Oesophageal Cancer: The Image after Surgery

Oesophageal Cancer: The Image after Surgery Poster No.: C-2253 Congress: ECR 2014 Type: Educational Exhibit Authors: A. Loureiro, N. V. V. B. Marques, M. Palmeiro, P. Pereira, 1 1 1 1 2 1 1 2 1 R. Gil, J. P. Penedo, R. Casaca, A. Bettencourt ; Lisboa/PT, 2 Lisbon/PT Keywords: Neoplasia, Infection, Diagnostic procedure, Conventional radiography, CT, Stomach (incl. Oesophagus), Gastrointestinal tract DOI: 10.1594/ecr2014/C-2253 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 49

Learning objectives To review of the current oesophagectomy techniques for oesophageal cancer. To illustrate the normal post-oesophagectomy imaging features seen on CT and contrast swallow examinations. To discuss and illustrate the most common complications of oesophagectomy. Page 2 of 49

Background Introduction Different surgical procedures can be performed for cure or palliation of oesophageal lesions. It is important that radiologists be aware of these surgical options and the anatomical changes associated with each option, to be able to evaluate the effectiveness of the surgical procedures and to detect surgery-related complications and recurrence. Anatomy Fig. 1 References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Oesophageal Cancer Page 3 of 49

Seventh leading cause of cancer death worldwide. Most common indication for oesophagectomy. Male-to-female ratio 3-4:1. Sixth-seventh decades of life. The epidemiology of oesophageal carcinoma is changing: - Squamous cell carcinoma, which is responsible for 95% of all oesophageal cancers worldwide, most commonly located in the thoracic oesophagus and related with a long history of smoking and alcohol consumption has seen a decreased in its incidence in developed countries. - The incidence of adenocarcinoma of the distal oesophagus and gastroesophageal junction has increased progressively. Adenocarcinoma is associated with high body mass index, GERD, and resultant Barrett oesophagus. The location of the primary tumor is defined by the position of the upper end of the cancer in the esophagus. This is best expressed as the distance from the incisors to the proximal edge of the tumor and conventionally by its location within broad regions of the esophagus. Page 4 of 49

Findings and procedure details Oesophagectomy techniques Primary goal - "en bloc" esophagectomy - removal of complete disease in order to minimize loco-regional recurrence: Removal of the oesophagus an surrounding lymph-nodes in the middle and posterior mediastinum, as well abdominal suspected nodes Techniques - Transthoracic oesophagectomy 1. 2. 3. Ivor Lewis procedure McKeown Procedure Left Thoracoabdominal Aproach - Transhiatal Oesophagectomy Ivor Lewis Procedure The most widely performed procedure. Provides ability to access for peritoneal disease and local invasion. Indications 1. 2. 3. Carcinoma of upper two thirds of oesophagus High grade dysplastic Barrett's oesophagus Complicated reflux disease Contraindications: 1. 2. High oesophageal carcinomas located within 20 cm of the incisors. Previous right thoracotomy due to postoperative adhesion (relative contraindication) Surgical technique: - Upper midline laparotomy + right-sided posterolateral thoracotomy (sixth intercostal interspace). Page 5 of 49

- Reconstruction of a conduit: ++ stomach - Anastomosis of the conduit to the residual oesophagus high in the thorax or sometimes in the neck. - Lymphadenectomy, division of the azygos vein and dissection of the thoracic duct are often part of the procedure. - A gastric drainage operation such as pyloromyotomy or pyloroplasty can be added as the vagus nerves are damaged during the procedure. Page 6 of 49

Fig. 2 References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT McKeown Procedure Surgical technique: - Thoracotomy through the fourth or fifth right intercostal space + laparotomy + cervical incision on either the right or left side. - Stomach mobilization, oesophagectomy and lymphadenectomy are as described for the Ivor Lewis procedure. - The anastomosis is created in the neck. Relative difficulty of radical lymphadenectomy compared with the Ivor Lewis procedure. Left Thoracoabdominal Approach Indications: 1. 2. Carcinoma of lower third of the oesophagus; Malignancy involving the esophagogastric junction. Surgical technique: - Upper midline laparotomy + left-sided anterolateral thoracotomy (sixth intercostal interspace). - Reconstruction of a conduit - ++ stomach. - Anastomosis of the conduit to the residual oesophagus high in the thorax or sometimes in the neck. - Lymphadenectomy, division of the azygos vein and dissection of the thoracic duct are often part of the procedure. Advantage: Operating time is shorter than the Ivor-Lewis procedure. Disadvantage: Access considerably restricted by the presence of great vessels. Page 7 of 49

