may be annular and constricting; intraluminal, polypoid, or masslike; infiltrative; ulcerating; or varicoid. A mixed pattern is most common.
• Early esophageal carcinoma may present as a small polypoid lesion or as coalescent plaques or nodules.
• A double-contrast technique should be used for optimal sensitivity.
• The length and location of the involved esophageal segment and the functional impairment resulting from the lesion should be reported.

Once a malignancy is detected on barium examination, the radiologist must be careful to evaluate the remainder of the esophagus and stomach for synchronous lesions. Endoscopy should follow.

Degree of Confidence

Levine et al reviewed 2484 barium esophagrams and found that endoscopy had been recommended in 26 patients (1%) because of findings suggestive of malignancy. Cancer was ultimately diagnosed in 11 patients, yielding a positive predictive value of 42%. The same investigators also retrospectively reviewed 50 cases of endoscopically proven esophageal carcinoma and found that lesions were present on barium esophagrams in 49 patients (98%). In addition, carcinoma was diagnosed or suggested in 48 patients (96%) on the basis of the barium study results.

False Positives/Negatives

The morphologic pattern of the lesion on barium esophagrams establishes the need to consider the differential diagnosis.

CT SCAN

Section 5 of 11  

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• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
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• Multimedia
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Findings

Contrast-enhanced CT plays an important role in the staging of esophageal carcinoma. Attention is directed to determining the extent of the local tumor; invasion of mediastinal structures; involvement of supraclavicular, mediastinal, or upper abdominal lymph nodes; and distant metastases. These observations are useful in distinguishing between T3 and T4 lesions and in determining the N and M status.

CT examination should extend from the thoracic inlet through the liver. Routine oral contrast material should be administered. This may be positive contrast agent, such as dilute barium, or a negative intraluminal contrast medium, such as water. A low-density 3% weight-for-weight esophageal barium paste may be administered immediately prior to scanning. Techniques for virtual esophageal endoscopy have also been described using effervescent granules and glucagon.

A sample helical CT (single detector) protocol includes the intravenous administration of 150 mL of 60% contrast material injected at a rate of 2-3 mL/s with a scanning delay of 50 seconds after the start of the injection; a pitch of 1.5 and a 5-mm section thickness may be used. For multidetector-row CT, 100 mL of 60% intravenous contrast medium may be injected at a rate of 3 mL/s with a scanning delay of 40 seconds after the start of the injection; a pitch of 6 and a 2.5-mm section thickness may be used.

CT scans should be obtained during full inspiration when patients are evaluated for esophageal carcinoma. Inward bowing or the trachea and mainstem bronchi during expiration may produce the false impression of tracheobronchial invasion.

Key findings include the following:

• Eccentric or circumferential wall thickening is greater than 5 mm.
• Peri-esophageal soft tissue and fat stranding may be demonstrated.
• A dilated fluid- and debris-filled esophageal lumen is proximal to an obstructing lesion.
• Tracheobronchial invasion appears as displacement of the airway (usually the trachea or left mainstem bronchus) as a result of mass effect by the esophageal tumor. Absence of a fat plane between the airway and the esophageal mass cannot be used as an indication of invasion. Even in patients without esophageal carcinoma, a fat plane is usually not evident between the esophagus and left mainstem bronchus.
• Note that the tracheal cartilage rings are incomplete posteriorly, which allows the posterior wall of the trachea to bow anteriorly during expiration; therefore, it is important that CT images be acquired during full inspiration.
• Aortic invasion may be assessed in 2 ways.
  • The Picus method considers the arc of contact between the tumor and aorta (Picus, 1983). Loss of the periaortic fat plane over less than 45° suggests no aortic invasion, whereas contact over 90° or more is predictive of invasion of the aortic wall. Contact between 45-90° is indeterminate. Accuracy with this method is 80%.
  • Obliteration of the triangular fat space between the aorta, esophagus, and spine is another predictor of aortic invasion.
• A careful search for lymph nodes is an essential component of the interpretation. A short-axis diameter exceeding 1 cm is considered abnormal for lymph nodes in all mediastinal locations except those in the subcarinal region, in which 1.4 cm is the upper limit of normal. Because lymph nodes may harbor metastases without being enlarged, noting the location of any identified lymph nodes is important. In addition, remembering that lymph nodes may be enlarged because of inflammatory or infectious etiologies is important.
• Esophageal carcinoma is often metastatic at presentation.
• In a review of 838 patients with M1 disease, Quint et al found that metastases were diagnosed most commonly in the abdominal lymph nodes (45%); liver (35%); lung (20%); cervical and/or supraclavicular lymph nodes (18%); bone (9%); adrenal glands (5%); peritoneum (2%); brain (2%); or stomach, pancreas, pleura, skin or body wall, pericardium, or spleen (1% each). The same group found that none of the cases with stage M0, as determined at chest and abdominal CT, were upstaged to M1 during either bone scanning or head CT.
• Reviewing a cohort of 116 cases of predominantly esophageal squamous cell carcinoma, Margolis et al determined that a solitary lung nodule found at the time of diagnosis is more likely to be a benign abnormality or a primary lung cancer than a metastatic lesion. However, during terminal phases of the disease, lung metastases are increasingly common.

