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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1015_Библиотеки_им_академика_М_И_Перельмана
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374 A. Ba-Ssalamah et al.
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Fig. 3 Hydro-MDCT of the oesophagus in axial (a) and
coronal (b) reformations shows a circumferential wall thickening 10 mm in depth in the middle third of the oesophagus, with
Fig. 4 Hydro-MDCT of the oesophagus in axial (a), coronal
(b), and sagittal (c) reformations shows a markedly diffuse
oesophageal wall thickening 18 mm in depth in the distal third
2005), N staging depends on the presence of positive
locoregional or perioesophageal lymph nodes (affected lymph nodes) (Fig. 8). The N staging is explained
according to the 7th edition (AJCC Cancer Staging
Manual, 7th edition) as following:
• N0 no regional lymph node metastasis.
• N1 1–2 positive regional lymph nodes.
• N2 3–6 positive regional lymph nodes.
• N3 C 7 positive regional lymph nodes.
homogeneous enhancement and smooth outer borders in terms
of the T2 tumour (arrows)
of the oesophagus, with inhomogeneous enhancement and
blurred outer borders in terms of the T3 tumour (arrows)
Lymph node assessment for metastatic spread
remains a challenge, even with PET/MDCT. However, improved evaluation appears possible if both
morphology including size and shape, contrast
enhancement pattern as well as tracer uptake of lymph
nodes are used (Blom et al. 2011; Okada et al. 2009).
On CT perioesophageal lymph nodes are considered
positive if they are C6 mm in diameter, rounded in
shape, and show marked or inhomogenous contrast
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Fig. 5 Hydro-MDCT of the oesophagus in axial (a), and
coronal (b), reformations shows a huge mass with inhomogeneous enhancement in the mediastinum arising from the
Fig. 6 Hydro-MDCT of the oesophagus in coronal reforma-
tions showing examples of large cancer in the lower third of the
oesophagus at the gastroesophageal junction, with AEG I (a),
oesophageal wall, with infiltration of the trachea (a, arrow),
in terms of the T4 tumour, note the enlarged pathologic lymph
node as stage N2 (a, arrowheads)
AEG II (b), and AEG III (c). The differentiation between distal
oesophageal cancer and gastric cancer located in the cardia is
difficult in some cases
enhancement (Ba-Ssalamah et al. 2003). In case of
FDG-PET there is no established SUV cutoff for
lymph node metastases, although single institutions
have their own cutoffs (Yu et al. 2011; Kato et al.
2009). However, in general, lymph nodes are con-
sidered involved if they show an FDG uptake that is
higher than the background. A meta-analysis of 12
studies (n = 490) examined the diagnostic accuracy
of FDG-PET in preoperative staging of oesophageal
cancer and reported sensitivity and specificity for
detecting locoregional lymph node involvement of 51
and 84 %, respectively (van Westreenen et al. 2004).
376 A. Ba-Ssalamah et al.
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Fig. 7 FDG-PET/CT of a
patient with oesophageal
cancer in axial and coronal
reformations. The area of the
untreated tumour shows
intense FDG uptake (a, b,
arrows). After treatment no
FDG uptake is appreciated
(c, d, arrows).
Histopathological work-up
after resection confirmed
no viable tumour tissue
M Staging. Hematogenous metastases from oesophageal carcinoma most commonly involve the liver
because the oesophagus is drained by the portal vein
(Fig. 8). Other less common sites of hematogenous
spreadincludethelungs,adrenal glands, kidneys,bones,
and brain. Lymph node involvement outside a perioesophageal location is considered M1 disease (Nomura
et al. 2012). Advanced distal cancers can develop
peritoneal metastases (Fig. 9).
FDG-PET is most helpful in distinguishing
potentially resectable, locally advanced disease (T3-4,
N0, M0) from distant disease (M1). In prospective
studies M1 disease was detected by FDG-PET and
missed by CT (with or without EUS) in 5–7 % of
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Fig. 8 FDG-PET/CT of a patient with distal oesophageal
b
cancer in axial and coronal reformations. There is an intense
FDG uptake in the area of primary tumour as well as in the liver
and left pubic bone indicating distant metastases (a, b, arrows)
cases (Meyers et al. 2007; Heeren et al. 2004). M1
disease was detected by FDG-PET and missed by CT
in 6–15 % of patients (Flamen et al. 2000; Meyers
et al. 2007; Heeren et al. 2004).
4.2 Follow-Up After Oesophagectomy
Tumour recurrence of oesophageal cancer can be
divided into locoregional recurrence and distant
metastatic disease. The rate of recurrence of oesophageal cancer even after curative surgery was found to
be high in most reports (AJCC 2009). In the detection
of tumour recurrence, the selected imaging modalities
are important in many regards. First of all, the
imaging modality must be suitable and cost-effective,
and able to detect the pathology in the early stages.
