Imaging and differential diagnosis of esophageal cancer

Esophageal cancer is a common malignant tumor of the upper gastrointestinal tract, and according to statistics, its mortality rate ranks fourth among all malignant tumors

1.

Patients with dysphagia should have an esophageal barium meal x-ray, which can observe the peristalsis of the esophagus, the relaxation of the wall, changes in the mucosa of the esophagus, defects of esophageal filling, and the degree of

(1) X-ray signs of early esophageal cancer: loss of smooth mucosa, local thickening or interruption of mucosal membranes; Sometimes single or multiple filling defects and niches of varying sizes may be seen; The local tube wall is stiff, cannot be expanded, and the peristalsis disappears

(2) Late signs: irregular mass lesions, irregular stenosis, obvious destruction and filling defects of mucosal folds, sudden angular shape of the esophagus, dilation of the proximal end and retention of

In addition, chest x-ray may show lung lesions

2、CT/MRI

(1) CT examination can clearly show the relationship between the esophageal wall and adjacent or peripheral organs (such as mediastinum, trachea, bronchus, pericardium, liver, etc.

(2) CT examination can also fully show the size of the esophageal cancer lesion, the scope and extent of tumor invasion, which is helpful

(3) CT is the best imaging method for detecting metastases

Magnetic resonance imaging (MRI) is similar

3.

Gastroscopy can not only clearly check whether there are lesions in the esophagus, the location of the lesions, the scope and extent of destruction under direct vision, but more importantly, it can take a biopsy to achieve the purpose of confirming the diagnosis

4.

EUS is a tomography of lesions in the esophagus cavity through a miniature high-frequency probe during endoscopic examination, which can more accurately determine the depth of infiltration of esophageal cancer in the wall, whether it invades the peripheral organs of the esophagus, show the enlarged lymph nodes around the lesion, distinguish between superficial and non-superficial esophageal cancer, and predict the possibility of surgical resection

Esophageal cancer EUS presents with localized or diffuse (annular) wall thickening with irregular image changes at the edges dominated by low echoes or uneven echoes

During EUS scans, the presence of structures that interfere with ultrasound, or severe narrowing of the lesions in the esophagus cavity and the inability of the probe to pass, affect the accuracy

However, EUS examination is not equivalent to histopathological examination, and more direct methods include EUS-guided fine needle puncture to attract suspicious tissues or lymph nodes, and histology
.

5.
Abdominal ultrasound

Although this test is not helpful in the diagnosis of esophageal cancer, it can detect retroperitoneal lymph node metastasis, liver metastasis, etc.
, which is helpful for the staging of esophageal cancer and the indications
for judging whether it can be surgically removed.

6、PET-CT

PET-CT is more accurate
at detecting metastases from esophageal cancer than traditional imaging methods.
Traditional imaging was diagnosed as resectable esophageal cancer, and PET-CT revealed that 20% of these lymph nodes and organ metastases
were found.
At the same time, PET-CT is widely used in the clinical staging, efficacy evaluation, postoperative recurrence detection and prognosis judgment of
esophageal cancer.

The efficacy evaluation of PET-CT on clinical radiotherapy and chemotherapy is more sensitive and earlier than the traditional evaluation method, and can adjust the treatment plan in time to achieve personalized treatment
of tumors.
It is also helpful for determining the target area of radiotherapy, but due to the high price, patients can choose
according to the economic situation.

1.
Benign stenosis of the esophagus

There is a history of chemical burns (swallowing strong bases, strong acids, certain drugs, etc.

).
Patients often develop severe burns and chest pain of varying degrees, dysphagia, nausea, and salivation immediately after swallowing
.
Dysphagia due to scar narrowing is often a clear precipitating factor
.
Barium x-ray swallowing examination may show esophageal narrowing, mucosal disappearance, and stiffness of
the tube wall.
Endoscopy can assess the location, extent, and severity of esophageal burns under direct view, but caution must be exercised to avoid esophageal perforation
.

2.
Benign tumor of the esophagus

The most common are leiomyomas, which can occur in various parts of the esophagus and are more common
in the lower segments.
The course of the disease is long and there are no specific clinical signs and symptoms
.

Barium x-ray swallowing reveals a smooth, rounded wall filling defect in the protruding lumen, no ulceration on the surface, and normal
local lumen dilation.
It often endoscopically presents as a raised mass covered with a smooth, intact mucous membrane
.
Occasionally ulcers form
in the center due to an inadequate blood supply.
There is a sliding sensation when the mass is touched
.
EUS is characterized by well-defined homogeneous low echoes or weak echoes, occasionally no echo lesions, and a small number of patients have uneven echoes and small regular edges
.
The surface is a mucosa normally shown by ultrasound scanning, which is usually located in the submucosal muscle layer
.

