Be careful of the "black rose sign" of the esophagus [YXZX093]

One of the manifestations of esophageal cancer under barium meal angiography, showing local irregular narrowing of the esophagus (yellow arrow: dried roses), proximal esophageal dilation (withered rose flowers), two irregular linear ulcers (red arrows: rose leaves / spines), shaped like black roses, originally named "black rose flower sign", to help memory and deepen the image

& Esophageal cancer manifests itself in a variety of
ways.

Early esophageal cancer may present as plaque-like or polypoid lesions in barium meals, or may present as focal irregularities
of the esophageal wall.

Advanced esophageal cancer typically presents with a stenosis due to a mass, with a "scapular sign" and irregular contours
.
Less common beaded findings can be confused with varicose veins, but tumors do not change shape due to peristaltic waves, whereas varicose veins do
.

Esophageal cancer can be squamous cell carcinoma or adenocarcinoma and cannot be reliably distinguished
from barium meal examination.
Squamous cell carcinoma tends to involve the upper or mid-esophagus, while adenocarcinoma usually involves the distal esophagus and can spread to the stomach
.

& Squamous cell carcinoma is most commonly caused by
smoking and alcohol abuse.
Less common risk factors include celiac disease, PIummer-Vinson syndrome, achalasia, and human papillomavirus (more commonly causing laryngeal squamous cell carcinoma).

& Adenocarcinoma is caused by chronic reflux and evolved from the distal Barrett esophagus
.
The incidence has continued to rise
in recent years.

(Above: Irregular thickening of the esophageal wall with enhanced CT)

Further reading:

Esophageal cancer is a malignant tumor caused by the epithelium or glands of the esophageal mucosa, and is one of
the most common malignant tumors in China.

1.
Pathological and clinical

Esophageal cancer (Carcinoma of Esophagus) is a malignant tumor that occurs in the epithelium or glands of the esophageal mucosa, and is one of the most common malignant tumors in
China.
More common in middle-aged and elderly patients
.

Onset is associated with
living conditions, poor diet, positive family history, and chronic inflammation of the esophagus.
Histology types include squamous cell carcinoma, adenocarcinoma, small cell carcinoma, acanthosis carcinoma and other types, and more than 90% are squamous cell carcinoma
.
Adenocarcinoma mostly occurs in the lower esophagus, accounting for 0.
8%~8%
of esophageal cancer.

The general pathology is divided into infiltrative type (or coarctation type), hyperplastic type (or mushroom type) and ulcer type
.
The symptoms of early esophageal cancer are not obvious, and there may be choking sensation of eating, burning sensation behind the sternum and back pain
.

The progressive phase presents with progressive and persistent worsening of dysphagia, marked chest tightness or chest and back pain, hoarseness, dyspnea, or choking on
eating.
Anemia, weight loss, and cachexia
occur in the late stage.

2.
Imaging performance

X-ray performance:

(1) X-ray manifestations of early esophageal cancer:

(1) Changes in esophageal mucosal folds: the mucosal folds at the lesion site are tortuous and thickened, and some mucosa interruptions and destruction can be seen, and the edges are rough
.
Roundabout thickening of mucosal folds is the most common sign of early esophageal cancer;

Less common, small niches of varying sizes and more or less may appear on the thickened mucosal surface, generally less than 5mm in diameter;

(3) Small filling defect: small nodular changes to the cavity, more superficial or papillary, diameter about 5~20mm;

(4) Abnormal function: local tube wall relaxation is reduced, hemilateral tube wall stiffness, peristalsis slows down, barium retention, etc
.

