Harika Tirumani, MBBS, Michael H

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Presentation transcript:

Esophageal Carcinoma: Current Concepts in the Role of Imaging in Staging and Management Harika Tirumani, MBBS, Michael H. Rosenthal, MD, PhD, Sree Harsha Tirumani, MD, Atul B. Shinagare, MD, Katherine M. Krajewski, MD, Nikhil H. Ramaiya, MD Canadian Association of Radiologists Journal Volume 66, Issue 2, Pages 130-139 (May 2015) DOI: 10.1016/j.carj.2014.08.006 Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 1 A 60-year-old woman with cervical esophageal cancer. (A) Axial contrast-enhanced computed tomography (CT) image of the chest reveals an intraluminal polypoid mass in the esophageal lumen (arrow). (B) Axial fused fluorodeoxyglucose (FDG) positron emission tomography/CT image demonstrates intense FDG uptake in the esophageal mass (arrow) and a concurrent FDG-avid right supraclavicular node (arrowhead). Endoscopic biopsy of the mass confirmed squamous cell carcinoma. Patient was treated with chemoradiotherapy. (C, D) Axial CT images of the chest 12 months after the treatment demonstrate extensive metastatic bilateral hilar lymphadenopathy (arrows) and metastatic pulmonary nodules (arrowheads). This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2015 66, 130-139DOI: (10.1016/j.carj.2014.08.006) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 2 An 82-year-old woman with adenocarcinoma of the distal esophagus. (A-C) Endoscopic ultrasound (EUS) of the esophagus demonstrates a large fungating friable partially obstructing distal esophageal mass (extending between 34 and 41 cm from the incisors), which is hypoechoic with irregular margins (arrow), invasion of the adventitia, and an abnormal enlarged lymph node at 38 cm from the incisors (arrowhead). Biopsy of the mass confirmed adenocarcinoma. Patient was treated with definitive chemoradiation. (D, E) Coronal maximum intensity projection (MIP) images from fluorodeoxyglucose (FDG) positron emission tomography/CT pre- and postchemoradiation demonstrate the distal esophageal mass to be FDG-avid on the pretreatment scan (D) with significant decrease in FDG avidity on the post-treatment scan (E) There is FDG uptake in the esophagus proximal to the tumour and in the stomach. This uptake mimics residual tumour but represents post radiotherapy inflammation, which was confirmed at endoscopic biopsy. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2015 66, 130-139DOI: (10.1016/j.carj.2014.08.006) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 3 A 74-year-old male with midthoracic esophageal carcinoma. (A) Axial contrast-enhanced computed tomography (CT) image of the chest demonstrates circumferential thickening of the esophageal wall (arrow) with loss of fat planes with the bronchi concerning for bronchial invasion (T4b). (B) Follow-up CT shows an esophageal stent with widening of the lumen (arrow). Canadian Association of Radiologists Journal 2015 66, 130-139DOI: (10.1016/j.carj.2014.08.006) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 4 A 65-year-old man with gastroesophageal junction (GEJ) adenocarcinoma. (A, B) Axial contrast-enhanced computed tomography (CT) images of the chest demonstrate polypoid thickening of the GEJ (arrow) and a periesophageal node (arrowhead, B) adjacent to the mid thoracic esophagus. (C-E) Axial fused fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT images demonstrate intense FDG uptake in the primary tumour (arrow) as well as the periesophageal node (white arrowhead, D) confirming its metastatic nature. In addition, PET/CT helped in detecting an additional FDG-avid periceliac node (black arrowhead, E). This highlights the ability of PET/CT to accurately stage esophageal cancer. Patient was treated with chemoradiotherapy. During follow-up, he presented with jaundice. (F) Axial contrast-enhanced CT image during the episode of jaundice demonstrates an enhancing nodule at the duodenal ampulla (arrow). (G) Coronal magnetic resonance cholangiopancreatography image demonstrates diffuse biliary dilatation with abrupt cut off at the lower end of common bile duct. Endoscopic retrograde cholangiopancreatography confirmed ampullary metastasis from esophageal adenocarcinoma. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2015 66, 130-139DOI: (10.1016/j.carj.2014.08.006) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 5 A 72-year-old-man with history of chronic lymphocytic leukemia and newly diagnosed gastroesophageal junction (GEJ) adenocarcinoma. (A) Axial contrast-enhanced computed tomography image reveals asymmetric thickening of the GEJ (arrow). Patient underwent esophageal exploration and was found to have unresectable disease. (B) Double-contrast barium esophagogram performed after surgery demonstrates tight irregular stricture at the GEJ (arrow). Canadian Association of Radiologists Journal 2015 66, 130-139DOI: (10.1016/j.carj.2014.08.006) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 6 A 40-year-old woman with history of Hodgkin’s disease treated with chemoradiotherapy, presented with extensive liver metastases. Biopsy of the liver lesion showed poorly differentiated carcinoma. Positron emission tomography/computed tomography (PET/CT) was performed to determine the site of the primary tumour. (A, B) Axial fused and coronal maximum intensity projection fluorodeoxyglucose (FDG) PET/CT images demonstrate intensely FDG-avid liver metastases (black arrowheads). There was incidental abnormal uptake in the gastroesophageal junction (GEJ; white arrow). No other site of FDG uptake was noted. (C) Upper gastrointestinal endoscopy demonstrates partially circumferential ulcerating mass at 31-35 cm from the incisors consistent with GEJ tumour. Biopsy confirmed poorly differentiated carcinoma. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2015 66, 130-139DOI: (10.1016/j.carj.2014.08.006) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 7 A 74-year-old woman with midesophageal squamous cell carcinoma. (A) Coronal MIP fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) image demonstrates intensely FDG-avid midesophageal tumour (arrow). There is a mildly FDG-avid right supraclavicular lymph node (arrowhead) but it has uptake less than the primary tumour and therefore most likely inflammatory a reactive rather than a metastatic node. (B) Follow-up PET/CT image after chemoradiotherapy shows significant decrease in the degree and extent of FDG uptake in the primary tumour consistent with treatment response. The right supraclavicular node has resolved. Canadian Association of Radiologists Journal 2015 66, 130-139DOI: (10.1016/j.carj.2014.08.006) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 8 A 48-year-old-woman with poorly differentiated adenocarcinoma of the esophagus. Coronal contrast-enhanced computed tomography image of the abdomen demonstrates asymmetric thickening of the gastroesophageal junction (arrows), multiple hepatic metastases (black arrowheads), and enlarged metastatic para-aortic nodes (white arrowheads). Canadian Association of Radiologists Journal 2015 66, 130-139DOI: (10.1016/j.carj.2014.08.006) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 9 A 71-year-old-man with poorly differentiated adenosquamous carcinoma of the esophagus. Axial contrast-enhanced computed tomography image demonstrates heterogeneous metastatic deposit in a right lower rib as well as ascites consistent with peritoneal carcinomatosis. Canadian Association of Radiologists Journal 2015 66, 130-139DOI: (10.1016/j.carj.2014.08.006) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 10 A 73-year-old woman with moderately differentiated adenocarcinoma of the esophagus. Axial postgadolinium fat-suppressed T1-weighted magnetic resonance image of the brain demonstrates a large heterogeneously enhancing metastatic deposit in the right parietal lobe (arrows) with midline shift. Canadian Association of Radiologists Journal 2015 66, 130-139DOI: (10.1016/j.carj.2014.08.006) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions