This document discusses imaging of neoplastic lesions of the esophagus. It describes the classification, risk factors, and imaging features of benign and malignant esophageal lesions. Common benign lesions include leiomyomas and fibrovascular polyps, while 80% of esophageal tumors are malignant, mainly squamous cell carcinoma and adenocarcinoma. Imaging modalities like barium swallow, EUS, CT, and PET are discussed for diagnosing and staging lesions. The document also provides an overview of the AJCC staging system and treatment options for esophageal cancer which include surgery, chemotherapy, radiation, and palliative care.

1. Imaging of neoplastic lesions of
esophagus including staging and
operability criteria in Ca esophagus

2. Esophageal neoplastic lesions
• Classified as:

3. Esophageal cancer
• Constitute 4-20% of all GI malignancies.
• Risk factors: (BELCH SPAT)
• Barrett esophagus
• Ethanol abuse
• Lye ingestion
• Celiac disease
• Head and neck tumor
• Smoking
• Plummer Vinson syndrome
• Achalasia, Asbestosis
• Tylosis.

4. Imaging modalities
• CXR
• Barium Swallow
• EUS
• CT
• PET

5. CXR
• Widened azygoesophageal recess with convexity to right
• Thickening of posterior tracheal stripe & right paratracheal stripe
• Tracheal deviation
• Widened mediastinum
• Posterior tracheal indention
• Retrocardiac mass
• Esophageal air fluid level
• Lobulated mass extending into gastric air bubble
• Repeated aspiration pneumonia changes

6. Barium swallow
• 1st examination for dysphagia.
• The barium coats the esophageal mucosa (like a coat of paint) and
mucosal abnormalities may be seen especially if the lumen is
distended with gas (carbon dioxide from effervescent tablets). This is
the 'double contrast' technique.
• Superficial lesion - plaquelike/polypoidal/ulcerated lesion.
• Advanced lesion – irregular luminal narrowing, ulceration, abrupt
shouldered margins

7. Barium swallow
Normal study Irregular
stricture with
shouldered
margin

8. Endoscopic US
• Relatively new technique.
• Specialized endoscope with high frequency (7-12MHz) US transducer
at the tip.
• Two types of EUS scopes:
Linear Radial
Forward/side view along the axis of the
scope
360° image at 90° to the axis of scope
Commonly used hepatobiliary imaging
and US guided sampling
Used in esophageal imaging, best for
staging epithelial superficial lesions.

9. EUS
Radial EUS scope Radial EUS scope with
special balloon inflated with
saline

10. EUS

11. EUS
Hypoechoic thickening of superficial layer Growth extending till muscularis propria

12. EUS
• Complication:
• EUS scopes generally have a greater diameter than modern simple
diagnostic (viewing) scopes due to the extra ultrasound technology
required to be fitted into the endoscope making it less flexible.
• Esophageal perforation is one of major complication of EUS in
esophageal cancer and it will upstage the tumor to T4 and worsens
the prognosis.

13. CT
• Stomach and esophagus are distended with water (or milk) which
allows enhancement of the esophageal or stomach wall tumor to be
better seen against the low attenuation of the lumen contents.
• IV Buscopan or glucagon used to reduce motion artefacts due to
peristalsis.
• Normal esophageal mural thickness ~ 3mm. It is not possible to
distinguish the layers of esophageal wall on CT. Hence for staging in
early T diseases EUS is the best modality.

14. CT – signs of invasion
• Loss of the fat plane between the tumor and adjacent organ
• Displacement of adjacent organ
• The amount of contact between the tumor and the aorta (esp > 90
degree sectorial contact with the growth)
• Secondary signs include pericardial and pleural effusion (does not
always indicate malignant spread).

15. CT
Growth with ~90 degree sectorial contact with aorta, compressing on
azygous vein and left main bronchus.

16. CT
• Also helpful to assess N and M stage
• Malignant nodes: usually >10mm, spherical or lobulated, hypodense
and well-defined.
• Esophageal cancers likely to metastases to liver>lung>bone.

17. PET
• Avid uptake of primary (unless confined to mucosa) and metastases (except
micrometastases).
• Primary tumor not identified in up to 20% (33% sensitive compared with
80% for EUS).
• Role of PET:
• Cost effective in preventing noncurative surgery
• Initial staging & detection of distant (unresectable) metastases.
• Monitoring the effectiveness of therapy
• Monitoring conversion from non-surgical to surgical lesion
• Follow-up after definitive treatment
• Pitfalls:
• Uptake in regional LN obscured by activity of primary tumor
• Lack of uptake in esophageal carcinoma confined to the mucosa and microscopic foci
in LN.