After oesophagectomy and gastric excision, the
anatomy of the posterior mediastinum is markedly
changed. This makes assessment of possible local
tumour recurrence difficult. Wall thickening or adjacent mass and suspicious lymph nodes are highly
predictive for recurrent disease (AJCC 2009). Hydro
technique in combination with FDG-PET/MDCT is
again the modality of choice in early detection of
recurrent tumour (Guo et al. 2007).
4.2.1 CT Findings
Locoregional recurrent oesophageal tumour is well
demonstrated by CT. A smooth or spiculated area of
extrinsic mass effect on the mediastinal border can be
visualised by CT. Furthermore, MDCT with multiplanar reformations is accurate in detecting masses
after oesophageal surgery and superior for distant
metastatic disease, and can accurately delineate the
neoesophagus and its surroundings (Fig. 10). However, differentiating between fibrosis and tumour tissue at CT is based on indirect signs and may be
difficult or even impossible in some cases. FDG-PET/
MDCT can overcome this limitation (Sun et al. 2009;
Carlisle et al. 1993; Tunaci 2002). Early postoperative
cases with possible inflammatory reactions or early
post-radiation changes, in particular, must be interpreted with caution.
378 A. Ba-Ssalamah et al.
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Fig. 9 Hydro-MDCT of the oesophagus in coronal reforma-
tions shows a distal oesophageal cancer (white arrow) with
marked ascites (small black arrow), and diffuse stranding of the
mesenteric root (black arrowhead) indicative of peritoneal
carcinomatosis (large black arrow). Note the oesophageal stent
(white arrowhead)
5 Other Oesophageal Malignancies
5.1 Oesophageal Lymphoma
The oesophagus is the alimentary organ least commonly involved with lymphoma, therefore lymphoma
of the oesophagus is rare. Any histologic variety of
lymphoma may affect the oesophagus (Mendelson
and Fermoyle 2005). To diagnose primary oesophageal lymphoma, the following criteria have been
proposed: (a) predominantly oesophageal involvement with only regional lymph node involvement; (b)
no definite enlargement of mediastinal lymph nodes;
(c) no involvement of liver and spleen; and (d) no
superficial lymphadenopathy (Kaplan 2004).
Fig. 10 Hydro-MDCT of the oesophagus in axial (a) and
coronal (b) reformations in a patient with a clinical history of
oesophageal cancer and esophagectomy and gastric transposition. We can detect a recurrence demonstrated as a solid mass
with inhomogeneous enhancement at the anastomosis site (right
side cervical, a, arrow). Note the stent dislocation (b, arrow)
5.1.1 CT and PET/CT Findings
CT may demonstrate a homogeneously enhancing
mass with irregular borders or sharply delineated,
pronounced, polypoid wall thickening in any part of
the oesophagus (Fig. 11), with or without associated
lymphadenopathy. Lymphoma may infiltrate the
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Fig. 11 Hydro-MDCT of the oesophagus in (a), coronal (b),
b
and sagittal (c) reformations in a patient with surgically proven
lymphoma shows a large polypoid mass in the cervical
oesophagus (arrows) without infiltration the oesophageal wall
entire oesophagus diffusely. While splenic involvement is suggestive of lymphoma, hepatic metastases
are characteristic of oesophageal cancer. There is no
specific CT finding for oesophageal lymphoma. PET/
CT scans can also be used in staging patients with
primary oesophageal lymphoma, as well as for monitoring these tumours after therapy (Suga et al. 2009).
However, the availability of FDG/PET and, in particular, FDG-PET/CT, is still limited and expensive.
5.2 Leiomyoma and GIST
Leiomyoma accounts for 60–70 % of all benign
oesophageal neoplasms and is the most common
benign tumour of the oesophagus, while rare in the
remaining gastrointestinal tract (Hatch et al. 2000;
Seremetis and Lyons 1976; Simmang et al. 1989).
The tumour is present more often in male patients
(2:1) at a median age of 30–35 years. Usually, leiomyomas are between two and eight cm in diameter.
They are multiple in less than 3 % of cases. More
than half of the patients with oesophageal leiomyoma
are asymptomatic. Typical complaints are either
dysphagia or substernal chest pain due to obstruction
of oesophageal bolus transit. Gastrointestinal stromal
tumours (GISTs) are the most common nonepithelial
tumours of the gastrointestinal tract, although they are
rare in the oesophagus (Monges et al. 2010).
