Esophageal carcinoma

Changed by Henry Knipe, 19 Sep 2014
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Carcinoma of the oesophagus 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.

Epidemiology

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

Additionally, 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:

Pathology

Histological types
Macroscopic appearence
    • 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 smooth transition
    • superficial spreading carcinoma
Staging

See main article: oesophageal cancer staging.

Metastases
  • 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

Radiographic features

Plain film - chest radiograph

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 upper third of oesophagus)
  • widened mediastinum
  • tracheal deviation
  • posterior tracheal indentation/mass
  • retrocardiac or posterior mediastinal mass
  • oesophageal air-fluid level
  • lobulated mass extending into gastric air bubble
  • repeated aspiration pneumonia (with tracheo-oesophageal fistula)
Barium Swallow
  • irregular stricture
  • pre-stricture dilatation with 'hold up'
  • shouldering of the stricture
CT
  • eccentric or circumferential wall thickening >5mm
  • peri-oesophageal soft tissue and fat stranding
  • dilated fluid- and debris-filled oesophageal lumen is proximal to an obstructing lesion
  • tracheobronchial invasion appears as displacement of the airway (usually the trachea or left mainstem bronchus) as a result of mass effect by the oesophageal tumour
  • aortic invasion

Complications

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

Treatment and prognosis

Oesophageal cancer has a high mortality with a five-year survival rate of only 10%. 

Surgical options include

Differential diagnosis

Imaging differential considerations include

  • -</ul><h5>Macroscopic appearence</h5><ol>
  • +</ul><h5>Macroscopic appearence</h5><ul>
  • -</ol><h5>Staging</h5><p>See main article: <a href="/articles/oesophageal-cancer-staging">oesophageal cancer staging</a>.</p><h5>Metastases</h5><ul>
  • +</ul><h5>Staging</h5><p>See main article: <a href="/articles/oesophageal-cancer-staging">oesophageal cancer staging</a>.</p><h5>Metastases</h5><ul>
  • -<li>retrocardiac mass</li>
  • +<li>retrocardiac or posterior mediastinal mass</li>
  • -<li>fistula formation to trachea (5-10%)/bronchi/mediastinum: can be either due to due direct tumour progression or iatrogenic effects (e.g. radiation therapy) </li>
  • +<li>fistula formation to trachea (5-10%), bronchi or mediastinum: can be either due to due direct tumour progression or iatrogenic effects (e.g. radiation therapy) </li>

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