Fig. 3 References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Trans-hiatal oesophagectomy Indications: 1. Distal oesophageal lesion Surgical technique: - Three phases: cervical dissection + mediastinal dissection (thoracoscopy + transhiatal direct visualization) + abdominal dissection - Anastomosis of the in the neck. Page 8 of 49

Advantage: avoids a thoracotomy and its associated morbidity and mortality; reduces the risk of mediastinitis; reduction of pulmonary complications. Disadvantage: Incomplete exposure of the mediastinum Fig. 4 References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Merendino Procedure Due to the endoscopic surveillance programs in patients with known Barrett's oesophagus, early stage oesophageal adenocarcinoma is being diagnosed with increasing frequency. Indications 1. 2. Early adenocarcinoma of the gastroesophageal junction (Tis or T1a) High grade dysplastic Barrett's oesophagus Page 9 of 49

3. Complicated reflux disease Surgical technique: - Limited resection of GE junction with isoperistaltic free jejunal loop interposition with preservation of vagal nerves (Merendino's procedure). Fig. 5 References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Bypass Surgery Page 10 of 49

To provide an alternative food passage when the esophagus is completely obstructed by cancer or is made dysfunctional by severe stricture or motor disorders. Oesophageal reconstruction routes Posterior mediastinal route +++ - Advantage: more physiologic; shortest route - Disavantage: may be unavailable if the mediastinum is inflamed, scarred, or involved by cancer Retrosternal tunnel è preferred for bypass surgery - when scarring or tumour grew make impossible the use of the posterior mediastinum. - Advantage: anatomically separated from tumour (palliative). - Disavantage: tortuous and the substitute may be by the xiphoid process, leading to vascular compromise. Subcutaneous route Cervical anastomosis +++ : less gastric reflux; leaks are less dangerous (risk of mediastinitis decreased) Page 11 of 49

Fig. 6 References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 12 of 49

Fig. 7: Posterior mediastinum route Axial, coronal and sagittal postoperative contrastenhanced CT scan shows the gastric pull-up in the posterior mediastinum. References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 13 of 49

Fig. 8: Substernal colon interposition without esophagectomy (a) and (b) Postoperative contrast-enhanced CT scan shows the colon located in the substernal area ( orange arrow). A mass is seen in the proximal esophagus. (c) Postoperative contrast swallow study shows substernal colon interposition. References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 14 of 49

Fig. 9: Subcutaneous colon interposition after oesophagectomy (a) and (b) Postoperative non-enhanced CT scan shows the the colon located anterior to the sternum, subcutaneously (orange arrow). Bilateral pleural effusion is also present. References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Conduit Stomach - Most commonly used - Easier - Better function - Usually can reach cervical esophagus - Better blood supply (right gastroepiploic artery) Colon Page 15 of 49

- Second most used - 3 anastomoses - more complicated - Can reach more proximal Jejunum - Merendino procedure Fig. 10 References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 16 of 49

Fig. 11: Stomach conduit (a) Contrast swallow study shows the gastric pull-up conduit in right paravertebral position. The gastric tube has a wider lumen than the esophagus and contains rugae. (b) contrast enhanced postoperative CT scan of the chest with coronal reconstruction shows the gastric pull-up in the posterior mediastinum. (c) Sagittal reconstruction of non-enhanced CT shows a long vertical staple line (orange arrow) used in the formation of the gastric tube. References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 17 of 49

Fig. 12: Colon conduit in the posterior mediastinum (a) Postoperative contrast swallow study and (b) coronal, (c) sagittal and (d) axial contrast enhanced CT images shows the use of colon as a conduit because the patient had a gastrectomy in the past ( orange arrow). References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 18 of 49

