DOI: 10.1148/rg.261045209
RadioGraphics 2006;26:271-274
Best Cases from the AFIP
Carcinoma of the Esophagus: Varicoid Pattern1
Giocondo Sabedotti, MD,
Marcelo O. Dreweck, MD,
Valdir Sabedotti, MD and
Mario R. M. Netto, MD
1 From the Departments of Diagnostic Imaging (G.S., M.O.D., V.S.) and Pathology (M.R.M.N.), Santa Casa de Misericordia Hospital, 774 Franscisco Burzio St, 84010-200 Ponta Grossa, Parana, Brazil. Received December 6, 2004; revision requested January 3, 2005, and received February 7; accepted February 9. All authors have no financial relationships to disclose.
Address correspondence to G.S. (e-mail: gsabedotti{at}yahoo.com.br).
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History
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A 68-year-old man was admitted because of subtle symptoms of dysphagia of solid foods and weight loss for more than 5 months. The results of the physical examination and laboratory studies performed at admission were normal. The patient underwent barium esophagography and esophagoscopy with biopsy.
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Imaging Findings
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The barium esophagogram showed filling defects in the middle and distal segments of the esophagus (Fig 1a). The defects were serpentine and sharply marginated, with a varicoid appearance (Fig 1b), and were unchanged in size or configuration by respiratory maneuvers or by repositioning of the patient. There was no internal narrowing of the esophagus, and esophageal distensibility and peristalsis were normal at the time of examination. At esophagoscopy, multiple solid, irregular, and firm nodular lesions were found that extended from the level of 20 cm to the esophagogastric junction. They were pallid or whitish and did not change in color with changes in the patient’s respiration or position (Fig 2). Multiple specimens were excised at biopsy.
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Figure 1a. Barium esophagogram. (a) Anteroposterior orthostatic projection shows several filling defects in the middle and distal segments of the esophagus. (b) Left posterior oblique projection shows sharply marginated, longitudinal, and serpentine lesions that mimic varices and that did not change in size or configuration with respiratory maneuvers or repositioning of the patient. Esophageal peristalsis was normal.
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Figure 1b. Barium esophagogram. (a) Anteroposterior orthostatic projection shows several filling defects in the middle and distal segments of the esophagus. (b) Left posterior oblique projection shows sharply marginated, longitudinal, and serpentine lesions that mimic varices and that did not change in size or configuration with respiratory maneuvers or repositioning of the patient. Esophageal peristalsis was normal.
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Figure 2. Photograph obtained at endoscopy shows multiple solid pallid or whitish nodular lesions with an infiltrative pattern that extended from the level of 20 cm to the esophagogastric junction.
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Pathologic Evaluation
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The results of pathologic evaluation indicated carcinoma. The patient underwent an esophagogastrectomy. At gross pathologic examination of the excised esophageal segment, multiple polypoid excrescences and intraluminal growth in a fungating and exophytic pattern were observed (Fig 3).
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Figure 3a. (a–c) Photographs of the gross specimen obtained at surgical excision show a large mass with a fungating pattern (most evident in b, the oblique view) and multiple polypoid excrescences (most evident in c, the magnified view). Note also the evidence of hemorrhage, superficial ulceration, and necrosis.
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Figure 3b. (a–c) Photographs of the gross specimen obtained at surgical excision show a large mass with a fungating pattern (most evident in b, the oblique view) and multiple polypoid excrescences (most evident in c, the magnified view). Note also the evidence of hemorrhage, superficial ulceration, and necrosis.
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Figure 3c. (a–c) Photographs of the gross specimen obtained at surgical excision show a large mass with a fungating pattern (most evident in b, the oblique view) and multiple polypoid excrescences (most evident in c, the magnified view). Note also the evidence of hemorrhage, superficial ulceration, and necrosis.
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Microscopic sections showed a poorly differentiated squamous cell carcinoma that had penetrated the muscularis mucosae. Massive submucosal infiltration was evident in areas where the circumference of the esophagus was expanded. The carcinoma had invaded the lymphatics of the submucosa and lamina propria and had produced intralymphatic carcinomatous emboli, some of which extended several centimeters beyond the gross tumor and were associated with multiple intramural metastases (Fig 4). The results of the stomach biopsy were normal.
