ct staging of ca esophagus

1. CT Staging of Carcinoma Esophagus
Dr Anil Rawat MD,
Assistant Professor
Department Of Radiodiagnosis
King George’s Medical University

2. Outline
 Introduction
 Anatomy
 AJCC 8th edition TNM staging
 Radiology perspective in staging
 Resectibilty criteria
 Evaluation of post-surgical complications
 Post-treatment response assessment
 Difference between AJCC 7th vs 8th edition TNM staging
 Futuristic trends
 Conclusion/take-home message
 References

3. Introduction
 Esophageal cancer is the seventh most common cancer and the sixth leading cause of cancer
deaths in the world, with a high mortality-to-incidence ratio.
 Globally, squamous cell carcinoma (SCC) accounts for nearly 85% of cases and predominates
in the so-called esophageal cancer belt, which includes western Turkey, Central Asia, western
and northern China, and eastern Africa.
 Esophageal cancer has a significant male predominance, with SCC 2.5 times more common
and EAC approximately 4.4 times more common in men than in women.
 Major risk factors for SCC include alcohol use and smoking Dietary factors such as
consuming large amounts of food containing N-nitroso compounds , and having an underlying
esophageal disease such as achalasia or caustic stricture are associated with increased risk of
SCC.

4. Introduction contd…
 Obesity, smoking, and gastroesophageal reflux disease have been shown as independent risk factors for
EAC.
 Esophageal cancer still remains one of the most lethal of all cancers. Since a multimodality approach is
presently used to treat esophageal cancer, early radiologic diagnosis and accurate tumour staging are
essential to direct therapy toward a cure or palliation.

5. Anatomy
 The esophageal wall consists of four layers: mucosa, submucosa, muscularis propria, and adventitia.
There is no serosa to serve as a barrier between the esophagus and the surrounding structures; lack of a
serosa facilitates tumor spread through the esophageal wall into adjacent structures. A rich plexus of
lymphatics encircles the entire length of the esophagus, enabling lymphatic spread of tumor to cervical,
mediastinal and upper abdominal lymph nodes.

9. AJCC 8th edition TNM staging introduced stage groupings based on treatment strategies:
clinical TNM (cTNM, before any treatment),
pathologic TNM (pTNM, after surgery alone),
post-neoadjuvant pathologic TNM (after neoadjuvant therapy and surgery)

10. Post-neoadjuvant pathologic TNM (after neoadjuvant
therapy and surgery)

11. Radiologists’ Role in Staging
 Radiologists play an integral role in staging esophageal cancer. However, despite tremendous advances in
imaging over the last decade, radiologists’ ability to provide accurate preoperative staging for esophageal
cancer using any single modality has been limited.
 In clinical practice, esophageal cancer staging remains a complementary mix of multiple modalities
including CT, FDG PET/CT, endoscopic ultrasound, esophagogastroduodenoscopy (EGD), and
minimally invasive procedures such as endoscopic mucosal resection (EMR) and endoscopic submucosal
dissection (ESD).

12. Tumor Staging
Early staging of esophageal cancers
Why???
 To prevent nontherapeutic laparotomies
 Maximize the value of endoluminal therapies, such as EMR, radiofrequency ablation, and photodynamic
therapy.
 Esophageal ultrasound (EUS) provides detailed examination of the esophageal wall and currently is the
procedure of choice for determining cT.
 T3–4 cancers have a high probability of N+ and require neoadjuvant therapy, while T1–2 cancers are
likely N0,requiring resection alone

13. Endoscopic Ultrasound (EUS)
 USG probe (7–12 MHz) mounted on endoscope
 Delineates five layers
A. Mucosa
B. Muscularis mucosa
C. Submucosa
D. Muscularis propria
E. Adventitia
 FNAC can also be performed
 Locoregional staging of esophageal ca