(2) X-ray manifestations of intermediate and advanced esophageal cancer

It is the most typical x-ray manifestation of
esophageal cancer.
Local mucosal folds are interrupted, destroyed, or even disappeared, conical, half-moon or irregular niches and filling defects in the cavity, and the lesion wall shows stiffness and peristalsis
.
The main manifestations of each type are as follows:

(1) Infiltrative type: the lesion esophagus is annular symmetrical stenosis or funnel-shaped obstruction, the lesion is about 20~30mm long, local soft tissue mass shadow is visible, the tube wall is stiff, the edge is more smooth, and the proximal esophagus is significantly dilated;

(2) Hyperplastic type: filling defect with low eccentricity in the lumen, uneven edges, shaped like cauliflower or mushroom, the middle of the lesion often shows superficial luminal niches, and hemilateral stenosis of the lumen appears in the late stage;

(3) Ulcer type: It is displayed as a cavity niche of different sizes and shapes, the edges are not polished, and the bottom of some niches exceeds the outline of
the esophagus.
When the ulcer ruptures along the long axis of the esophagus with a bulge at the edge, a "half-lunar sign" appears, circling an irregular ring embankment
.

Barium meal contrast images of intermediate and advanced esophageal cancer

a.
Invasive esophageal cancer, showing centripetal narrowing of the upper esophagus, irregular margins, local soft tissue mass, and esophagus dilation above stenosis

b.
Proliferative esophageal cancer, eccentric irregular filling defect in the middle of the esophagus, irregular margin

c.
Ulcerative esophageal cancer, eccentric mass in the middle of the esophagus, local intraluminal niche

(3) X-ray manifestations of complications of esophageal cancer

The perforation of the esophageal cancer forms a fistula, and contrast media can be seen spilling beyond the contour of
the esophagus.
Fistula into the mediastinum can cause mediastinitis and mediastinal abscess, widening the mediastinal shadow, and some can see the fluid level, in which barium enters
.

Complicated by esophageal tracheal fistula, barium enters the corresponding bronchi through the fistula to make it develop, mostly the left lower lobe
.
Esophageal cancer with large lymph nodes with intrathoracic metastases can cause the hilum to enlarge and become nodular, widening
the upper mediastinum.
Markedly enlarged lymph nodes can displace
the esophagus.

Mid-stage esophageal cancer complicated by esophageal tracheal fistula barium meal contrast image

Narrowing of the mid-esophagus after barium swallowing, with bronchial splendence

CT findings:

(1) Esophageal wall changes: the esophageal wall is annular or locally irregular thickened, and the corresponding plane lumen narrows or disappears, and changes like a mass;

(2) Blurring and disappearance of the fat space around the esophagus: indicating outward invasion of esophageal cancer;

(3) Involvement of surrounding tissues and organs: mostly trachea and bronchi, often forming esophageal-tracheal fistula, followed by invasion of the pericardium, left atrium and aorta;

(4) Metastasis: mediastinum, hilar and cervical lymph node metastasis is more common, retrograde metastasis can also be retrograde to the upper abdominal lymph nodes, and lung metastasis
is rare.
CT scan with contrast shows mild enhancement
of the tumor.
Larger tumors are unevenly strengthened, often combined with low-density necrotic foci, and smaller tumors are evenly
strengthened.

CT images of lower esophageal cancer

The lumen of the lower esophagus disappears, changes in mass, and the plain scan is of equal density, which is significantly strengthened after enhancement

MRI findings:

Similar to CT findings, MRI clearly shows the normal upper and lower esophagus, which often fails due to compression behind the left atrium
.

MRI can clearly show the size of the tumor, the degree of invasion to the surrounding area, and whether it has invaded adjacent organs, making it easier to stage
the tumor.
The tumor showed equal T1 length and T2 signal during plain scanning; The tumor is significantly strengthened
on contrast scanning.

3.
Differential diagnosis

Esophageal cancer is mainly distinguished from
esophageal varices, benign stricture of the esophagus, and reflux esophagitis.
Imaging findings such as wall stiffness, mucosal destruction, intraluminal filling defects, irregular intraluminal niches, and upper esophageal dilation in patients with esophageal cancer can be differentiated
.
The wall of benign lesions is soft and changes with the size and shape of the swallowing lumen, and does not show intraluminal niches
.

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