1

Esophagus

Esophageal Carcinoma

Overview

Adenocarcinoma

• Most common esophageal cancer in the United States

• More common in the lower third of the esophagus

Squamous cell carcinoma

• Most common esophageal cancer worldwide

• More common in the upper third of the esophagus

Risk Factors

Tobacco use

Heavy alcohol use

Barrett esophagus

Caustic injury

Signs and Symptoms

Dysphagia and odynophagia

Weight loss

Midsternal chest pain

Hoarseness of voice

Early esophageal cancer is usually asymptomatic

Diagnosis

Esophagogram

Endoscopy with biopsy

Endoscopic ultrasound for staging purposes-assess the depth of invasion and involvement of regional nodes

Bronchoscopy to assess for airway invasion

CT of the chest, abdomen, and pelvis for staging purposes

PET scan to evaluate local and distant metastasis

Treatment

Depending on the stage of the disease, treatment may include surgery, chemotherapy, and radiation therapy

Advanced disease with dysphagia—may palliate symptoms with esophageal stent placement, laser therapy, or electrocoagulation

RADIOLOGY

Plain film findings

• Air-fluid level within the superior mediastinum with widening of the azygoesophageal line

Esophagram findings

• Focal strictures with irregular borders/abrupt shoulder margins

• Can also appear as long tubular filling defects similar to esophageal varices, but do not change with patient positioning

• There may be stiffening of the mucosa and failure to collapse completely after the peristaltic wave passes, unlike achalasia

• In contrast, leiomyomas and gastrointestinal stromal tumors (GISTs) are smooth wide-based, submucosal filling defects that form obtuse angles with the normal esophagus

CT findings (Fig. 1.1)

• Mainly used in the staging of esophageal cancer

Mediastinal lymphadenopathy

Effacement of the surrounding mediastinal fat, representing local invasion

• Although nonspecific, there may be thickening of the esophageal wall

• Dilated esophagus cranial to the lesion due to obstruction

PET/CT findings

• Hypermetabolic soft tissue within the esophagus

• More sensitive and specific than CT in identifying lymphadenopathy and overall staging

Endoscopic US findings

• Carcinoma appears as a hypoechoic mass which interrupts the layers of the esophageal wall

FIGURE 1.1 A,B

A. Vertebra

B. Descending aorta

C. Heart

D. Stomach

E. Small bowel loops

F. Psoas muscle

FIGURE 1.1 A

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