5.2.1 CT Findings
Enhanced CT scans reveal a smooth or lobulated
tumour margin, with either iso or homogeneously low
attenuation. Leiomyoma and GIST may appear as a
well-circumscribed, intensely enhancing mass or may
be a sessile (Fig. 12), pedunculated, polypoidal, exophytic intraluminal solid mass, sometimes with secondary ulceration. Leiomyomas are the only tumours
that may contain calcification (Fig. 13). Absence of
infiltration of theoesophageal wall ortheabsence of the
typical circumferential growth pattern enables differentiation from oesophageal cancer. GISTs may not
change in size or may even enlarge during therapy, but
show a decrease in CT attenuation values (Hounsfield
380 A. Ba-Ssalamah et al.
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Fig. 12 Hydro-MDCT of the oesophagus in axial (a), coronal (b) and sagittal (c) reformations in a patient with leiomyoma,
demonstrated as a small soft tissue mass with slight calcifications in thoracic area of the oesophagus (arrows)
Fig. 13 Hydro-MDCT of the oesophagus in axial (a), coronal
(b) and sagittal (c) reformations in a patient with biopsy-proven
leiomyoma, demonstrated as a large tumour-like mass with
units, HU) (Choi et al. 2004). PET/CT is able to show
early effects in patients undergoing treatment. Functional imaging proved significantly more accurate than
CT alone when assessing GIST response to therapy.
Combined PET/CT imaging is, therefore, a valuable
diagnostic tool for the primary diagnosis of GISTs or
for the assessment of therapeutic response (Suga et al.
2009; Antoch et al. 2004).
5.3 Fibrovascular Polyps
Fibrovascular polyps of the oesophagus are rare
benign tumours, comprising about 1 % of all benign
oesophageal tumours. However they are the most
common intraluminal benign tumours of the oesophagus (Sargent and Hood 2006). Giant fibrovascular
marked calcifications invading the oesophagus in the thoracic
area (arrows)
polyps are defined as polyps larger than 5 cm in
maximum diameter. Even though they are benign,
they may be lethal due to either bleeding or, rarely,
asphyxiation if a large polyp is regurgitated. Patients
commonly present with dysphagia or hematemesis.
5.3.1 CT Findings
The polyps may not be well visualised on endoscopy
and imaging plays a vital role in aiding diagnosis as
well as providing important information for preoperative planning, such as the location of the pedicle, the
vascularity of the polyp and the tissue elements of the
mass. These polyps contain predominantly fibrovascular and fatty tissue, which gives them their typical
CT appearance of a pedunculated intraluminal mass
of fat density, which expands the oesophagus (Ascenti
et al. 1999).
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5.4 Oesophageal Fistula
Oesophageal fistulas can be classified according to
their anatomic relationship into oesophageal-airway,
oesophago-pleural, aorto-oesophageal and oesophagopericardial fistulas. Oesophageal-airway fistulas can be
either congenital (so-called tracheo-oesophageal
fistulas) or acquired. The development of an oesophageal–airway fistula is a life-threatening complication
of oesophageal cancer or secondary to oesophageal
trauma, infection, or radiochemotherapy. Initial
symptoms most often include cough, aspiration and
fever, frequentlyculminating inpneumonia. More than
half such fistulas involve the trachea; alternatively, a
connection with the left or right main or lower lobe
bronchus may be formed. Patients with oesophagealairway fistulas are treated withcovered stents toseal off
the leak. CT may benecessary to localise the fistulaand
to aid in treatment planning. CT can also be used to
detect pleuro-plumonary or mediastinal inflammatory
reactions to oesophageal fistulae (Peyrin-Biroulet et al.
2006; Liu et al. 2006).
5.4.1 CT Findings
CT can demonstrate a fistulous connection between
the oesophagus and the tracheobronchial system,
pleura, pericardium, or mediastinal fat if the fistulous
tract is of sufficient size and contains air or oral
contrast medium. Oral administration of dilute iodine
contrast material (contrast material: water 1:100) can
help to delineate the fistula. CT can also detect perifocal reactions in the form of empyema, pneumonia,
or mediastinitis (Fig. 14).
5.5 Oesophageal Perforation
Oesophageal injuries include penetrating injuries, blunt
traumatic perforation, iatrogenic perforation as well as
spontaneous perforation due to a sudden rise in intraluminal pressure during vomiting (so-called Boerhaave
syndrome). Most often, oesophageal perforation occurs
during endoscopic investigation of malignant disease
and presents a difficult problem. Oesophageal diseases,
suchas strictures,achalasia,andtumours,predisposethe
oesophagus to perforation. Oesophageal perforation is
associated with high mortality, and postoperative leaks
Fig. 14 Hydro-MDCT of the oesophagus in axial (a) and
sagittal (b) reformations in a patient with a clinical history of
oesophageal cancer with symptoms suspicious for fistula, due
to continuous coughing and recurrent pneumonia, shows a
fistula tract between the tumour and the trachea (arrows)
