Oesophageal carcinoma

Oesophageal carcinoma is relatively uncommon. It tends to present with increasing dysphagia, initially to solids and progressing to liquids as the tumour increases in size, obstructing the lumen of the oesophagus.

Oesophageal cancer is responsible for <1% of all cancers and 4-10% of all GI malignancies. There is recognised male preponderance with the squamous cell subtype, M:F 4:1. Blacks are more susceptible than caucasians, 2:1.

The incidence of the subtypes has regional variation. The squamous cell subtype has the greatest worldwide incidence (~90%), but the adenocarcinoma subtype is more common in many parts of North America and Europe. In addition, there are certain regions where individuals are at particularly high risk of developing oesophageal cancer, e.g. Iran, parts of Africa, Italy and China.

Predisposing factors include 8:

Patients present with progressive dysphagia, weight loss, chronic worsening gastroesophageal reflux and hoarseness, cough, vocal cord paralysis, or other signs and symptoms of mediastinal invasion.

* in western world adenocarcinoma is as common or even slightly more common than SCC

  • polypoid/fungating (most common)
    • sessile/pedunculated tumour
    • lobulated surface protruding
    • irregular, polycyclic, overhanging, step-like "apple core" lesion
  • ulcerating: large ulcer niche within bulging mass
  • infiltrating: gradual narrowing with a smooth transition
  • superficial spreading carcinoma

See main article: oesophageal cancer staging.

  • lymphatic
    • anterior jugular chain and supraclavicular nodes (primary in upper 1/3)
    • para-oesophageal and subdiaphragmatic nodes (primary in middle 1/3)
    • mediastinal and paracardial and coeliac trunk nodes (primary in lower 1/3)
  • haematogenous: lung, liver, adrenal glands

A combination of CT scan, transoesophageal ultrasound and PET/CT scan are used for staging of the disease. CT is the best initial modality for detection of the distant metastasis, gross direct invasion, and enlarged lymph nodes. Ultrasound is the most sensitive modality for assessment of the depth of invasion and regional enlarged lymph nodes. PET can be useful for re-staging after the initial neoadjuvant therapy 7

Many indirect signs can be sought on a chest radiograph and these include:

  • widened azygo-oesophageal recess with convexity toward right lung (in 30% of distal and mid-oesophageal cancers)
  • thickening of posterior tracheal stripe and right paratracheal stripe >4 mm (if tumour located in the upper third of oesophagus)
  • tracheal deviation or posterior tracheal indentation/mass
  • retrocardiac or posterior mediastinal mass
  • oesophageal air-fluid level
  • lobulated mass extending into gastric air bubble (Kirklin sign)
  • repeated aspiration pneumonia (with tracheo-oesophageal fistula)
  • irregular stricture
  • pre-stricture dilatation with 'hold up'
  • shouldering of the stricture

It is the most accurate imaging modality for the T staging of oesophageal cancer

It defines the layers of the oesophageal wall hence can differentiate T1, T2, and T3 tumors

The oesophagus consists of five layers.

  • the first hyperechoic layer represents the interface between the balloon and the superficial mucosa.
  •  the second hypoechoic layer represents the lamina propria and muscularis mucosae.
  •  the third hyperechoic layer represents the submucosa
  •  the fourth hypoechoic layer represents the muscularis propria
  • the fifth layer represents the interface between the adventitia and surrounding tissues
  • eccentric or circumferential wall thickening >5 mm
  • peri-oesophageal soft tissue and fat stranding
  • dilated fluid- and debris-filled oesophageal lumen is proximal to an obstructing lesion
  • tracheobronchial invasion appears as a displacement of the airway (usually the trachea or left mainstem bronchus) as a result of mass effect by the oesophageal tumour
  • aortic invasion

PET/CT is useful for detecting oesophageal primary tumors yet it has little role in helping determine the specific T classification because it provides limited information about the depth of tumor invasion.

PET/CT is also superior to CT for detecting lymph node metastases and can depict metastases in normal-sized lymph nodes through the uptake of FDG. 

PET/CT has a primary role in the depiction of distant sites of metastatic disease.

The most common sites of distant metastases detected at PET (but frequently missed at CT) are the bones and liver. 

  • fistula formation to trachea (5-10%), bronchi or mediastinum: can be either due to direct tumour progression or iatrogenic effects (e.g. radiation therapy) 
  • oesophageal perforation

The 5-year mortality depends on the stage of the tumour. Unfortunately, most cases present with regional or distant metastatic disease (30% and 40%, respectively.

  • localised disease: ~40% 5-year survival
  • distant metastatic disease: ~5% 5-year survival

Endoscopic mucosal resection, without or with localised ablation is an option for localised (T1a) disease. These epithelial tumours are usually <2 cm, asymptomatic, and noncircumferential.

For T1b tumours and above, surgical options are mostly limited to oesophagectomy (including sometimes with palliative colonic interposition (see case 19))

Imaging differential considerations include:

Oesophageal pathology
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Article information

rID: 1765
Synonyms or Alternate Spellings:
  • Esophageal cancer
  • Oesophageal cancer
  • Carcinoma of the oesophagus
  • esophageal carcinoma
  • Oesophageal malignancy
  • Carcinoma of oesophagus
  • Esophageal malignancy
  • Carcinoma of the esophagus
  • Carcinoma of esophagus

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Cases and figures

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    Figure 1: endoscopic view
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    Case 1: squamous cell carcinoma barium swallow
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    An irregular hypo...
    Case 2 : transesophageal endoscopic ultrasound
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    Case 3: CT
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    Case 4: Barium swallow
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    Scleroderma with ...
    Case 5: oesophageal cancer and peptic stricture
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    Case 6
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    Case 7: adenocarcinoma
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    Case 8: squamous cell cancer with lung metastases
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    Case 9
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    Mass in the esoph...
    Case 10: with recurrent laryngeal nerve palsy
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    Case 11: mid esophagus
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    Case 12
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    Case 13
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    Case 14
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    Case 15: fluoroscopy
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    Case 16
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    Case 17: squamous cell carcinoma
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    Case 18: with oesophageal stent
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    Case 19: treated oesophageal cancer by colonic interposition
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    Case 20: with a aorto-oesophageal fistula
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