Degree of Confidence

Multiple groups have reported on the sensitivity and specificity of CT in determining lymph node involvement. Its sensitivity for the detection of lymph node metastases is in the range of 60-80%. Its specificity is higher, approximately 90%.

False Positives/Negatives

An impression of tracheal invasion may be caused by expiratory bowing of the posterior trachea. Lymph node metastases may be present without enlarged lymph nodes, and lymph node enlargement may not be the result of malignancy. Lesions in solid organs identified at CT may represent primary benign or malignant processes or metastatic disease, and biopsy is frequently necessary to obtain histologic proof.

MRI

Section 6 of 11  

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• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Multimedia
• References

Findings

MRI presents the advantage of direct multiplanar imaging capabilities, which may be of particular use in assessing tracheobronchial, aortic, and pericardial invasion. Currently, MRI has not yielded other significant advantages compared with CT in the staging of esophageal carcinoma.

Recent research studies suggest that T2-weighted MRIs obtained with an endoluminal coil can reveal 7 layers of the esophageal wall:

• Epithelial layer (intermediate intensity)
• Lamina propria and muscularis mucosa (low intensity)
• Submucosa (high intensity)
• Inner circular muscularis propria (low intensity)
• Intermuscular structure (high intensity)
• Outer longitudinal muscularis propria (low intensity)
• Subadventitial structures (high intensity)

In the future, such resolution may offer superior assessment of the depth of tumoral invasion.

Degree of Confidence

Preliminary studies have shown that the sensitivity and specificity of MRI for the determination of tumor invasion are equivalent to those of CT.

False Positives/Negatives

False-positive and false-negative findings are similar to those seen on CT scans.

ULTRASOUND

Section 7 of 11  

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• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Multimedia
• References

Findings

Unlike CT, EUS allows visualization of the distinct layers within the esophageal wall. Alternating circumferential layers define the mucosal interface (hyperechoic), the mucosa (hypoechoic), the submucosa (hyperechoic), the muscularis propria (hypoechoic), and the adventitial interface (hyperechoic). Such resolution permits the distinction of T1, T2, T3, and T4 tumors. Esophageal carcinoma appears as a hypoechoic lesion disrupting the normal circumferential layers. However, with standard EUS equipment, often only 3 layers are seen in the esophageal wall: the mucosa and submucosa (hyperechoic), the muscularis propria (hypoechoic), and the adventitial interface (hyperechoic).

Local lymph nodes are also demonstrated by using EUS. Nodes are considered malignant if they are round, if they are hypoechoic, and if they have well-defined borders. Usually, benign nodes are hyperechoic and less well defined.

Degree of Confidence

T-stage accuracy with EUS is in the range of 79-94%. Accuracy is better for T3 or T4 lesions than for T1 or T2 lesions. Massari et al showed that a 12-MHz transducer outperforms a 7.5-MHz transducer, with accuracy for T staging of 94% and 82%, respectively. N-stage accuracy is in the range of 69-90%. Distant metastases cannot be reliably identified with EUS because of the limited field of view. N-stage accuracy is in the range of 69-90%; according to Rasanen et al, the technique probably outperforms CT and PET in the detection of locoregional lymph node metastasis.

At this time, only EUS is useful in distinguishing T1 and T2 lesions.

NUCLEAR MEDICINE

Section 8 of 11  

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• Ultrasound
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Findings

PET is quickly becoming a standard oncologic imaging modality. The technique is useful not only for the primary detection of tumor and metastases but also for the further characterization of abnormalities discovered by using other imaging modalities.

2-[Fluorine 18]-fluoro-2-deoxy-D-glucose (FDG) is the most commonly used radiopharmaceutical. FDG is taken up by cells and trapped within them by means of phosphorylation. FDG decays inside the cell, with a half-life of approximately 110 minutes, while emitting positively charged electrons called positrons. A positron travels a short distance in tissue before colliding with an electron. Collision results in annihilation of the 2 particles and the emission of photons. The detection of the photons by using ring detectors is the basis for image formation.

Radiopharmaceuticals other than FDG can be used in PET imaging. Carbon-11 choline has received particular attention. Choline, a component of the cell membrane, is taken up by actively dividing cells. In theory, this agent provides some advantages over FDG. Uptake of FDG requires that the tumor derive a portion its energy supply from glycolysis, an anaerobic condition that exists when the oxygen supply to some part of the tumor is low. For example, this circumstance may occur when a tumor outgrows its arterial supply. On the other hand, the uptake of ¹¹C-choline requires only the presence of cell division. Cardiac uptake of FDG may be significant, even in the fasting state, and this characteristic complicates the interpretation of findings in the mediastinum. Conversely, cardiac uptake is not significant with ¹¹C-choline.

¹¹C-choline PET scanning has been shown to outperform FDG PET scanning in the detection of malignant mediastinal lymph nodes. With this agent, tumor-containing mediastinal lymph nodes as small as 4 mm have been identified. The short half-life of ¹¹C-choline (approximately 20 min) will likely limit its use to major academic centers. The agent is not useful in the abdomen because of intense liver uptake. FDG PET scanning remains the technique of choice for the detection of metastatic abdominal lymph nodes.

