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Esophageal Cancer - Case #2

Patient Presentation

This patient is a 74-year-old male with a history of gastroesophageal reflux and recent progressive dysphagia. Endoscopic biopsy demonstrated adenocarcinoma in the distal esophagus.

Image Interpretation

Esophageal Cancer
  • The elongated area of intense increased activity in the lower posterior mediastinum is consistent with a primary esophageal cancer.

Patient Management

  • Mediastinoscopy was performed to sample the right paratrcheal nodes for metastatic disease.
  • This patient has a large primary tumor and will require combined radiation therapy and chemotherapy for treatment.
  • A negative PET scan or at least marked reduction of tumoral FDG uptake after 3 cycles of chemotherapy and radiotherapy predicts improved survival.

Case Summary

PET scan showed a large T3 esophageal cancer in the distal esophagus likely extending to the gastroesophageal junction. A right paratracheal node was seen on PET. Mediastinoscopy biopsy confirmed that the PET finding did reflect a nodal metastasis. A distant node is often treated as a distant metastasis for staging purposes.

This patient underwent chemoradiotherapy and follow-up PET revealed a >70% drop in FDG within the tumor. The patient had successful resection and gastric pull-up. Follow-up PET at 6 and 12 months demonstrated no recurrence.

Nodal involvement is the most important prognostic factor in esophageal cancer. There is a dramatic fall in the cure rate of patients with positive lymph nodes at the time of surgery. Lymph node metastasis from esophageal cancer can involve the local lymph nodes right adjacent to the tumor and secondarily the lymph node regions one or two regions removed from the local cancer. Esophageal ultrasound is generally superior to CT or PET imaging for the local lymph nodes.

PET is superior to both CT and esophageal ultrasound for those patients who have lymph nodes involved by esophageal cancer that are more than 5 cm away from the primary lesion. Overall, PET performs 15 to 20% better in detecting nodal metastases than conventional CT and esophageal ultrasound. The presence of regional nodal metastasis may not in itself rule out curative surgery. The presence of these regional nodal metastases is important, as they must be included within the surgical resection or planned for in preoperative radiation and chemotherapy.

References

  1. Skehan SJ, Brown AL, Thompson M, Young JE, Coates G, Nahmias C. "Imaging Features of Primary and Recurrent Esophageal Cancer at FDG PET." Radiographics. 2000 May-Jun; 20(3): 713-23.
  2. Lerut T, Flamen P, Ectors N, Van Cutsem E, Peeters M, Hiele M, De Wever W, Coosemans W, Decker G, De Leyn P, Deneffe G, Van Raemdonck D, Mortelmans L. "Histopathologic Validation of Lymph Node Staging with FDG-PET Scan in Cancer of the Esophagus and Gastroesophageal Junction: A Prospective Study Based on Primary Surgery with Extensive Lymphadenectomy." Ann Surg. 2000 Dec; 232(6): 743-52.
  3. Flamen P, Lerut A, Van Cutsem E, De Wever W, Peeters M, Stroobants S, Dupont P, Bormans G, Hiele M, De Leyn P, Van Raemdonck D, Coosemans W, Ectors N, Haustermans K, Mortelmans L. "Utility of Positron Emission Tomography for the Staging of Patients with Potentially Operable Esophageal Carcinoma." J Clin Oncol. 2000 Sep 15; 18(18): 3202-10.
PET Foundations