14. Nodal Staging
EUS, CT, and fluorodeoxyglucose positron emission tomography (FDG-PET) afford regional lymph node
imaging and are the principal non-invasive modalities for cN determination.
 EUS is used to evaluate regional lymph nodes’ size, shape, border, and internal echocardiographic
characteristics. Larger, more rounded, well-demarcated hypoechoic lymph nodes are most likely to
contain metastasis.
 An enlarged lymph node on CT suggests nodal metastasis. SAD>1 cm intrathoracic and abdominal
lymph nodes are considered enlarged
 Metabolic evaluation of esophageal cancer by FDG-PET relies on metastatic deposit size and the
intensity of FDG uptake and decay. So it is possible to identify microscopic metastases if glucose
metabolism is sufficient to concentrate large quantities of FDG.
 FDG-PET cannot differentiate adjacent N+ from primary cancer and is least sensitive in assessing
lymph nodes in the mid-and lower-thoracic esophagus.
 Endosonographic-directed fine needle aspiration (EUS-FNA) is strongly recommended by the AJCC
for histologic confirmation.

15. Nodal Staging

16. Metastasis Staging
 Evaluation for metastatic disease in esophageal cancer commonly begins with a CT of the chest,
abdomen, and pelvis. On CT, liver metastases are best seen in the portal venous phase as hypodense
lesions. As with any other cancer, small lung nodules in esophageal cancer are difficult to diagnose as
metastases, particularly if prior imaging is not available.
 If the lungs are the only potential site of metastatic disease, a biopsy by interventional radiology or
thoracoscopy can be obtained. The addition of PET to CT improves the detection of distant metastases,
and FDG PET/CT is recommended for the initial workup of esophageal cancer. However, if the distant
disease is detected on CT, FDG PET/CT may not be needed.
 Endoscopic ultrasound may not be needed if distant metastases are detected by CT or FDG PET/CT (or
both), because palliative chemotherapy will be the chosen treatment. AJCC also recommends
histopathologic confirmation of cM status.

17. Role of CT in cT4 category
 Tracheobronchial invasion
 Displacement and posterior wall bowing
 Nodularity/Irregularity of airway
 Limitations
 Bowing seen in normal expiratory scans
 Bowing – normal in cervical esophagus
 Dilated esophagus

18. Role of CT in cT4 category
 Aortic invasion
 Area of contact >90°
 Obliteration of triangular fat space
 Pericardial invasion
 Mass effect with concave deformity of heart

19. Tracheobronchial Fistula

20. Source: Saliba G, Hayami M, Klevebro F, Nilsson M. Surgical
treatment of Siewert type II gastroesophageal junction cancer:
esophagectomy, total gastrectomy or other options? Ann Esophagus
2020;3:18.

21. Resectability
*** NCCN(national comprehensive cancer network) Guidelines –Version 2, 2017.
 Esophagectomy as the first line therapy can be considered for:-Adenocarcinoma-Tis to T1bN0M0
 Squamous Cell Cancer –Tis to T1bN0M0-T2N0M0 –only if low-risk lesions(<2cm, well-differentiated)-
 pTis: Endoscopic mucosal resection (EMR), ablation, or esophagectomy-
 pT1a: EMR, EMR after ablation, or esophagectomy-
 Superficial pT1b: EMR after ablation, or esophagectomy
 T1bN0M0 –T4aNxM0: After neoadjuvant chemotherapy or chemoradiation, esophagectomy can be
considered.
 Multi-station lymphatic involvement: relative contraindication-
 Unresectable tumors: -Involving the heart, great vessels, trachea, adjacent organs (liver, pancreas,
spleen)-
 Multi-station, bulky lymphadenopathy-Supraclavicular nodal involvement
 Non-regional nodal disease-Metastatic disease.

23. Evaluation of Postsurgical Complications
 Postoperative complications that radiologists should watch:
 Fistula formation (which can result from tracheobronchial tree injury, anastomotic leak, or ischemia in
the stomach),
 Anastomotic leak,
 chylothorax,
 delayed emptying, and herniation of abdominal viscera.
Patients with neo-esophago-tracheal or bronchial fistula formation can develop recurrent pneumonia and
empyema and may require surgical repair. Pulmonary and pleural complications include pneumonia, pleural
effusions, and atelectasis.
 CT and fluoroscopic evaluation continue to play a central role in the postsurgical evaluation of patients
with esophageal cancer.

