Esophageal Cancer Staging Essentials: The New TNM Staging System (7th edition) and Clinicoradiologic Implications Poster No.: E-0060 Congress: ESTI 2012 Type: Scientific Exhibit Authors: K. Lee, T. J. Kim, S. J. Hong; Seongnam-si/KR Keywords: Stomach (incl. Oesophagus), CT, Ultrasound, Staging, Neoplasia DOI: 10.1594/esti2012/E-0060 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 41
Objectives Staging cancer of the esophagus has been extensively changed in the 7th edition of the American Joint Committee on Cancer (AJCC), Cancer Staging Manual. Improvements include new definitions of Tis, T4, regional LN, N classification, M classification, and addition of the non-anatomic cancer characteristics. The intent of this exhibit is to review the new 7th edition of the TNM staging system of esophageal cancer and its clinicoradiologic implications. Page 2 of 41
Materials and Methods Primary Tumor (T) Classifications Primary tumor (T) classification has been changed for Tis and T4 cancers. Tis is now defined as high-grade dysplasia and includes all noninvasive neoplastic epithelium that was previously called carcinoma in situ. T4 tumors invading local structures, has been subclassified as T4a and T4b; T4a tumors are resectable cancers invading adjacent structures, such as pleural, pericardium, or diaphragm. T4b are unresectable cancers invading other adjacent structures, such as aorta, vertebral body, or trachea. Otherwise, T classifications are unchanged. TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis High-grade dysplasia T1 Tumor invades lamina propria, muscularis mucosae, or submucosa T1a Tumor invades lamina propria or muscularis mucosae T1b Tumor invades submucosa T2 Tumor invades muscularis propria T3 Tumor invades adventitia T4 Tumor invades adjacent structures T4a Resectable tumor invading pleura, pericardium, or diaphragm T4b Unresectable tumor invading other adjacent structures, such as the aorta, vertebral body, and trachea T classifications Page 3 of 41
Fig. 1: T1 esophageal squmaous cell carcinoma in a 57 year-old man (Stage IA, T1N0M0). No demonstrable lesion on CT. References: Seoul National University Bundang Hospital - Seongnam-si/KR Page 4 of 41
Fig. 2: T1 esophageal squmaous cell carcinoma in a 57 year-old man (Stage IA, T1N0M0). Esophageal mucosal mass was seen on endoscopic ultrasound (EUS). Note intact hyperechoic submucosa layer (arrows). References: Seoul National University Bundang Hospital - Seongnam-si/KR Page 5 of 41
Fig. 3: T1 esophageal squmaous cell carcinoma in a 57 year-old man (Stage IA, T1N0M0). Elevated mucosal lesion on resected specimen (arrow). References: Seoul National University Bundang Hospital - Seongnam-si/KR T Staging: CT Findings T1: usually not visible, sometimes subtle enhancing lesion T2: mass confined within the esophageal wall T3: mass with periesophageal infiltration T4: direct invasion of adjacent structures Page 6 of 41
Fig. 4: T1 esophageal SCC (Stage IA, T1N0M0, Gr1). A small nodular protruding lesion (arrow) on CT. References: Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 7 of 41
Fig. 5: T1 esophageal SCC (Stage IA, T1N0M0, Gr1). A polypoid lesion (arrow) with extension into the second (hypoechoic) deep mucosal layer. Note the normal alternating hyper- and hypoechoic architecture of the esophageal wall (arrowheads). The first layer is hyperechoic and represents the interface between balloon and superficial mucosa, the second layer (hyperechoic) represents the lamina propria and muscularis mucosa, the third layer (hyperechoic) represents the submucosa, the fourth layer (hypoechoic) represents the muscularis propria, and the fifth hyperechoic layer represents the interface between the serosa and surrounding tissues. References: Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 8 of 41
Fig. 6: T2 esophageal SCC (Stage IIA, T2N0M0, Gr2). An eccentric, nodular esophageal lesion (arrow) on CT. References: Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 9 of 41
Fig. 7: T2 esophageal SCC (Stage IIA, T2N0M0, Gr2). A mural nodule (*) with penetration into the fourth (hypoehoic) layer of the esophageal wall (muscularis propria) (arrowheads). References: Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 10 of 41
Fig. 8: T3 esophageal SCC in a 61 year-old man (Stage IIA, T3N0M0, Gr2). A mass involving the lower esophagus, along with periesophageal fat infiltration on CT (arrow). A periesophageal lymph node (arrowhead) was confirmed to be benign References: Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 11 of 41