18. PET-CT
CT PET-CT fusion image showing primary
lesion in the upper esophagus
Isotopic image

19. PET-CT
PET-CT showing “hot” node in paraaortic region far away
from the surgical plane making it unresectable.

20. Esophageal cancer – workup

21. Benign esophageal neoplasms
• Represent 20% of esophageal tumors
• They are small and asymptomatic.
• General imaging findings of benign tumors:
• Smooth intramural or intraluminal mass without ulceration or nodularity at
barium examination
• Absence of peritumoral invasion lymphadenopathy, or distant metastases

22. Leiomyoma
• Non-epithelial intramural lesion
• Tumor of mature smooth muscle cells and most common benign
tumor
• M>F, 2:1.
• Most patients are asymptomatic, but dysphagia and pain may
develop, depending on the size of the lesion and amount lumen
encroachment.
• Treatment options include endoscopic resection, surgical enucleation,
and observation.

23. Leiomyoma – imaging features
• CXR - abnormal azygoesophageal recess and coarse Ca2+ (rare).
• BS - typical intramural mass, appearing as smooth-surfaced crescent-
shaped filling defects that form right angles or slightly obtuse angles
with esophageal wall.
• CT - Smoothly marginated homogeneous masses in the mid to lower
esophagus, occasionally containing areas of calcification,
isoattenuating or hypoattenuating to muscle at nonenhanced CT.
• MR – slightly T2 hyperintense and enhance homogeneously

24. Leiomyoma
Double-contrast BS shows a smoothly
marginated filling defect (arrow) that
forms a slightly obtuse angle with the
adjacent esophageal wall.
Axial CECT image shows homogeneous
isodense lesion in the distal esophagus
with luminal narrowing and maintained
fat planes with adjacent structures.

25. Esophageal GIST
• Uncommon site for GIST.
• Small GISTs may be homogeneous intramural masses
indistinguishable from leiomyomas.
• Large GISTs may be differentiated by central low attenuation
secondary to necrosis or cyst formation.

26. Esophageal leiomyomatosis
• Rare condition with diffuse proliferation of smooth muscle in the
esophageal wall, indistinguishable from multiple leiomyomas.
• Can be familial, a/w alport syndrome.
• A/w leiomyomatosis of tracheobronchial tree and GU tract.
• Present at childhood

27. • BS - tapered narrowing of the distal esophagus mimicking achalasia
with thickened esophageal wall may extend across GEJ.
• CT & MR - Marked homogeneous thickening of the distal esophageal
wall.
Esophageal leiomyomatosis
Axial CECT image shows circumferential
homogeneous wall thickening involving the
distal esophagus extending across GEJ causing
luminal narrowing.

28. Fibrovascular polyp
• Endoluminal polyps containing various amounts of fibrous and
adipose tissue and a/w blood supply.
• Imaging appearances depends on the proportions of fat and fibrous
tissue in these lesions.
• Heterogeneous lesion, with areas of fat attenuating, hyperechoeic, or
high T1 signal from adipose tissue mixed with areas of soft-tissue
attenuation, hypoechogenicity, or low T1 signal from fibrovascular
component.
• Punctate calcification can be seen on CT.

29. Fibrovascular polyp
Double contrast BS shows smooth, sausage-shaped mass
(arrow) extending proximally into the cervical esophagus
Axial and sagittal CECT image shows an intraluminal esophageal mass
with predominantly fat attenuation and pedicle extending to cervical
esophagus

30. Malignant esophageal neoplasms
• Represent 80% of esophageal tumors
• More than 90% of these are SCCs or adenoCa.
• General imaging findings of malignant esophageal neoplasm:
• Stricture or mass with mucosal irregularity or ulceration at BS
• Tumor spread with infiltration of the periesophageal fat, lymphadenopathy,
or distant metastases.

31. Squamous cell carcinoma
• Most common esophageal tumor worldwide. Strong a/w smoking.
• Peak age: 60-74 y. M>F. Location: middle > lower > upper 3rd.
• Asymptomatic superficial tumors
• Progressive dysphagia, odynophagia, weight loss, chest pain,
hoarseness of voice.

32. Squamous cell carcinoma – imaging features
• BS:
• Superficial lesion: plaquelike/polypoidal/ulcerative appearances
• Advanced lesion: irregular luminal narrowing, abrupt shouldering margins.
• EUS:
• Homo-heterogenous mass
• Disruption of esophageal wall layers
• Lymph nodes: spherical >10mm hypoechoic nodes

33. Squamous cell carcinoma – imaging features
• CT:
• Asymmetrical/circumferential wall thickening of esophageal wall/soft tissue mass.
• Peak enhancement in late arterial phase
• Mediastinal/aortic invasion
• Distant metastases
• PET:
• Avid uptake of primary and metastases
• Complication:
• Esophageal obstruction, TEF, aspiration pneumonia
• Prognosis:
• Overall 5-year survival rate is 10%.

