Role of precision imaging in esophageal cancer

Abstract

Esophageal cancer is a major cause of morbidity and mortality worldwide. Recent advancements in the management of esophageal cancer have allowed for earlier detection, improved ability to monitor progression, and superior treatment options. These innovations allow treatment teams to formulate more customized management plans and have led to an increase in patient survival rates. For example, in order for the most effective management plan to be constructed, accurate staging must be performed to determine tumor resectability. This article reviews the multimodality imaging approach involved in making a diagnosis, staging, evaluating treatment response and detecting recurrence in esophageal cancer.

Keywords: Esophageal cancer; MRI; endoscopic ultrasonography; esophageal adenocarcinoma (EAC); esophageal squamous cell carcinoma (ESCC).

Figure 1

A 63-year-old male with squamous cell carcinoma of distal esophageal mass. (A) Axial contrast CT, (B) axial FDG PET/CT images show large necrotic FDG avid tumor at the lower esophagus (black arrow) invading the stomach, pancreas and liver. (C) EGD shows a circumferential partial obstructive ulcerative esophageal mass (black arrow). (D,F) Axial contrast CT and (E,G) axial FDG PET/CT images show FDG avid enlarged necrotic cervical (thick white arrows) (D,F) and retroperitoneal metastatic lymphadenopathy (black arrowheads) (E,G). (H) Coronal MIP image shows cervical (white arrow), mediastinal (white arrowhead) and retroperitoneal (black arrowhead) metastatic lymphadenopathy and distal esophageal carcinoma with metastatic lymphadenopathy (black arrow). PET, positron emission tomography; CT, computed tomography; EGD, esophagogastroduodenoscopy; MIP, Maximum Intensity Projection.

Figure 2

A 76-year-old female with adenocarcinoma of the gastroesophageal junction (GEJ). (A) Axial non-contrast CT and (B) axial FDG PET/CT images show asymmetrical irregular thickening FDG avid tumor (white arrow) at the GEJ invading the stomach, pancreas and liver. (C) EGD shows a single 2 cm mucosal nodule (yellow arrows) at GEJ. (D) EUS shows 2.0 cm × 10 cm poorly defined one-third circumferential hypoechoic nodule/mass (white arrow) at the GEJ with likely invasion of muscularis propria. PET, positron emission tomography; CT, computed tomography; EGD, esophagogastroduodenoscopy; EUS, endoscopic ultrasound.

Figure 3

A 76-year-old female with squamous cell carcinoma at the mid esophagus. (A) Axial non-contrast CT and (B) axial FDG PET/CT images show an FDG avid thickening at the mid esophagus (white arrow) abutting the posterior wall of the left mainstem bronchus. (C) EGD shows a friable exophytic mass in the mid esophagus (white arrow) with significant stenosis. (D,E) EUS shows near circumferential hypoechoic nodule/mass (white arrow) at the mid esophagus level with significant stenosis and penetration into the adventitia. A 0.7 cm × 0.5 cm hypoechoic peritumoral node (yellow arrowhead) consistent with metastatic invasion. PET, positron emission tomography; CT, computed tomography; EGD, esophagogastroduodenoscopy; EUS, endoscopic ultrasound.

Figure 4

A 70-year-old female with squamous cell carcinoma at the proximal esophagus. (A,C,E) Axial non-contrast CT and (B,D,F) axial FDG PET/CT images shows FDG avid proximal esophageal mass (thin white arrows) (A,B) and right side displacement of the trachea (C,D) (white arrowheads) with FDG avid metastatic subcarinal lymph node and FDG avid liver metastasis (thick white arrows) (E,F). PET, positron emission tomography; CT, computed tomography.

Figure 5

A 71-year-old male with squamous cell carcinoma at the mid esophagus. (A) Axial non-contrast CT soft tissue window, (C) axial FDG PET/CT and (E) axial non-contrast CT lung window shows mid esophageal mass (thick white arrow) and lung metastases (thin white arrows) and all are FDG avid in the FDG PET/CT image (C). (B,D) EGD shows nodular irregular mass at the mid esophagus (black arrow). (F) EUS shows an irregular hypoechoic ill thickening at the site of esophageal mass (white arrowhead) and it extends into submucosa with focal disruption of muscularis layer. PET, positron emission tomography; CT, computed tomography; EGD, esophagogastroduodenoscopy; EUS, endoscopic ultrasound.

Figure 6

A 60-year-old male with adenocarcinoma of the GEJ. (A) Axial contrast CT, (B) axial FDG PET/CT, (C) axial T2WI and (D) coronal T2WI images show T2 isointense FDG avid irregular thickening (white arrows) at the GEJ. GEJ, gastroesophageal junction; PET, positron emission tomography; CT, computed tomography; T2WI, T2-weighted imaging.

Figure 7

A 59-year-old female with squamous cell carcinoma at the proximal esophagus. (A) Axial contrast CT and (B) axial FDG PET/CT images show an FDG avid 3.7 cm thickening in the proximal esophagus (thin white arrows) and tracheoesophageal fistula. (C) Axial and (D) coronal non-contrast CT shows an esophageal stent (white arrowheads) extending from thoracic inlet up to the subcarinal level. PET, positron emission tomography; CT, computed tomography; T, trachea; E, esophagus.

Figure 8

A 57-year-old male with squamous cell carcinoma at the proximal esophagus. (A) Axial contrast CT and (B) axial FDG PET/CT images show an FDG avid proximal esophageal mass (thin white arrow); (C) EGD shows a large ulcerative partially obstructive non-circumferential mass (thick white arrow) in the upper one-third of the esophagus; (D,E) EUS shows a 3 cm thickness of the wall of the esophagus (white arrowhead) and a 1 cm oval hypoechoic well defined right paraesophageal lymph node (thick yellow arrow). He underwent 3 months of chemoradiation. (F) Axial contrast CT and (G) axial FDG PET/CT images show interval decrease in the size and FDG activity of the proximal esophageal mass (thick black arrow). (H) EGD shows mild residual thickening in the upper one-third of the esophagus (thick black arrow) with surrounding normal esophageal mucosa (thin yellow arrows). (I,J) EUS shows a mild residual thickening thickness of the wall of the esophagus (black arrowhead) and reduction in 0.5 cm oval hypoechoic right paraesophageal lymph node (thin yellow arrows). PET, positron emission tomography; CT, computed tomography; EGD, esophagogastroduodenoscopy; EUS, endoscopic ultrasound.

Figure 9

A 63-year-old male with adenocarcinoma of a distal esophageal mass. (A) Axial non-contrast CT and (B) axial FDG PET/CT images show an FDG avid thickening of the distal esophagus (white arrow). (C) EGD shows a ulcerative distal esophageal mass (thick white arrow). After chemoradiation, (D) axial contrast CT and (E) axial FDG PET/CT images show interval decrease in FDG avidity and thickening at the distal esophagus (black arrows). (F) Axial CT image with oral contrast shows the gastric conduit (thick short white arrow) after the patient underwent Ivor-Lewis esophagectomy. A follow-up CT after 1 year (G) axial non-contrast CT and (H) axial FDG PET/CT images show focal FDG uptake with a circumferential thickening at the anastomosis the native esophagus and interposed conduit (white arrowheads). (I) EGD shows a non-obstructing non-circumferential fungating mass in the upper esophagus (thin yellow arrow). (J) EUS shows a 1.3 cm localized wall thickening in the upper esophagus (thick yellow arrow) with focal disruption of muscularis propria without lymphadenopathy. PET, positron emission tomography; CT, computed tomography.