T4 Esophagus Level

In esophageal carcinoma, direct invasion of mediastinal structures can be predicted using criteria of mass effect or localized loss of fat planes39,42-47 (Figs. 5-24 through 5-30). Actual unresectability, however, remains difficult to predict with CT or MRI.47-52 In the assessment of unresectability by EUS, criteria include tumor invasion into the left atrium, the wall of the descending aorta,

Gastric Cancer Muscularis Propria

EUS demonstrates a hypoechoic tumor deeply invading the muscularis propria layer (arrow).

the pulmonary vein and/or artery, the tracheobronchial system, and a vertebral body.39

T4 gastric cancers show obliteration of the fat plane between the gastric tumor and the adjacent organ (Figs. 5-31 and 5-32).

text continues on page 283

Fig. 5—14. T2 gastric cancer demonstrated by dynamic MR imaging.

(a) Early-phase (25 sec) and (b) late-phase (120 sec) images show the gastric cancer in the subcardia (arrow) as a highly enhanced thickened wall. A low-intensity band is observed around the stomach, and that of the lesion remains clear and smooth. (Reproduced from Oi et al. )

Fig. 5—14. T2 gastric cancer demonstrated by dynamic MR imaging.

(a) Early-phase (25 sec) and (b) late-phase (120 sec) images show the gastric cancer in the subcardia (arrow) as a highly enhanced thickened wall. A low-intensity band is observed around the stomach, and that of the lesion remains clear and smooth. (Reproduced from Oi et al. )

Fig. 5—16. T2 rectal cancer demonstrated by endorectal MR image.

(a) Dynamic turbo FLASH sequence after Gd-DTPA administration demonstrates a depressed lesion and complete disruption of the submucosa with an involved but not disrupted muscu-laris propria (white arrowheads).

(b) Histopathology demonstrates tumor invading into but not through the muscularis propria (black arrowheads) (hematoxylin-eosin stain, X 20). (Reproduced from Pegios et al.38)

Fig. 5—17. T3 esophageal cancer.

EUS obtained from the midesophagus approximately at the level of the carina reveals a hypoechoic semicircular tumor (T) with penetration into the adventita (AD). The border between the tumor and the aortic wall (AO) is still intact. LA = left atrium. (Reproduced from Tio.39)

Esophageal CancerEsophageal Cancer

Fig. 5-19. T3 carcinoma of the gastric antrum.

CT demonstrates focal nodular thickening of the posterior wall with mild irregularity of the outer contour (arrows), indicating direct extension of tumor into the perigastric fat. (Reproduced from Yee and Halvorsen.41)

Esophagus Contoured

Fig. 5-18. T3 carcinoma of the lower esophagus.

On CT, the slightly irregular outlines of the tumor are due to invasion of the periesophageal fat. (Reproduced from van Overhagen and Becker.40)

Fig. 5-18. T3 carcinoma of the lower esophagus.

On CT, the slightly irregular outlines of the tumor are due to invasion of the periesophageal fat. (Reproduced from van Overhagen and Becker.40)

Fig. 5-19. T3 carcinoma of the gastric antrum.

CT demonstrates focal nodular thickening of the posterior wall with mild irregularity of the outer contour (arrows), indicating direct extension of tumor into the perigastric fat. (Reproduced from Yee and Halvorsen.41)

Fig. 5-20. T3 gastric cancer.

Early phase of bolus-enhanced dynamic CT of water-distended stomach shows a well defined, protruding lesion (solid arrows), with destruction of the multilayered pattern and marked enhancement at lesser curvature of upper body of stomach. The lesion has a reticular outer margin in contrast to the normal three-layered pattern of uninvolved gastric wall (open arrows) at cardia. (Reproduced from Cho et al.36)

Esophageal Cancer

Fig. 5—21. T3 gastric carcinoma.

Tl-weighted gradient-echo MR image following intravenous administration of Gd-DTPA shows marked enhancement of the thickened antral wall with evidence of irregularity and blurring of the low-signal band along the posterior border of the stomach (arrow). This reflects tumor infiltration through all layers of the gastric wall as well as extraserosal extension. (Reproduced from Yee and Halvorsen.41)

Fig. 5—21. T3 gastric carcinoma.

Tl-weighted gradient-echo MR image following intravenous administration of Gd-DTPA shows marked enhancement of the thickened antral wall with evidence of irregularity and blurring of the low-signal band along the posterior border of the stomach (arrow). This reflects tumor infiltration through all layers of the gastric wall as well as extraserosal extension. (Reproduced from Yee and Halvorsen.41)

Fig. 5—22. T3 gastric cancer demonstrated by dynamic MR imaging.

(a) Late phase image shows that the low-intensity band at the base of the enhancing tumor is interrupted (arrow).

(b) Sagittal image during delayed phase (10 min) shows the enhanced elevated lesion in the posterior wall of the gastric body.

(c) Microscopic section of this interrupted-band lesion reveals extraserosal invasion by the gastric cancer. M = muscularis propria. (hematoxylin-eosin stain, X 400.)

(Reproduced from Oi et al.37)

Stage Mucosal Melanoma

Fig. 5—23. T3 polypoid carcinoma of the rectum.