Leiomyomas can be oppressed but do not invade surrounding tissues
.
Leiomyosarcoma is most commonly considered if accompanied by uneven echoes, unclear edges, or irregular submucosal tumors
.
CT signs include round masses of soft tissue density protruding into or outside the cavity, sometimes crescent-shaped, with smooth surfaces, uniform internal density, focal thickening of the walls of the tube, and larger masses that can compress and displace
surrounding tissues.
MRI is mostly a medium T1 and T2 muscle signal, and the edges are smooth and lumpy
.
Confirmation depends on histopathological evidence
.

3.
Esophageal tuberculosis

It is rare, mostly secondary, and is usually located in the middle of the esophagus
.
It lacks specific symptoms, and the clinical manifestations mainly depend on the pathological type and the scope of the invasion, and may have different degrees of dysphagia or pain, obstruction, and dizziness
reduction.
The course of the disease is slow, more common in young adults, and often has a history of
tuberculosis.

Barium x-ray swallow contrast has no specific manifestations, and can be seen in the narrowing and stiffness of the lesion site, mucosal ulcer filling defect or destruction, fistula, paraesophageal lymphadenopathy, esophageal displacement, etc
.
Superficial, irregular, basal greyish-white ulcers may be seen endoscopically, with small yellow nodules of yellow tuberculosis in the marginal mucosa
.
Proliferative patterns are seen in mucosal edema, thickening, and luminal stenosis
.
The miliary type is seen in the yellow miliary nodules of
the mucous membrane.
Biopsy specimens finding tuberculous granulomas and acid-fast bacilli confirm the diagnosis
.

4.
Achalasia

The course of the disease is long, and the dysphagia is mild and severe, mostly intermittent, often accompanied by retrosternal pain, reflux symptoms, and mostly after eating
.
Taking nitroglycerin, calcium channel blockers, antispasmodics, etc.
can often alleviate
symptoms.

Barium x-ray swallowing is typically characterized by smooth beak-like or funnel-like stenosis of the lower segment of the esophagus, with varying degrees of dilation
of the esophageal body.
Intraesophageal intraluminal pressure measurement found that the patient's lower esophageal sphincter (LES) pressure increased, THE LENGTH OF LES was larger than normal, and LES laxity disorder after swallowing
.
Endoscopic visible esophageal cavity star concentric narrowing, smooth mucosa, normal color or hyperemia, edema, thickening, and sometimes mucosal erosion or superficial ulcers
.
Pathological examination of the mucosa biopsy is useful for differential diagnosis
.

EUS may show concentric thickening of the gastroesophageal junction and distal esophageal wall, particularly the myastomostaspheric layer, but more commonly all tissue layers are affected
.
In the case of pseudotarkasia due to tumor infiltration, EUS presents with eccentric thickening of the tube wall, with irregular outer margins and low echo asymmetrical lesions, disruption of normal hierarchy, and often invasion of adjacent tissues
.

5.
Varicose veins of the esophagus

Patients often have signs and symptoms of cirrhosis, portal hypertension, and complain of dysphagia
.
Barium x-ray swallowing may reveal thickened or beaded filling defects in the lower mucosal folds of the lower esophagus, soft walls, and unrestricted
lumen dilation.
Varicose veins may be seen endoscopically, or straight, slightly curved, snake-like, pedantic, raised on the mucosal surface, or beaded nodular bulges that partially obstruct the lumen
.
EUS presents as a circular, echoless, snake-like spiral tubular structure that can be found in or outside the wall, mostly in the submucosal layer
.

6.
Barrett's esophagus

Its main symptom is associated with reflux esophagitis and its accompanying lesions
.
The most common symptoms are swallowing discomfort, retrosternal pain, heartburn, nausea, etc
.
Barium x-ray swallowing examination reveals sliding hiatal hernia; Localized annular stenosis, ulceration, mesh or granular microstructural changes in the lower esophagus
.
Endoscopy is the most commonly used and reliable method, which can be seen on the dentate line at the junction of esophageal cardia, showing a full-circumferential, tongue-type, and island-type; Mucosal hyperemia, erosion, stenosis, or ulceration
.
Diagnosis is confirmed by histological examination
.
By spraying Lugol iodine solution from the endoscopic biopsy hole to the suspicious site, the columnar epithelium is not stained, and biopsy is taken here to help improve the diagnostic rate
.
EUS may show focal thickening
of the esophageal wall.
Since EUS provides high-resolution images of the walls of the esophagus, it may be a useful method for detecting early cancer in barrett patients with the esophagus
.