Fig. 13: Jejunum interposition (a) Postoperative contrast swallow study in a patient that underwent distal oesophagectomy reveals a segment of jejunum that is anastomosed with the esophagus and with the stomach. (b) Postoperative contrast swallow in a patient submitted to distal esophagectomy and proximal gastrectomy with a segment of jejunum interposed between the esophagus and the gastric reminiscent. (c) Coronal CT images showing the same as (b) References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Complications 1. 2. Intraoperative complications: haemorrhage, tracheobronchial tree injury, recurrent laryngeal nerve injury, thoracic duct injury - chylothorax Postoperative complications: respiratory complications - pleural effusion, pneumothorax, pneumonia, and acute respiratory distress syndrome; conduit related - anastomotic leak, mediastinitis, conduit ischemia, anastomotic stricture, functional conduit disorders; Page 19 of 49

diaphragmatic hernia. Fig. 14: Pleural effusion (a) and (b) Axial and (c) Coronal contrast enhanced CT showing bilateral pleural effusion. References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 20 of 49

Fig. 15: Pneumothorax (a) Axial and (b) Coronal CT reconstructed in lung window showing a large right pneumothorax (orange arrow) and a small left pneumothorax (yellow arrow) after a right thoracotomy for oesophagectomy. References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 21 of 49

Fig. 16: Empyema (a) and (b) Axial contrast enhanced CT in small parts and lung windows showing a loculated ovoid collection containing an air-fluid level and rim enhancing, consistent with an empyema (orange arrow). References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 22 of 49

Fig. 17: Postoperative pneumonia (a) Axial and (b) coronal contrast enhanced CT scan of the chest (lung window) demonstrates bilateral consolidation with air bronchograms and pleural effusion. (c) X-ray PA view reveals a consolidation of the right lung with air bronchogram. References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 23 of 49

Fig. 18: Anastomotic leak in 62 year old male status post Ivor-Lewis oesophagectomy. (a) Contrast swallow study showing a contrast leak; (b) and (c) Axial, (d) coronal and (e) sagittal CT images showing the contrast leak in the anastomotic site to the pleural space. References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 24 of 49

Fig. 19: 55 year old male status post oesophagectomy (a) And (b) axial and (c) coronal CT images showing a small aspiration of contrast that leaks from the tracheal lumen to the right mediastinal pleura. There is also an hydro-pneumothorax in the right pleural space. (d) and (e) A tracheal covered stent was placed to treat the fistula. References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 25 of 49

Fig. 20: Benign stricture in the esophagogastric anastomotic site 6 months after surgery. (a) and (b) Contrast enhanced CT scan of the chest shows thickening and obliteration of the lumen in the anastomotic site. (c) Contrast swallow study shows normal caliber of the gastric pull-up distal to the anastomosis, the distended reminiscent esophagus and the stricture at the anastomotic site. (d) and (e) Stent placed in site to treat the stricture. References: Radiologia, IPO Lisboa - Lisboa/PT Page 26 of 49

Fig. 21: Diaphragmatic hernia (a) AP radiography of the chest reveals colon in the left lower third of the thorax. It's not possible to see the diaphragm. (b) Sagittal, (c) coronal, (d) and (e) axial CT image demonstrates the splenic flexure of the colon lying in the left thorax. Right pleural effusion is also noted. References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 27 of 49

Fig. 22: Men, 51 years-old with locoregional recurrance. (a) and (b) Axial and (c) Coronal contrast enhanced CT scan shows thickening of the proximal oesophagus and adjacent lymphadenopathy (orange arrow); and in the abdomen celiac lymphadenopathy. Endoscopy and biopsy confirmed recurrent cancer. (d) Pet scan shows the corresponding FDG uptake in the same locations. References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 28 of 49

Fig. 23: Pulmonary and bone metastasis (a) Coronal non-enhanced CT scan of the chest shows pulmonary metastasis (orange arrow). (b) Axial non-enhanced CT scan shows a rib lytic lesion with a solid mass. (c) Bone scintigraphy shows uptake by the rib lesion. References: Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 29 of 49

Images for this section: Fig. 1 Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 30 of 49

Fig. 7: Posterior mediastinum route Axial, coronal and sagittal postoperative contrastenhanced CT scan shows the gastric pull-up in the posterior mediastinum. Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 31 of 49

Fig. 8: Substernal colon interposition without esophagectomy (a) and (b) Postoperative contrast-enhanced CT scan shows the colon located in the substernal area ( orange arrow). A mass is seen in the proximal esophagus. (c) Postoperative contrast swallow study shows substernal colon interposition. Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 32 of 49

Fig. 11: Stomach conduit (a) Contrast swallow study shows the gastric pull-up conduit in right paravertebral position. The gastric tube has a wider lumen than the esophagus and contains rugae. (b) contrast enhanced postoperative CT scan of the chest with coronal reconstruction shows the gastric pull-up in the posterior mediastinum. (c) Sagittal reconstruction of non-enhanced CT shows a long vertical staple line (orange arrow) used in the formation of the gastric tube. Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 34 of 49