24. Post-treatment Response Assessment
 A recent systematic review by Goense et al. shows that for recurrent disease, both FDG PET/CT and CT
are used, but FDG PET/CT is currently the most reliable imaging modality and has a sensitivity of 89–
100% and specificity 55–94%.
 Evaluation of posttreatment FDG uptake within the esophageal tumor is complicated by the difficulty in
distinguishing posttreatment inflammatory changes versus residual viable tumor.

26. Emerging Imaging Trends
 Fluorine-18-labelled fluoro thymidine is a marker for cellular proliferation and has been evaluated for use
in Post neoadjuvant esophageal cancer imaging to differentiate between residual tumour and post-
treatment inflammatory change. However, it may have a high false-negative rate, and uptake parameters
may not correspond with prognosis, limiting its usefulness in routine clinical practice.
 In addition to PET scans, MRI with the functional feature of diffusion-weighted imaging (DWI) is another
advancing imaging technology, which has current and future potential to overcome the limitations of
conventional staging methods in patients with ESCC.
MRI is often considered technically challenging because of artefacts due to organ motion and blood flow.
However, the usefulness of MRI in ESCC may expand as technical improvements allow proper visualization
of the esophagus.

27. Emerging Imaging Trends
 Narrow band imaging: Narrow band imaging (NBI) uses spectral characteristics of endoscopic light to
enhance the visibility of vasculature in the mucosa[16-18]. An optical filter with a narrow band
spectrum is applied to correspond to the peak absorption spectrum of haemoglobin to enhance the
visualization of mucosal and submucosal microvascular patterns. A panel of nine experts from Asian-
Pacific countries agreed that NBI could replace chromoendoscopy, which distinguishes normal
esophageal mucosa by applying Lugol’s iodine stain during routine examination because it is easy to
use and imparts considerable information[19]. On NBI, early lesions appear brown and well-
demarcated, and it is reported that microvascular patterns correspond to the depth of tumor invasion,
which is classified into five types and several subtypes[20]. Thus, NBI is being increasingly used to
stage superficial ESCC.

28. ACR Appropriateness Criteria® 2022
Staging and Follow-up of Esophageal Cancer
 Variant 1(Newly diagnosed esophageal cancer. Pre-treatment clinical staging. Initial imaging ): CT chest
and abdomen with IV contrast or FDG-PET/CT skull base to mid-thigh is usually appropriate for the initial
staging of patients with newly diagnosed esophageal cancer.
 Variant 2(Imaging during treatment ): FDG-PET/CT skull base to mid-thigh is usually appropriate for the
evaluation of patients with esophageal cancer undergoing treatment.
 Variant 3(Esophageal cancer. Posttreatment imaging. No suspected or known recurrence ): CT chest and
abdomen with IV contrast or FDG-PET/CT skull base to mid-thigh is usually appropriate for patients who
had esophageal cancer with no suspected or known recurrence after treatment
 Variant 4(Posttreatment imaging. Suspected or known recurrence): CT chest and abdomen with IV contrast
or FDG-PET/CT skull base to mid-thigh is usually appropriate for patients with esophageal cancer with
suspected or known recurrence after treatment.

29. conclusions
 Esophageal cancer stage is based on depth of tumor invasion, involvement of regional
lymph nodes, and the presence of metastatic disease. Most patients present with either
locally advanced or metastatic disease.
 Appropriate work-up is critical to identify accurate pre-treatment staging so that both under-
treatment and unnecessary treatment is avoided.
 Staging evaluation should start with CT or PET scan, and patients who do not have
metastatic disease should have EUS to determine the locoregional extent of disease.
Treatment strategy should follow guideline recommendations, and generally should be
developed after multidisciplinary evaluation.
 Surgery or local mucosal treatments should be considered for superficial cancers.
Multimodality therapy that includes surgery is generally considered the best treatment for
locally advanced cancers, while patients that have metastatic disease should be considered
for chemotherapy along with best supportive care.

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31. THANK YOU