Carcinoma of the esophagus

Navigating the thoracic inlet

The thoracic inlet is often seen on the "edge of the film" at computed tomography (CT); consequently, lesions affecting this structure are easily overlooked. A vascular abnormality that may be overlooked is venous thrombosis. The CT appearance of jugular vein thrombosis varies with the age of the lesion: In the acute phase, there is often loss of soft-tissue planes surrounding an enlarged, peripherally enhancing thrombus. In the chronic phase, the jugular vein appears as a tubular, nonenhancing "mass" without loss of surrounding fat planes. Intrathoracic goiters typically manifest as well-defined, markedly enhanced inhomogeneous lesions that are continuous with the cervical thyroid gland. Thyroid adenomas are typically round or oval low-attenuating lesions that enhance after contrast material administration. Thyroid carcinomas may manifest as single or multiple, irregularly shaped low-attenuating areas with or without calcification. Primary tracheal malignancies may appear as smooth or irregular, sessile or pedunculated intraluminal filling defects. Tracheomalacia manifests as destruction of the tracheal walls with soft-tissue narrowing of the tracheal lumen, whereas esophageal abnormalities manifest as thickening of the esophageal wall, dilatation of the esophageal lumen, or both. Schwannomas manifest as well-circumscribed lesions with soft-tissue attenuation that enhance after contrast material administration. Neurofibromas tend to have lower attenuation than schwannomas. Lymphangiomas typically have a cystic appearance with near water attenuation. Familiarity with the normal anatomy of the thoracic inlet as well as the CT features of related abnormalities is critical for correct diagnosis and prompt treatment.

Retrosternal bypass operation for unresectable squamous cell cancer of the esophagus

BACKGROUND

A palliative bypass operation may be beneficial when severe dysphagia or tracheoesophageal fistula occurs after radiochemotherapy for unresectable tumor of the esophagus.

METHODS

Thirty-two patients with an unresectable tumor of the esophagus underwent a palliative retrosternal gastric (29) or colonic (3) bypass operation with ligature of the lower esophagus (3) or drainage (27). Tracheoesophageal fistula was present at operation in 20 (62.5%), including 8 after radiochemotherapy.

RESULTS

The overall operative mortality rate was 34.4%: 45% with tracheoesophageal fistula and 16.6% without (p < 0.01). Median intensive care and hospitalization times were 5 and 19 days, respectively. Median postoperative survival was 6 months (range, 53 to 492 days). Complications in 21 survivors were lung infections (seven), cervical fistulas (eight), and failure of the esophageal suture (two); 19 patients resumed oral nutrition, and quality of life was excellent in 6. All eight cervical fistulas regressed favorably. Postoperative radiotherapy or chemotherapy did not improve survival.

CONCLUSIONS

Despite the high operative mortality rate, bypass operation can provide good palliation and allow subsequent radiochemotherapy in selected patients with an unresectable tumor of the esophagus.

Esophageal cancer

The important concepts of carcinoma of the esophagus are reviewed in this article. Pathology of malignant esophageal tumors is described and tumor behavior of squamous cell carcinoma is discussed and illustrated. Various classifications and staging methods are reviewed with emphasis placed on the TNM system. The role of current imaging techniques in patients with esophageal carcinoma is presented. Computed tomography is discussed and illustrated in detail. The relative cost effectiveness of these procedures is presented and an imaging approach emphasizing TNM staging is described for patients with known carcinoma of the esophagus. This imaging approach is integrated with the basic aspects of treatment and both curative and palliative pathways are presented. The final section of the article deals with these same concepts in patients with carcinoma of the gastroesophageal junction. The important differences between adenocarcinoma of the gastroesophageal junction and esophageal carcinoma are described.