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Figure 4a. Photomicrographs show a poorly differentiated squamous cell carcinoma that consists of a primary mass of round cells arranged in closely packed cords (black box in a) and surrounded by normal epithelium (red box in a), and secondary foci (white box in b) caused by intramural metastasis with massive submucosal infiltration, subepithelial extension, and diffuse lymphatic spread.
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Figure 4b. Photomicrographs show a poorly differentiated squamous cell carcinoma that consists of a primary mass of round cells arranged in closely packed cords (black box in a) and surrounded by normal epithelium (red box in a), and secondary foci (white box in b) caused by intramural metastasis with massive submucosal infiltration, subepithelial extension, and diffuse lymphatic spread.
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Discussion
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Carcinomas of the esophagus are among the most common tumors of the gastrointestinal tract, and most are not difficult to diagnose. However, uncommon types, such as the varicoid carcinoma in this case, may be difficult to recognize.
The term varicoid is used to denote an esophageal carcinoma that has an uncommon pattern of dissemination via the vasculature and the lymphatic system to the submucosa. At barium esophagography, this type of carcinoma may simulate esophageal varices, especially descendant ("downhill") varices (1,2).
The esophagogram in this case shows irregular intraluminal filling defects that mimic varices. The defects appear tortuous, serpentine, longitudinal, and rigid, with no changes in this pattern during respiratory maneuvers and repositioning of the patient. In contrast, esophageal varices are flexible, and their size does change according to the patient’s respiratory pattern and position. Similar nodular patterns are found at radiography in esophageal varices, lymphoma, acanthosis nigricans, superficial spreading carcinoma, and moniliasis and in severe esophagitis (1–3).
Esophagoscopy with biopsy is necessary for histologic diagnosis and correlation with radiographic findings. At esophagoscopy, varicoid esophageal carcinomas appear as pallid or whitish, solid, nodular lesions that are aligned longitudinally in the middle and distal segments of the esophagus. The characteristics of these lesions are different from those of esophageal varices, which typically are soft and slightly bluish (3,4).
Worldwide, squamous cell carcinoma is the most common esophageal malignancy. Submucosal infiltration and intramural metastasis are uncommon occurrences in patients with squamous cell carcinoma and cause a gradual narrowing of the esophagus because of the longitudinal spread of the tumor. Dysphagia due to narrowing, therefore, usually occurs at a late stage (5,6). Intramural metastasis results from lymphatic spread accompanied by the establishment of secondary intramural tumor deposits (7).
Patients with intramural metastases have a significantly larger primary tumor than those without such metastases, and they may also have metastases to the mediastinal lymph nodes, liver, or stomach. In addition, those who have a family history of esophageal cancer may have a higher risk for recurrence of carcinoma of the esophagus (7,8).
For these reasons, it is important to consider the presence of intramural metastases when evaluating the prognosis of squamous cell carcinoma of the esophagus and when determining the appropriate margins for surgical resection (8–10).
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References
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- Itoh H, Ohtani H, Kataoka M, et al. Carcinoma of the esophagus simulating "downhill" varices. Radiat Med 1987;5(3):83–85.[Medline]
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- Ebihara Y, Hosokawa M, Kondo S, Katoh H. Thirteen cases with intramural metastasis to the stomach in 1259 patients with oesophageal squamous cell carcinoma. Eur J Cardiothorac Surg 2004;26(6):1223–1225.[Abstract/Free Full Text]
- Yuasa N, Miyake H, Yamada T, et al. Prognostic significance of the location of intramural metastasis in patients with esophageal cancer. Langenbecks Arch Surg 2004;389(2):122–127.[CrossRef][Medline]
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- Nishimaki T, Suzuki T, Tanaka Y, Aizawa K, Hatakeyama K, Muto T. Intramural metastases from thoracic esophageal cancer: local indicators of advanced disease. World J Surg 1996;20(1): 32–37.[CrossRef][Medline]
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History
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