382 A. Ba-Ssalamah et al.
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Fig. 15 Hydro-MDCT of the oesophagus in axial (a), coronal
(b), and sagittal (c) reformations in a patient with oesophageal
perforation after dilation of tumour stenosis. CT scan shows
Fig. 16 Hydro-MDCT of the oesophagus in a patient with primary achalasia shows a marked diffuse dilatation of the entire
oesophagus, which is filled with fluid and food without wall thickening and malignancy (arrows)
occur frequently after primary surgical repair (Chao
et al. 2005). Early and accuratediagnosis of oesophageal
perforation is critical, because the consequences of
missed oesophageal injury are devastating, with potential progression to fulminate mediastinitis and septic
shock. Delay in treatment beyond 24 h after onset may
adversely affect prognosis. Contrast studies are the
method of choice to demonstrate oesophageal rupture.
pneumomediastinum, and air bubbles in the mediastinum (a, b,
arrows),as wellasa tissuedefectof theoesophagealwall(arrows),
and extensive soft tissue emphysema in the cervical region (c)
nasogastric tube when it is inserted, and a left lower
lobe atelectasis. CT can also display subtle signs such
as localised oesophageal wall thickening, mucosal
hyperemia, mucosal dissection, and oesophageal
hematoma, as well as oedema (De Lutio di Castelguidone et al. 2005). CT also allows the visualisation of
very small collections of mediastinal air in cases with
small tears (Fig. 15).
CT has been increasingly used for the diagnosis of
oesophageal injuries (LeBlang and Nunez 1999).
6 Other Conditions
5.5.1 CT Findings
Radiographic detection of oesophageal injuries relies
on the presence of indirect radiological signs, including
subcutaneous or muscular, thoracic or cervical
emphysema, a widened mediastinum, pneumomediastinum, pneumopericardium, left-sided pneumothorax, pleural effusion, an abnormal course of a
6.1 Achalasia
Achalasia is a primary rare motor disorder of the
oesophagus, with an incidence of about 1/100,000.
Symptoms usually become manifest in early adult
age, but even children may be affected. Achalasia is
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Botoman 1987). In 1947, Ogilvie recognised the
syndrome of neoplastic involvement of the distal
oesophagus that mimicked idiopathic achalasia, with
submucosal infiltration of the lower oesophagus and
cardia by carcinoma, which is now commonly referred to as pseudoachalasia (Carter et al. 1997).
Therefore, CT can be helpful in differentiating
between achalasia and the pseudoachalasia of malignancy. Usually endoscopy and biopsy are used to
detect tumour spread in pseudoachalasia. However,
CT may be used in suspect cases, when submucosal
tumour growth escaped endoscopic detection. Moreover, CT may delineate the presence of other tumour
manifestations (Carter et al. 1997).
6.1.1 CT Findings
CT shows uniform dilatation that affects a long segment of the oesophagus, with no wall thickening and
with normal-appearing boundary surfaces and mediastinal fat. The oesophagus narrows abruptly at the
oesophagogastric junction with no evidence of an
intramural or extrinsic obstructive lesion (Fig. 16). In
contrast to a stricture, the oesophageal wall is not
thinned at the site of the narrowing, and the wall is not
thickened as it is with the oesophageal tumour or
oesophagitis. Most pseudoachalasia patients have CT
findings of oesophageal dilation, more marked and/or
asymmetric wall thickening, or mass. In this group,
asymmetric or marked thickening ([10mm) indicates
pseudoachalasia.
Fig. 17 Hydro-MDCT of the oesophagus in axial (a), and
sagittal (b) reformations shows a small, circumscribed bulge at
the gastroesophageal junction, representing a small diverticulum (arrow)
characterised by incomplete relaxation of the lower
oesophageal sphincter (LES) on swallowing and
aperistalsis of the oesophageal body (Gelfand and
6.2 Diverticula
Oesophageal diverticula are divided into the pulsion or
traction type. The two predominant locations of
oesophageal diverticula are the mid-oesophagus (at the
level of the tracheal bifurcation) and the distal oesophagus (so-called epiphrenic diverticula). Diverticula are
incidental findings at CT (Pearlberg et al. 1983).
6.2.1 CT Findings
Diverticula appear as an air-, water- or contrast-filled
bulge. Mid-oesophageal and epiphrenic diverticula
are better visualised on coronal or sagittal (Fig. 17).
reformations on hydro-MDCT. The most frequent
location is posteroinferior to the cricoid cartilage, the
so-called Zenker diverticulum, which actually is a
pharyngeal diverticulum (Fig. 18).
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