Fig. 12: Colon conduit in the posterior mediastinum (a) Postoperative contrast swallow study and (b) coronal, (c) sagittal and (d) axial contrast enhanced CT images shows the use of colon as a conduit because the patient had a gastrectomy in the past ( orange arrow). Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 35 of 49

Fig. 14: Pleural effusion (a) and (b) Axial and (c) Coronal contrast enhanced CT showing bilateral pleural effusion. Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 37 of 49

Fig. 15: Pneumothorax (a) Axial and (b) Coronal CT reconstructed in lung window showing a large right pneumothorax (orange arrow) and a small left pneumothorax (yellow arrow) after a right thoracotomy for oesophagectomy. Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 38 of 49

Fig. 16: Empyema (a) and (b) Axial contrast enhanced CT in small parts and lung windows showing a loculated ovoid collection containing an air-fluid level and rim enhancing, consistent with an empyema (orange arrow). Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 39 of 49

Fig. 17: Postoperative pneumonia (a) Axial and (b) coronal contrast enhanced CT scan of the chest (lung window) demonstrates bilateral consolidation with air bronchograms and pleural effusion. (c) X-ray PA view reveals a consolidation of the right lung with air bronchogram. Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 40 of 49

Fig. 18: Anastomotic leak in 62 year old male status post Ivor-Lewis oesophagectomy. (a) Contrast swallow study showing a contrast leak; (b) and (c) Axial, (d) coronal and (e) sagittal CT images showing the contrast leak in the anastomotic site to the pleural space. Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 41 of 49

Fig. 19: 55 year old male status post oesophagectomy (a) And (b) axial and (c) coronal CT images showing a small aspiration of contrast that leaks from the tracheal lumen to the right mediastinal pleura. There is also an hydro-pneumothorax in the right pleural space. (d) and (e) A tracheal covered stent was placed to treat the fistula. Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 42 of 49

Fig. 21: Diaphragmatic hernia (a) AP radiography of the chest reveals colon in the left lower third of the thorax. It's not possible to see the diaphragm. (b) Sagittal, (c) coronal, (d) and (e) axial CT image demonstrates the splenic flexure of the colon lying in the left thorax. Right pleural effusion is also noted. Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 44 of 49

Fig. 22: Men, 51 years-old with locoregional recurrance. (a) and (b) Axial and (c) Coronal contrast enhanced CT scan shows thickening of the proximal oesophagus and adjacent lymphadenopathy (orange arrow); and in the abdomen celiac lymphadenopathy. Endoscopy and biopsy confirmed recurrent cancer. (d) Pet scan shows the corresponding FDG uptake in the same locations. Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 45 of 49

Fig. 23: Pulmonary and bone metastasis (a) Coronal non-enhanced CT scan of the chest shows pulmonary metastasis (orange arrow). (b) Axial non-enhanced CT scan shows a rib lytic lesion with a solid mass. (c) Bone scintigraphy shows uptake by the rib lesion. Department of Radiology, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE; Lisboa/PT Page 46 of 49

Conclusion In operable esophageal cancers there are several options available. The radiologist has a role in the follow-up of these patients and must be familiar with the normal postoperative anatomy and possible complications. Page 47 of 49

Personal information Ana Loureiro analoureiro@claperm.com Instituto Português de Oncologia de Lisboa, Francisco Gentil Department of Radiology Head of Department: Dr. José Venâncio Page 48 of 49

References 1: Kim TJ, Lee KH, Kim YH, Sung SW, Jheon S, Cho SK, Lee KW. Postoperative imaging of esophageal cancer: what chest radiologists need to know. Radiographics. 2007 MarApr;27(2):409-29. 2: Kim SH, Lee KS, Shim YM, Kim K, Yang PS, Kim TS. Esophageal resection: indications, techniques, and radiologic assessment. Radiographics. 2001 SepOct;21(5):1119-37; discussion 1138-40. 3: Koshy M, Esiashvilli N, Landry JC, Thomas CR Jr, Matthews RH. Multiple management modalities in esophageal cancer: epidemiology, presentation and progression, work-up, and surgical approaches. Oncologist. 2004;9(2):137-46. Page 49 of 49