(a) Endorectal T1-weighted MR image after Gd-DTPA administration demonstrates the inhomogeneous mucosal thickening of a rectal cancer that completely disrupts the submucosa (white arrowheads) and the muscularis propria (black arrowheads). Additionally, one 5-mm-diameter perirectal lymph node (white arrow) was positive for carcinoma at pathologic examination.

(b) Resected specimen shows tumor invading completely through the muscularis propria with focal strands extending into perirectal fat (hematoxylin-eosin stain, x 30).

(Reproduced from Pegios et al. )

Fig. 5—24. T4 esophageal carcinoma.

(a) Sagittal and (b) coronal MR views at the level of the cervicothoracic junction reveal direct invasion of an esophageal neoplasm into the lumen of the trachea (arrow). (Reproduced from Balzarini et al.42)

Fig. 5—24. T4 esophageal carcinoma.

(a) Sagittal and (b) coronal MR views at the level of the cervicothoracic junction reveal direct invasion of an esophageal neoplasm into the lumen of the trachea (arrow). (Reproduced from Balzarini et al.42)

Prominent Mediastinal Fat

Fig. 5—25. Unresectable squamous cell carcinoma of the upper thoracic esophagus with indentation of the posterior wall of the trachea indicating neoplastic invasion (T4).

Note the enlarged periesophageal lymph node adjacent to the tumor (arrow).

(Reproduced from van Overhagen and Becker.40)

Squamous Cell Carcinoma The Esophagus

Fig. 5—26. Squamous cell carcinoma of the middle thoracic esophagus.

A large esophageal mass (T4) indents the posterior wall of the left mainstem bronchus. Tracheobronchial invasion and resectability were confirmed at surgery. (Reproduced from van Overhagen and Becker.40)

Prominent Mediastinal Fat

Fig. 5—27. T4 esophageal carcinoma with invasion of mediastinal structures.

Axial MR images at the level of the tracheal bifurcation (a) and subcarinal space (b).

(a) Extraluminal extension of the tumor mass has obliterated the fat adjacent to the wall of the main bronchi (arrowheads).

(b) With neoplastic invasion of the subcarinal space, the left main bronchus is displaced anteriorly and compressed (arrowhead). The angle of contact between the tumor and aorta is approximately 100° (white arrows). The triangular fat plane between the esophagus, spine, and aorta has been obliterated. All criteria of aortic invasion are present.

(Reproduced from Balzarini et al.42)

Fig. 5—27. T4 esophageal carcinoma with invasion of mediastinal structures.

Axial MR images at the level of the tracheal bifurcation (a) and subcarinal space (b).

(a) Extraluminal extension of the tumor mass has obliterated the fat adjacent to the wall of the main bronchi (arrowheads).

(b) With neoplastic invasion of the subcarinal space, the left main bronchus is displaced anteriorly and compressed (arrowhead). The angle of contact between the tumor and aorta is approximately 100° (white arrows). The triangular fat plane between the esophagus, spine, and aorta has been obliterated. All criteria of aortic invasion are present.

(Reproduced from Balzarini et al.42)

Fig. 5—28. T4 esophageal cancer.

EUS at the level of the carina shows a transmural hypoechoic tumor (T) with deep penetration into and beyond (arrows) the posterior wall of the trachea (TR). AO = aorta. (Reproduced from Tio.39)

Fig. 5—29. T4 esophageal cancer.

EUS obtained from the level of the distal esophagus reveals a circular hypoechoic tumor (T) with deep infiltration (arrowheads) into the aortic wall (AO). (Reproduced from Tio.39)

Ivc Aortic Bifurcation Spinal Level

Fig. 5—30. T4 esophageal cancer demonstrated with catheter echoprobe.

EUS obtained with 7.5-MHz miniature catheter echoprobe reveals a transmural hypoechoic tumor (T) with multiple invasion into the aortic wall (AO) at 7 o'clock (arrows) and into the right bronchus (BR) and the bifurcation (arrowheads) of the bronchus seen as hyperechoic (white) lines between the esophagus and the left atrium. (Reproduced from Tio.39)

Duodenocolic Ligament

Fig. 5—31. T4 gastric carcinoma.

CT demonstrates loss of the normal fat plane between the diffuse thickening of the wall of the antrum and the body of the pancreas (small arrow), indicating pancreatic invasion. Metastatic perigastric adenopathy is present (large arrow), (Reproduced from Yee and Halvorsen.41)

Gastric Atrium

Fig. 5—31. T4 gastric carcinoma.

CT demonstrates loss of the normal fat plane between the diffuse thickening of the wall of the antrum and the body of the pancreas (small arrow), indicating pancreatic invasion. Metastatic perigastric adenopathy is present (large arrow), (Reproduced from Yee and Halvorsen.41)

Bolus-enhanced dynamic CT in early phase shows diffuse wall thickening and destruction of multilayered pattern involving antrum and body of stomach (S) with strong heterogeneous enhancement. Focal obliteration of the fat plane (arrowheads) between thickened gastric wall and pancreatic body, indicating pancreatic invasion, as well as an enlarged metastatic subpyloric lymph node (arrow) are clearly identified. (Reproduced from Cho et al.36)

Essentials of Human Physiology

Essentials of Human Physiology

This ebook provides an introductory explanation of the workings of the human body, with an effort to draw connections between the body systems and explain their interdependencies. A framework for the book is homeostasis and how the body maintains balance within each system. This is intended as a first introduction to physiology for a college-level course.

Get My Free Ebook


Post a comment