34. Squamous cell carcinoma – imaging features
MPR CECT images shows marked
thickening of the upper thoracic
esophageal wall with an abrupt transition
inferiorly). The esophagus is otherwise
diffusely dilated from achalasia. There is
displacement and indentation of the
trachea, findings consistent with tracheal
invasion. An involved lymph node shows
peripheral enhancement from central
necrosis. Axial fused PET/ CT image shows
avid uptake by the esophageal carcinoma
obscuring the involved lymph node..

35. Squamous cell carcinoma – imaging features
Axial CECT image shows concentric thickening of the esophageal wall.
Contact of the tumor with greater than 90° of the aortic circumference
s/o concerning for aortic invasion, and stranding of the adjacent fat is
consistent with mediastinal invasion.
Endoscopic US image shows a hypoechoic mass
that extends from the esophageal wall to invade
the aorta.

36. Adenocarcinoma
• Malignant epithelial neoplasm that almost always arises from
malignant degeneration of underlying Barrett epithelium.
• Barrett esophagus is a premalignant condition, char/by replacement
of the normal stratified squamous epithelium in the esophagus by
columnar epithelium as a result of chronic GERD and reflux
esophagitis.
• Adenocarcinoma is the second common Ca esophagus.
• M>F, 85:15. peak incidence in 7th decade. Location: lower 3rd (75%).
• Asymptomatic (mostly) or GERD symptoms.

37. Adenocarcinoma
• AdenoCa and SCC is indistinguishable at imaging on the basis of
morphologic findings.
• But the vast majority of adenocarcinomas involve the lower third of
the esophagus, and these tumors are much more likely to invade the
stomach.

38. Adenocarcinoma – imaging features
Double contrast BS shows polypoid
lesion (arrows) in the distal esophagus
with scalloped borders and mucosal
irregularity.
Axial CECT image shows a mass
projecting into the esophageal lumen.
The mass is outlined by foci of air.

39. Adenocarcinoma – imaging features
Endoscopic US image shows a
hypoechoic mass involving the mucosa
through the muscularis propria
Axial CECT image shows a low-attenuation mass
with scattered punctate calcifications involving the
gastroesophageal junction and lesser curvature of
the stomach.

40. Lymphoma
• Rare site of extranodal lymphoma. <1% GIT lymphoma
• Esophageal involvement usually results from direct extension from
stomach or adjacent mediastinal nodes. Primary esophageal
lymphoma is extremely rare.
• Risk factors include: 1. HIV, 2. chronic immunosuppression.
• Commonly present with dysphagia, but usually asymptomatic.
• Treatment include – chemotherapy, radiotherapy, surgery.

41. Lymphoma – imaging features
• BS:
• Commonly appears as irregular narrowing of the distal esophagus due to direct
spread of tumor from the adjacent proximal stomach
• Esophageal lymphoma may also result in multiple submucosal nodules, polypoid or
ulcerated lesions, enlarged folds, or rarely aneurysmal dilatation of the esophagus
• CT:
• Cause concentric or asymmetric thickening of the esophageal wall with or without
adjacent mediastinal lymphadenopathy.
• EUS:
• Manifests as transmural homogeneous hypoechoic thickening, although
anechoic/hyperechoic masses.
• PET:
• Shows avid uptake.

42. Lymphoma – imaging features
Axial CECT image shows a homogeneous soft-tissue
mass impinging on the esophageal lumen.

43. Staging esophageal tumors

44. Staging esophageal tumors

45. 7th and 8th AJCC clinical staging
• Addition of peritoneal spread to the criteria for T4a.
• Squamous and adenocarcinoma follow much different pattern of
stage grouping.
• GE junction has been revised in 8th edition TNM staging, such that
cancers involving it with epicenters no > 2 cm into the gastric cardia
are staged as adenocarcinomas of the esophagus and those with
more than 2-cm involvement of the gastric cardia are staged as gastric
cancers.

46. Treatment
• Options include
1. Surgery
2. Chemotherapy
3. Radiotherapy
4. Palliative care
• Decided based on:
1. Site of lesion
2. Extent of involvement
3. Co-morbidities
4. Patient preference

47. Treatment – surgery
• Types of surgery:
• Transhiatal esophagectomy
• Right thoracotomy (Ivor-Lewis procedure)
• Left thoracotomy
• Radical en—bloc resection.

48. Summary – Take home points
• Esophageal tumors: broadly divided as epithelial and non-epithelial.
• Esophageal Ca: 8th leading cause of cancer death worldwide.
• AdenoCa is commoner is developed countries. SCC is prevalent in
developing and under-developed countries.
• Imaging modalities are: CXR, barium swallow, PET-CT, MR.
• EUS is new innovative technique to diagnose and stage mural lesions.
• AJCC 8th ed is new staging method with fewer changes to AJCC 7th ed.
• Treatment include: Surgery, RT, CT and palliative care.

49. Thank you