Fig. 9: T3 esophageal SCC in a 61 year-old man (Stage IIA, T3N0M0, Gr2). The mass had infiltrated all the layers of the esophageal wall and into the adventitia (arrowheads). References: Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 12 of 41
Fig. 10: T3 esophageal SCC in a 61 year-old man (Stage IIA, T3N0M0, Gr2). Sagittal CT shows tumor involvement of the lower esophagus and gastroesophageal junction (arrowheads). References: Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 13 of 41
Fig. 11: T4 esophageal SCC in a 61 year-old man (T4bN1M0, Stage IIIc). Midthoracic esophageal cancer with bronchial (arrowheads) and aortic invasion (arrows) References: Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 14 of 41
Fig. 12: T4 esophageal SCC in a 61 year-old man (T4bN1M0, Stage IIIc). Sagittal image shows a broad interface (arrowheads) between the esophageal mass and the thoracic aorta. References: Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 15 of 41
Fig. 13: T4 esophageal SCC in a 61 year-old man (T4bN1M0, Stage IIIc). EUS shows loss of the interface (arrowheads) between the esophageal mass (arrows) and the thoracic aorta (*), a finding suggestive of aortic invasion. References: Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Regional Lymph Node (N) Classification A regional lymph node has been redefined to include any paraesophageal lymph node extending from cervical nodes to celiac nodes. Data analyses support convenient coarse Page 16 of 41
groupings of the number of cancer-positive nodes. Regional lymph node (N) classification comprises N0 (no cancer positive nodes), N1 (1 or 2), N2 (3-6), N3 (7 or more). N classification for cancers of the esophagus and esophagogastric junction are identical to stomach cancer N classification. Fig. 14: LN map for Esophageal Cancer. Lymph node stations: 1=supraclavicular, 2L=left paratracheal, 2R=right paratracheal, 3P=posterior mediastinal, 4L=left tracheobronchial angle, 4R=right tracheobronchial angle, 5=aortopulmonary, 6=anterior mediastinal, 7=subcarinal, 8=middle paraesophageal, 9=inferior pulmonary ligament, 10L=left hilar, 10R=right hilar, 15=diaphragmatic, 16=paracardial, 17=left gastric, 18=common hepatic, 19=splenic, 20=celiac References: Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Non-anatomic Cancer Characteristics Page 17 of 41
Nonanatomic cancer characteristics identified as important for stage grouping were histopathologic cell type, histologic grade, and tumor location. Increasing histologic grade was associated with poor survival. For adenocarcinoma (ADC), G1 and G2 (well and moderately differentiated) cancers showed better survival than G3 (poorly differentiated) cancers. For squamous cell carcinoma (SCC), the distinction of G1 from G2 and G3 cancers was important for grouping stage I and II cancers. Tumor location (upper and middle thoracic esophagus vs lower thoracic esophagus) was important for grouping T2-3N0M0 SCC. Histopathologic cell type Adenocarcinoma Squamous cell carcinoma Histologic grade G1 well differentiated G2 moderately differentiated G3 poorly differentiated G4 undifferentiated Cancer location Upper thoracic 20-25 cm from incisors Middle thoracic >25-30 cm from incisors Lower thoracic >30-40 cm from incisors Eophagogastric junction includes cancers whose epicenter is i) in the lower esophagus, ii) in the esophagogastric junction, or iii) within proximal 5cm of the stomach (cardia) that extend into the esophagogastric junction or lower thoracic esophagus. Page 18 of 41
Fig. 15: Esophageal divisions Cervical esophagus: cricopharyngeus ~ sternal notch (15-18cm*) Upper thoracic esophagus: sternal notch~azygos arch (18-24cm*) Middle thoracic esophagus: azygos arch~inferior pulmonary vein (24-32cm*) Lower thoracic esophagus: inf. pulmonary vein~gej (32-40cm*). *:from the incisors GEJ: gastroesophageal junction References: Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 19 of 41
Images for this section: Fig. 1: T1 esophageal squmaous cell carcinoma in a 57 year-old man (Stage IA, T1N0M0). No demonstrable lesion on CT. Seoul National University Bundang Hospital - Seongnam-si/KR Page 20 of 41
Fig. 2: T1 esophageal squmaous cell carcinoma in a 57 year-old man (Stage IA, T1N0M0). Esophageal mucosal mass was seen on endoscopic ultrasound (EUS). Note intact hyperechoic submucosa layer (arrows). Seoul National University Bundang Hospital - Seongnam-si/KR Page 21 of 41
Fig. 3: T1 esophageal squmaous cell carcinoma in a 57 year-old man (Stage IA, T1N0M0). Elevated mucosal lesion on resected specimen (arrow). Seoul National University Bundang Hospital - Seongnam-si/KR Page 22 of 41