Degree of Confidence

Flamen et al performed a prospective study to compare the staging of esophageal carcinoma with FDG PET versus the combination of CT and EUS in 74 patients. For T stages, FDG PET scanning demonstrated increased activity in the primary tumor in 70 patients (95% sensitivity). Four proven T1 lesions had negative findings on FDG PET scans.

The sensitivity of FDG PET in assessing nodal metastasis is reportedly 33-83%, but studies have shown the superiority of FDG PET to CT and EUS for determining the N status. FDG PET is more sensitive than CT for the detection of distant metastases.

In the study by Flamen et al, FDG PET had higher accuracy in diagnosing stage IV disease compared with the accuracy of CT and EUS combined; the results lead to upstaging of the disease in 11 of 74 patients and downstaging of the disease in 5 of the patients. Kobori et al have shown that the combination of FDG and ¹¹C-choline PET permitted the identification of 85% of the cases with metastatic lymph nodes.

False Positives/Negatives

FDG PET scans may fail to demonstrate T1 primary lesions. Inflammatory processes cause increased uptake of FDG. In addition, patients with no esophageal pathology may have minimal esophageal FDG uptake, particularly in distal areas.

ANGIOGRAPHY

Section 9 of 11  

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• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Multimedia
• References

Findings

Angiography does not play a role in the diagnosis and staging of esophageal carcinoma.

MULTIMEDIA

Section 10 of 11  

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• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Multimedia
• References

Media file 1:  Anteroposterior barium esophagram demonstrates an abrupt change in the caliber of the esophagus, with a long, irregular, annular stricture of the thoracic esophagus. Note the masslike shouldering at the proximal extent of the lesion at which filling defects are present within the dilated esophageal lumen. Findings are most consistent with esophageal carcinoma.
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Media file 2:  Lateral barium esophagram demonstrates an abrupt change in the caliber and contour of the esophagus caused by an irregular circumferential stricture containing focal ulcerations. Findings are most consistent with esophageal carcinoma.
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Media file 3:  Lateral barium esophagram demonstrates marked irregular narrowing of the esophageal lumen with focal ulcerations and almost complete obstruction; these findings are consistent with esophageal carcinoma.
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Media type:  X-RAY

Media file 4:  Oblique barium esophagram demonstrates a focal, fixed, concave contour deformity of the posterior esophageal wall. This represents superficial spreading esophageal carcinoma.
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Media type:  X-RAY

Media file 5:  Lateral barium esophagram demonstrates a large, intraluminal, lobulated filling defect diagnosed as esophageal carcinoma during endoscopic biopsy.
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Media file 6:  Nonenhanced axial CT image at the level of the origin of the great vessels demonstrates a nasogastric tube in place. The esophageal wall is thickened circumferentially and exerts mass effect on the posterolateral tracheal wall. Infiltration of the mediastinal fat adjacent to the great vessels is present. Findings are consistent with esophageal carcinoma with tracheal invasion.
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Media type:  CT

Media file 7:  Sagittal reformatted chest CT scan demonstrates marked, long-length, esophageal wall thickening abutting the posterior tracheal wall. Tracheal invasion by esophageal carcinoma was found at bronchoscopy.
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Media type:  CT

Media file 8:  Enhanced axial CT image demonstrates irregular wall thickening of the esophagus. A heterogeneously enhancing mass to the right of the esophagus represents a markedly enlarged metastatic lymph node. No significant loss of the fat plane is noted between the esophageal mass and the descending thoracic aorta, indicating the absence of aortic invasion. Small bilateral pleural effusions are present.
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Media type:  CT

Media file 9:  Nonenhanced axial CT image demonstrates a large proximal esophageal mass with asymmetric impression on the posterior tracheal wall, suggestive of invasion. Recall that the posterior tracheal wall may bow inwardly (usually symmetrically) during expiration because of incomplete tracheal cartilage rings. Infiltration of the peri-esophageal fat is demonstrated, although no evidence of aortic invasion is present.
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Media type:  CT

Media file 10:  Enhanced axial CT image demonstrates a large esophagogastric junction carcinoma and several large liver lesions, with heterogeneous peripheral contrast enhancement and irregular margins consistent with metastases.
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Media type:  CT

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Multimedia
• References

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• Kim K, Park SJ, Kim BT, et al. Evaluation of lymph node metastases in squamous cell carcinoma of the esophagus with positron emission tomography. Ann Thorac Surg. Jan 2001;71(1):290-4. [Medline].
• Kitamura K, Kuwano H, Yasuda M, et al. What is the earliest malignant lesion in the esophagus?. Cancer. Apr 15 1996;77(8 Suppl):1614-9. [Medline].
• Kobori O, Kirihara Y, Kosaka N, Hara T. Positron emission tomography of esophageal carcinoma using (11)C- choline and (18)F-fluorodeoxyglucose: a novel method of preoperative lymph node staging. Cancer. Nov 1 1999;86(9):1638-48. [Medline].
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Article Last Updated: Sep 1, 2005