Joint Program in Nuclear Medicine

Imaging of Esophageal Cancer

Don Yoo, MD
Rachel A. Powsner, MD

December 9,2003

Presentation

A 64 year old male with history of gastroesophageal reflux disease since age 20 presented to the ER with bright red blood per rectum and hematemesis.

Imaging Technique

CT of abdomen and pelvis performed after administration of IV and oral contrast.
Approximately 45 minutes after the intravenous administration of 22.1 mCi of F18-FDG, 2-dimensional PET scan performed from skull base to proximal thighs. Transmission attenuation correction was applied.

Imaging Findings

EGD/EUS was performed which showed a 1.2 cm circumferential, non-bleeding, friable mass at the gastroesophageal junction which was contained to the muscularis propria. Paraesophageal and gastrohepatic lymph nodes were seen. Esophageal biopsy from this procedure showed moderately to poorly differentiated adenocarcinoma

For staging, the patient had a CT scan followed by a PET scan.

CT showed circumferential thickening at the GE-junction (shown by arrow) consistent with the site of tumor. There were lymph nodes seen at the right hilum (shown by arrow), gastrohepatic ligament (shown by arrow), and celiac axis (shown by arrow).

A PET scan showed high uptake at the GE-junction but did not show high uptake at the sites of lymph nodes seen on CT. The most important lymph node for staging was the celiac axis lymph node. If abnormal high uptake was seen at the celiac axis this would have been considered to be distant metastases and would have staged the patient as stage IV and inoperable.

Follow Up

Patient was staged at T2N1M0 or stage IIB. Patient had neoadjuvant chemotherapy and radiation and surgery 3 months later.

Repeat PET scan after surgery showed no abnormal uptake suspicious for residual or recurrent tumor. Pre- to post-surgical comparison shows marked change in the uptake at the GE-junction (shown by arrow).

Differential Diagnosis

Malignant neoplasms - Squamous cell, Adenocarcinoma, Sarcoma, Lymphoma, Melanoma, Carcinoid, Metastatic disease
Benign neoplasms - Leiomyoma
Esophagitis - Reflux, Caustic(lye ingestion), Infectious, Scleroderma induced, Post-radiation esophagitis

Diagnosis

Moderately to poorly differentiated adenocarcinoma

Discussion

Introduction

The incidence of esophageal cancer varies geographically and racially. In the U.S., African Americans (24/100000) have a four-fold risk compared to Caucasians (6.5/100000). Esophageal cancer accounts for only about 1% of all malignancies in the U.S. But worldwide, it is the 6th leading cause of death among malignancies. The incidence among men has been increasing 4-10% annually. The prevalence has increased 350-800% in the last 30 years.

Types

The two main types of esophageal cancer are squamous cell carcinoma and adenocarcinoma. The esophagus is lined by squamous epithelium so it would be expected that most esophageal cancers would be squamous carcinoma. While that was true in the past (in 1974, 75% of all esophageal cancers was squamous cell carcinoma), adenocarcinoma has been rapidly increasing over the last 20 years and now it is the most common type of esophageal cancer. Other rare types of esophageal cancers include sarcoma, lymphoma, melanoma, and carcinoid.

Risk Factors

Tobacco,
alcohol,
Barrett's esophagus,
achalasia,
lye strictures,
celiac disease,
Plummer-Vinson Syndrome,
tylosis, and
radiation.

Clinical Presentation

The most common symptom is dysphagia. Less common symptoms are odynophagia, weight loss, dyspnea, cough, hoarseness, and retrosternal pain.

Imaging Modalities

The imaging modalities commonly used for the diagnosis and staging of esophageal cancer are upper GI study, endoscopy, endoscopic ultrasound, CT, and PET.

In the past, a double contrast upper GI study was the first imaging test in a patient with dysphagia. A double contrast upper GI barium study is very sensitive in diagnosing esophageal cancer 96% while it can exclude other causes of dysphagia i.e. esophagitis, webs, and strictures. Every patient with suspicious findings on upper GI study would have endoscopy (EGD) where biopsy can be performed for histologic diagnosis.
Now many patients with dysphagia are having EGD as the initial diagnostic study. Endoscopic ultrasound (EUS) can be performed at the same time for locoregional staging. It has been shown that EUS is the most accurate study for locoregional staging (imaging wall layers): 85% for T and 75% for N staging.
CT has been shown to be better than MRI in staging esophageal cancer. Before PET it was considered the best study to evaluate for distant metastases. CT alone has an accuracy of 50-60% for staging esophageal cancer. It is best for hepatic and adrenal metastases and less sensitive for locoregional lymph nodes.
PET is superior to CT and EUS combined in diagnosing stage IV disease. In a study by Flamen et al., PET was more accurate 82% vs. 64% for CT and EUS combined in staging esophageal cancer. 18 out of 74 patients had discordant findings between PET vs. CT and EUS. PET was correct in 16 out of 18 patients based on surgical findings. It upstaged 11 patients and downstaged 5 patients. In 3 other studies PET demonstrated distant metastasis not seen on conventional imaging in (21/105 pts.)

