Figure 1

History: 51-year-old male with biopsy-proven adenocarcinoma of the esophagus. The patient was referred to Main Street Radiology for an esophagram and whole-body PET scan.

Findings: The air contrast esophagram (figure 1) demonstrates a polypoid mass (arrow) in the mid-esophagus, compatible with carcinoma. Nodular changes of the distal esophagus may represent superficial spread of malignancy, esophagitis, or Barrett esophagus.

Coronal (figure 2) and sagittal (figure 3) PET images show a single hypermetabolic focus in the mid-esophagus corresponding to the mass seen on the esophagram. Normal activity is present within the distal esophagus, indicating absence of malignancy. No distant metastases are evident on the PET scan.

Figure 2

Discussion: Barrett esophagus represents replacement of squamous epithelium of the esophagus by metaplastic columnar epithelium, secondary to chronic gastroesophageal reflux. These patients have a 40-fold higher risk than the general population in developing adenocarcinoma. Squamous cell carcinoma typically represents greater than 90% of esophageal cancers.

Accurate staging is crucial in patients with esophageal cancer, due to the poor prognosis and risks involved with extensive surgery. PET has been shown to be the most accurate non-invasive imaging modality in detecting distant metastases (Am J Roentgenol 1997; 168:417-424), superior to CT. Although not advocated for use in screening, PET has also achieved nearly 100% sensitivity in detection of the primary tumor in patients with known esophageal cancer. Neither CT nor PET has shown the accuracy of endoscopic ultrasound in detecting local invasion. Therefore, pre-operative staging of esophageal cancer should include both PET and endoscopic ultrasound. In addition, PET is advocated as the most accurate imaging study to detect recurrent disease, and to follow patients who have undergone chemotherapy and radiation therapy (Radiographics 2000;20:713-723).

Figure 3

Esophageal cancer, including squamous and adenocarcinoma, is one of many oncological indications approved for reimbursement by Medicare/Medicaid and most private insurance companies.