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ESOPHAGEAL CANCER Nguyễn Thị Thu Trang CK1-K25 Epidemiology Esophageal cancer is responsible for 5 mm peri-esophageal soft tissue and fat stranding  dilated fluid- and debris-filled esophageal lumen is proximal to an obstructing lesion  tracheobronchial invasion appears as a displacement of the airway (usually the trachea or left mainstem bronchus) as a result of mass effect by the esophageal tumor  aortic invasion CT: Local invasion  loss of fat planes between the tumor and adjacent structures  displacement or indentation of other mediastinal structures Aortic invasion is suggested if 90° or more of the aorta is in contact with the tumor obliteration of the triangular fat space between the esophagus, aorta, and spine adjacent to the primary tumor Displacement of the trachea or bronchus, or indentation of the posterior wall of the trachea or bronchus by the tumor Pericardial invasion is suspected if pericardial thickening, pericardial effusion, or indentation of the heart with loss of the pericardial fat plane is seen T1 N0 M0 (stage I) SCC of the midesophagus in a 52-year-old man (a) Contrast material– enhanced CT scan obtained at the level of the left superior pulmonary vein shows a small, nodular protruding lesion (arrow) (b) Endoscopic US image clearly depicts a polypoid lesion (arrow) with extension into the second (hypoechoic) deep mucosal layer Note the normal alternating hyper- and hypoechoic architecture of the esophageal wall (arrowheads) The first layer is hyperechoic and represents the interface between balloon and superficial mucosa, the second layer (hypoechoic) represents the lamina propria and muscularis mucosae, the third layer (hyperechoic) represents the submucosa, the fourth layer (hypoechoic) represents the muscularis propria, and the fifth layer (hyperechoic) represents the interface between the serosa and surrounding tissues   T4 N1 M0 (stage III) SCC of the midesophagus in a 61-year-old man. Contrast-enhanced CT scan obtained at the level of the mainstem bronchi shows marked esophageal wall thickening with tumor extension into the periesophageal fat Note the diffuse wall thickening and narrowing of the left main bronchus (arrowheads) There is loss of the normal fat plane (arrows) between the esophagus and the thoracic aorta, a finding that is suggestive of aortic invasion. Sagittal reformatted CT image shows a broad interface (arrowheads) between the esophageal mass and the thoracic aorta PET/CT PET/CT is useful for detecting esophageal primary tumors PET/CT is also superior to CT for detecting lymph node metastases and can depict metastases in normal-sized lymph nodes The most common sites of distant metastases detected at PET (but frequently missed at CT) are the bones and liver.  PET/CT Contrast-enhanced CT scan shows circumferential wall thickening in the lower esophagus (arrowhead), a finding that is consistent with esophageal cancer There is also a suspect low-attenuation lesion in the posterior wall of the left ventricle (arrow), a finding that was missed at initial interpretation Fused PET/CT image shows intense FDG uptake by the primary tumor (arrowhead) and an unexpected additional focus of FDG uptake in the left ventricle (arrow), a finding that is consistent with metastasis PET/CT Pitfalls in the determination of N stage with FDG PET (a) CT scan obtained at the level of the right inferior pulmonary vein shows esophageal wall thickening (arrow), a finding that corresponds to esophageal cancer Note also the enlarged periesophageal lymph node (arrowhead), a finding that is suggestive of N1 disease (b) Coronal PET scan shows intense FDG uptake by the primary tumor (arrowhead) However, this uptake is difficult to differentiate from the FDG uptake in the periesophageal lymph node seen in a due to the limited spatial resolution of PET The periesophageal lymph node was confirmed to be malignant (metastatic) at subsequent surgery Thank for attention! ... centimeter non-circumferential mass in the mid esophagus, with an irregular surface and shouldering demonstrated This lesion is suspicious for malignancy Endoscopic US Endoscopic US is considered... represents the lamina propria and muscularis mucosae, the third layer (hyperechoic) represents the submucosa, the fourth layer (hypoechoic) represents the muscularis propria, and the fifth layer... FDG uptake by the primary tumor (arrowhead) However, this uptake is difficult to differentiate from the FDG uptake in the periesophageal lymph node seen in a due to the limited spatial resolution