Staging

TUMOR Stages: (T)

T(X): Primary tumor cannot be assessed
T(O): No evidence of primary tumor
Tis: Carcinoma in situ
T(1): Tumor invades lamina propria or submucosa
T(2): Tumor invades muscularis propria
T(3): Tumor invades adventitia
T(4): Tumor invades adjacent structures

NODE Stages: (N)

N(X): Regional LN cannot be assessed
N(0): No regional lymph node metastasis
N(l): Regional lymph node metastasis

METASTASIS Stages: (M)

M(X): Presence of distant metastasis cannot be assessed
M(0): No distant metastasis
M(1): Distant metastasis
- supraclavicular, cervical, celiac nodes - are considered distant metastases

STAGE TNM Descriptors

STAGE O Tis, N0, M0

STAGE I T1, N0, M0

STAGE IIA T2, N0, M0

STAGE IIB T1, N1, M0
T2, N1, M0

STAGE III T3, N1, M0
T4, any N, M0

STAGE IV Any T, Any N, M1

STAGE	TNM Descriptors
STAGE O	Tis, N0, M0
STAGE I	T1, N0, M0
STAGE IIA	T2, N0, M0
STAGE IIB	T1, N1, M0 T2, N1, M0
STAGE III	T3, N1, M0 T4, any N, M0
STAGE IV	Any T, Any N, M1

Prognosis and Treatment

Correct staging is critical as Stages I,IIA, IIB, and depending on the surgeon, stage III are treated with surgery as well as chemotherapy and radiation therapy.
Stage IV is nonsurgical. Chemotherapy and radiation treatment is given for palliation.
The prognosis of esophageal cancer is very poor with overall 5 year survival of <10% and stage IV <5%. If there is only local diseased without nodal involvement the prognosis increases to 40%. Unfortunately, 50% of patients are unresectable at presentation.
Surgery increases the overall 5 year survival increases to 20%, but the risk of mortality from surgery is 5-10%. Therefore correct staging is critical in determining which patients should have surgery.
Neoadjuvant chemotherapy and radiation therapy prior to surgery have shown mixed results. One study by Chidal et al., showed that Cisplatin/Fluorouracil and accelerated radiation therapy decreased local recurrence but not distant metastases in 90% vs. 64% of 154 patients. Another by Walsh et al., showed a benefit of neoadjuvant chemotherapy and radiotherapy in 113 patients prior to having surgery with increased 3 year survival. Most studies were inconclusive.

References

1. Enzinger P, Mayer R. Medical Progress: Esophageal Cancer NEJM 2003; 349;23: 2241-52.

2. Walsh T, Noonan N, Hollywood, Kelly A, Keeling N, Hennessey TPJ. A comparison of multimodal therapy and surgery for esophageal cancer. NEJM 1996 335;462-7.

3. Iyer RB, Silverman PM, Tamm EP, Dunnington JS, DuBrow RA. Diagnosis, staging, and follow-up of esophageal cancer. AJR Am J Roentgenol. 2003 Sep;181(3):785-93.

4. Skehan SJ, Brown AL, Thompson M, Young JE, Coates G, Nahmias C. Imaging features of primary and recurrent esophageal cancer at FDG PET. Radiographics. 2000 May-Jun;20(3):713-23.

5. Flamen P, Van Cutsem E, Lerut A, Cambier JP, Haustermans K, Bormans G, De Leyn P, Van Raemdonck D, De Wever W, Ectors N, Maes A, Mortelmans L. Positron emission tomography for assessment of the response to induction radiochemotherapy in locally advanced oesophageal cancer. Ann Oncol. 2002 Mar;13(3):361-8.

6. Chidel MA, Rice TW, Adelstein DJ, Kupelian PA, Suh JH, Becker M. Resectable esophageal carcinoma: local control with neoadjuvant chemotherapy and radiation therapy. Radiology. 1999 Oct;213(1):67-72.

Click here to go to Joint Program in Nuclear Medicine home page and Copyright notice.

J. Anthony Parker, MD PhD, Tony_Parker@CareGroup.Harvard.edu