Figure 1
Endoscopy
Oesophagus and Cardia cancer: preoperative and postoperative imaging.
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsRuschi F, Gori G, Caproni G, Caramella D, Bartolozzi C.
Connected authors
63 years, male
Clinical History
A patient affected by oesophageal and cardial squamous cell carcinoma underwent preoperative CT scan. After the surgical technique also postoperative diagnostic procedures were performed in order to follow up patient's condition. These exams included chest radiographs, a CT scan and a contrast oesophagogram.
Imaging Findings
The patient presented with progressive dysphagia lasting for months for liquid and solid food and sob. An endoscopy was performed and it showed an area of irregular mucosa extending for 6 cm next to the gastro-oesophageal junction. Biopsy revealed a squamous cell carcinoma of the distal portion of oesophagus.
Also a CT scan was performed and it showed a cardial mass extending to the distal portion of oesophagus and to the lesser gastric curvature; furthermore a 2 cm lymphadenopathy was evident within the gastro-hepatic ligament.
The surgical technique based on oesophagectomy of the affected portion and gastroplasty using a right transthoracic approach. A drainage was positioned next to the right pulmonary apex and it was followed up using daily chest radiographs.
Some days before surgery an area compatible with right pleural effusion was evident on radiographs and another CT scan was performed in order to study this condition better.
Thoracic tomography confirmed a circumscribed area of effusion among the right side and a small effusion also on the left side. Furthermore an area of parenchymal consolidation was evident on the right lung and it was compatible with parenchymal disventilation because of the absence of fever and leukocytosis.
A contrast oesophagogram showed either obstacles or spills at the site of surgery.
Also a CT scan was performed and it showed a cardial mass extending to the distal portion of oesophagus and to the lesser gastric curvature; furthermore a 2 cm lymphadenopathy was evident within the gastro-hepatic ligament.
The surgical technique based on oesophagectomy of the affected portion and gastroplasty using a right transthoracic approach. A drainage was positioned next to the right pulmonary apex and it was followed up using daily chest radiographs.
Some days before surgery an area compatible with right pleural effusion was evident on radiographs and another CT scan was performed in order to study this condition better.
Thoracic tomography confirmed a circumscribed area of effusion among the right side and a small effusion also on the left side. Furthermore an area of parenchymal consolidation was evident on the right lung and it was compatible with parenchymal disventilation because of the absence of fever and leukocytosis.
A contrast oesophagogram showed either obstacles or spills at the site of surgery.
Discussion
Oesophagus and cardial cancer (ECC) is relatively rare and has a predilection for the male gender. It develops in old age, beyond the sixth and seventh decade and it accounts for 5.5% of all malignant neoplasms of the gastrointestinal tract. However in the last 20 years the incidence of ECC has increased, with a decline in the epidermoid type, which tends to affect the median and lower third of the oesophagus and an increase in the proportion of adenocarcinomas, localised mainly in the distal portion and cardia and developing in Barrett’s epithelium.
The incidence of squamous cell carcinoma of the oesophagus varies geographically worldwide and varies depending on the socioeconomic status of the population. Alcohol consumption, smoking, diet, human papilloma virus (HPV) infection, radiation exposure, consumption of food and water rich in nitrates and nitrosamines, vitamin deficiencies and genetic factors have all been reported as risk factors for cancer development. In addition, achalasia, Plummer-Vinson syndrome and chronic strictures resulting from acid or lye ingestion are also predisposing conditions.
Oesophageal squamous cell carcinoma develops through a progression of premalignant precursor lesions; dysplasia is found in 60% to 90% of resected cases.
Endoscopic ultrasound (EUS) and CT are the methods of choice for identifying diffusion of ECC within and beyond the oesophageal wall. The great advantage of EUS lies in its ability to show the separate layers of the oesophageal wall in order to establish depth of infiltration and to identify any satellite lymph node disease.
CT scan of the chest and abdomen is the basic imaging method for global staging of the tumour and also for an assessment of its spread into the mediastinum.
EUS is the only way to distinguish oesophageal tumour tissue from adjacent mediastinal lymphadenopathy (N1). This method relies exclusively on morphological assessment of the peritumoral lymph node, for example an increase in size, structural alterations, distinct or irregular margins. Diagnosis of the metastatic or inflammatory nature of peri-oesophageal lymph nodes must be confirmed by a biopsy. CT-PET is useful in identifying stage IV (M1).
Surgery is considered to be the best treatment for oesophageal cancer for locoregional control and long-term survival. Since more than a third of patients have extensive disease already at diagnosis and accordingly the survival rates are around 25% at 5 years after surgery alone, a multidisciplinary approach that includes surgery, radiotherapy (RT) and chemotherapy (CT), alone or in combination, may be necessary.
