IMAGE OF THE WEEK 2015

IMAGE 05 - 21 SEPTEMBER 2015

Esophageal Carcinoma

Esophageal cancer is still a devastating disease and is the eighth most common cancer worldwide, with an estimated incidence of 456,000 new cases in 2012 and the sixth most common cause of cancer death, with a mortality rate that closely follows the incidence rate, claiming an estimated 400,000 lives (GLOBOCON 2012).  Men are more likely to develop esophageal cancer than women (2-4:1).

The epidemiology of esophageal carcinoma has changed over the past few decades with squamous cell carcinoma which commonly occurs in the thoracic esophagus, now being over taken by adenocarcinoma affectphageal cancer is still a devastating disease and is the eighth most common cancer worldwide, with an estimated incidence of 456,000 new cases in 2012 and the sixth most common cause of cancer death, with aing the distal esophagus and gastroesophageal junction. The latter now accounts for more than 70% of all new cases of esophageal cancer.

In Brunei Darussalam, cancer is still the leading cause deaths but esophageal cancer is not common and ranked 18^th among all cancer deaths in 2013 (HIB 2013).

Common signs and symptoms of esohageal cancer includes dyphagia (most common, initially with solids progressing to include liquids), weight loss, bleeding, epigastric or retrosternal pain, hoarseness, persistent cough with bone pain usually indicating late symptoms. There is usually very little physical signs except in advance disease with hepatomegaly from hepatic metastases and supraclavicular lymphadenopathy.

Modern imaging techniques that can be used to make a diagnosis of esophageal cancer include barium esophagography or barium swallow, contrast-enhanced computed tomography, multidetector CT, MRI, endoscopic ultrasonography (EUS) and positron-emission tomography (PET).

Barium swallow or esophagography (Figure 1) is still the preferred modality in most centres for evaluating patients with symptoms of dysphagia, as it allows for assessment of esophageal morphology and motility. It has optimal sensitivity for the detection of lesions when a double-contrast technique is used (Figure 1).  Features of esophageal cancer on barium esophagography includes abrupt changes to calibre of the esophagus, with a long, annular stricture of the esophagus with masslike shouldering at the proximal extent with a dilated proximal esophagus being the most common (Figure 2). Other lesions may be infiltrative, ulcerating or varicoid or mixed pattern (Figure 2).

CT scan is useful in staging the disease although its limitation lies in characterisation of lymph nodes. Enlarge lymphnodes may be infectious or inflammatory and subcentimetre lymphnodes may harbour metastatic tumour.

EUS also is useful for assessing tumour depth and lymphnodes involvement although it is highly operator dependent and may be limited by the difficulty in passing the probe through a tight malignant stricture. T-stage accuracy with EUS is about 79-94%.

MRI has the advantage of direct multiplanar imaging capabilities, which is useful in assessing tracheobronchial, aortic and pericardial involvement.

PET using 2-[Flourine 18]-flouro-2-deoxy-D-glucose (FDG) is a useful metabolic imaging modality for staging of the disease. Combined with CT scan, PET/CT for esophageal cancer has a sensitivity of 96% and specificity of 78%.

Treatment of esophageal cancer varies depending on the stage of presentation of the disease. Early stage 1 disease (Tis and T1aN0) can be treated by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) in specialised centres.  Patients with T1b and any N,  esophagectomy is the initial treatment. For Stage 2 and above, multidisciplinary evaluation and multimodality therapy is the standard. Trimodality of chemoradiation followed by surgery is the recommended treatment for patients who can tolerate this treatment regimen and is supported by strong level 1.  Evidence. 15-30% of patients undergoing this trimodality treatment will have a complete pathologic response (pCR) by the time of surgery and this group of patients have a 3-yr survival rate of about 50% as opposed to 27% for those without a pCR. Stage 4 disease is treated with chemotherapy or symptomatic and supportive care.

Images contributed by

Dr Ian Bickle, Department of Radiology,RIPAS Hospital

and text contributed by

Mr William Chong, Cardiothoracic Surgeon, Department of Surgery, RIPAS Hospital

All images are copyrighted and property of RIPAS Hospital.