Fig. 4: T1 esophageal SCC (Stage IA, T1N0M0, Gr1). A small nodular protruding lesion (arrow) on CT. Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 23 of 41
Fig. 5: T1 esophageal SCC (Stage IA, T1N0M0, Gr1). A polypoid lesion (arrow) with extension into the second (hypoechoic) deep mucosal layer. Note the normal alternating hyper- and hypoechoic architecture of the esophageal wall (arrowheads). The first layer is hyperechoic and represents the interface between balloon and superficial mucosa, the second layer (hyperechoic) represents the lamina propria and muscularis mucosa, the third layer (hyperechoic) represents the submucosa, the fourth layer (hypoechoic) represents the muscularis propria, and the fifth hyperechoic layer represents the interface between the serosa and surrounding tissues. Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 24 of 41
Fig. 6: T2 esophageal SCC (Stage IIA, T2N0M0, Gr2). An eccentric, nodular esophageal lesion (arrow) on CT. Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 25 of 41
Fig. 7: T2 esophageal SCC (Stage IIA, T2N0M0, Gr2). A mural nodule (*) with penetration into the fourth (hypoehoic) layer of the esophageal wall (muscularis propria) (arrowheads). Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 26 of 41
Fig. 8: T3 esophageal SCC in a 61 year-old man (Stage IIA, T3N0M0, Gr2). A mass involving the lower esophagus, along with periesophageal fat infiltration on CT (arrow). A periesophageal lymph node (arrowhead) was confirmed to be benign Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 27 of 41
Fig. 9: T3 esophageal SCC in a 61 year-old man (Stage IIA, T3N0M0, Gr2). The mass had infiltrated all the layers of the esophageal wall and into the adventitia (arrowheads). Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 28 of 41
Fig. 10: T3 esophageal SCC in a 61 year-old man (Stage IIA, T3N0M0, Gr2). Sagittal CT shows tumor involvement of the lower esophagus and gastroesophageal junction (arrowheads). Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 29 of 41
Fig. 11: T4 esophageal SCC in a 61 year-old man (T4bN1M0, Stage IIIc). Midthoracic esophageal cancer with bronchial (arrowheads) and aortic invasion (arrows) Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 30 of 41
Fig. 12: T4 esophageal SCC in a 61 year-old man (T4bN1M0, Stage IIIc). Sagittal image shows a broad interface (arrowheads) between the esophageal mass and the thoracic aorta. Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 31 of 41
Fig. 13: T4 esophageal SCC in a 61 year-old man (T4bN1M0, Stage IIIc). EUS shows loss of the interface (arrowheads) between the esophageal mass (arrows) and the thoracic aorta (*), a finding suggestive of aortic invasion. Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 32 of 41
Fig. 14: LN map for Esophageal Cancer. Lymph node stations: 1=supraclavicular, 2L=left paratracheal, 2R=right paratracheal, 3P=posterior mediastinal, 4L=left tracheobronchial angle, 4R=right tracheobronchial angle, 5=aortopulmonary, 6=anterior mediastinal, 7=subcarinal, 8=middle paraesophageal, 9=inferior pulmonary ligament, 10L=left hilar, 10R=right hilar, 15=diaphragmatic, 16=paracardial, 17=left gastric, 18=common hepatic, 19=splenic, 20=celiac Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 33 of 41
Fig. 15: Esophageal divisions Cervical esophagus: cricopharyngeus ~ sternal notch (15-18cm*) Upper thoracic esophagus: sternal notch~azygos arch (18-24cm*) Middle thoracic esophagus: azygos arch~inferior pulmonary vein (24-32cm*) Lower thoracic esophagus: inf. pulmonary vein~gej (32-40cm*). *:from the incisors GEJ: gastroesophageal junction Kim TJ et al. (2009) Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy. Radiographics 29:403-421 Page 34 of 41
Results Table 1 References: AJCC 7th edition Page 35 of 41
Table 2 References: AJCC 7th edition Page 36 of 41
Table 3 References: AJCC 7th edition Page 37 of 41
Images for this section: Table 1 AJCC 7th edition Page 38 of 41
Table 2 AJCC 7th edition Page 39 of 41
Table 3 AJCC 7th edition Page 40 of 41
Conclusions The new staging system of esophageal cancer is data driven and harmonized stomach cancer. This required changes in THM definitions and addition of nonanatomic cancer characteristics. Chest radiologists must understand the details set forth in the TNM staging system of esophageal cancer and be familiar with the changes in the 7th edition, which attempts to better correlate disease with prognostic value and treatment strategy. Page 41 of 41