Surgical resection is usually performed by right transthoracic or transhiatal approaches; complete transthoracic oesophagectomy with two field lymphadenectomy (abdominal and thoracic) and gastroplasty is considered, worldwide, as the approach of choice. RT and CT could improve the control of local or general disease with the aim of downstaging cancer, increasing resectability, eradicating micrometastatic disease and decreasing cancerous cell dissemination during intervention.
There is recurrence of squamous cell carcinoma of the oesophagus in about one third of persons who undergo curative resection surgery. The early diagnosis of recurrent disease is helpful for selecting postoperative adjuvant therapy and may improve patient survival.
The incidence of squamous cell carcinoma of the oesophagus varies geographically worldwide and varies depending on the socioeconomic status of the population. Alcohol consumption, smoking, diet, human papilloma virus (HPV) infection, radiation exposure, consumption of food and water rich in nitrates and nitrosamines, vitamin deficiencies and genetic factors have all been reported as risk factors for cancer development. In addition, achalasia, Plummer-Vinson syndrome and chronic strictures resulting from acid or lye ingestion are also predisposing conditions.
Oesophageal squamous cell carcinoma develops through a progression of premalignant precursor lesions; dysplasia is found in 60% to 90% of resected cases.
Endoscopic ultrasound (EUS) and CT are the methods of choice for identifying diffusion of ECC within and beyond the oesophageal wall. The great advantage of EUS lies in its ability to show the separate layers of the oesophageal wall in order to establish depth of infiltration and to identify any satellite lymph node disease.
CT scan of the chest and abdomen is the basic imaging method for global staging of the tumour and also for an assessment of its spread into the mediastinum.
EUS is the only way to distinguish oesophageal tumour tissue from adjacent mediastinal lymphadenopathy (N1). This method relies exclusively on morphological assessment of the peritumoral lymph node, for example an increase in size, structural alterations, distinct or irregular margins. Diagnosis of the metastatic or inflammatory nature of peri-oesophageal lymph nodes must be confirmed by a biopsy. CT-PET is useful in identifying stage IV (M1).
Surgery is considered to be the best treatment for oesophageal cancer for locoregional control and long-term survival. Since more than a third of patients have extensive disease already at diagnosis and accordingly the survival rates are around 25% at 5 years after surgery alone, a multidisciplinary approach that includes surgery, radiotherapy (RT) and chemotherapy (CT), alone or in combination, may be necessary.
Surgical resection is usually performed by right transthoracic or transhiatal approaches; complete transthoracic oesophagectomy with two field lymphadenectomy (abdominal and thoracic) and gastroplasty is considered, worldwide, as the approach of choice. RT and CT could improve the control of local or general disease with the aim of downstaging cancer, increasing resectability, eradicating micrometastatic disease and decreasing cancerous cell dissemination during intervention.
There is recurrence of squamous cell carcinoma of the oesophagus in about one third of persons who undergo curative resection surgery. The early diagnosis of recurrent disease is helpful for selecting postoperative adjuvant therapy and may improve patient survival.
Differential Diagnosis List
Oesophageal and cardial squamous cell carcinoma.
Final Diagnosis
Oesophageal and cardial squamous cell carcinoma.
References
[1] Shimizu M, Ban S, Odze R. Squamous dysplasia and other precursor lesions related to esophageal squamous cell carcinoma. Gastroenterology Clinics of North America 2007; 36: 797-811. (PMID: 17996791)
[2] Fiore D. et al. Multimodal imaging of esophagus and cardia cancer before and after treatment. La Radiologia Medica 2006; 111: 804-817. (PMID: 16896560)
[3] Wakelin S. et al. A comparison of computerised tomography, laparoscopic ultrasound and endoscopic ultrasound in the preoperative staging of oesophago-gastric carcinoma. European Journal of Radiology 2002; 41: 161-167. (PMID: 11809546)
[4] Sharpe D, Moghissi K. Resectional surgery in carcinoma of the oesophagus and cardia: what influences long-term survival?. Eur J Cardiothorac Surg. 1996;10(5):359-63; discussion 363-4. (PMID: 8737693)
Case information
| URL: | https://eurorad.org/case/8174 |
| DOI: | 10.1594/EURORAD/CASE.8174 |
| ISSN: | 1563-4086 |
Figure 2
Histology
Histological microscopic specimen confirms the diagnosis of oesophageal squamous cell carcinoma.
Figure 4
Chest X-ray
Chest radiograph indicates an area of pleural effusion on the right side.
Figure 6
Contrast oesophagogram
Contrast oesophagogram shows either obstacles or spills at the site of surgery.
Histology
Histological microscopic specimen confirms the diagnosis of oesophageal squamous cell carcinoma.
Chest X-ray
Chest radiograph indicates an area of pleural effusion on the right side.
Contrast oesophagogram
Contrast oesophagogram shows either obstacles or spills at the site of surgery.