Tumor outline of esophageal carcinoma.

Abstract

The roentgen diagnosis of carcinoma of the esophagus is usually based upon the alterations seen in the barium-filled lumen, such as filling defects produced by the fungating tumor, excavations due to necrotic ulcers, obstruction, suprastenotic dilatation, perforation, and indentations by para-esophageal lymph node metastases. The extension of the tumor is usually determined from the length of the lesion as indicated by the filling defect, and this is the basis for surgical indications and statistics. This procedure is unsatisfactory, since it fails to outline the tumor in its lateral extent and therefore does not satisfy the general principles of tumor localization, for which all the dimensions of the lesion should be determined: length, width, and depth. The intramural and/or extra-esophageal extension may significantly affect therapeutic indications and prognosis. Also, the added knowledge of lateral or depth extension may influence radiation technic and selection of fields. For these reasons it would be desirable to depict on the roentgenogram not only the internal contours of the esophagus, but also the external soft-tissue shadow. This seems to be a simple and natural requirement, and it could be fulfilled in many of our radiotherapy cases, enabling us to follow the radiation effect. At times the soft-tissue shadow was evident in the plain films of the chest, without barium filling of the esophagus (Figs. 1, 2, and 6). Barium filling served to confirm the diagnosis and to complete the details as to alterations of the lumen, degree of patency, etc. Although direct visualization of the esophageal tumor radiographically should be regarded as of diagnostic and therapeutic significance, it would seem to be a neglected field. Only short sporadic notes on this subject were found in the American and English literature (Rigler, 5; Shanks et al., 7). In the continental European literature, controversial discussions appeared following the first affirmative statement by Arnsperger (1). Eisenstein (2), who reported one case, regarded visibility of the tumor as exceptional. In 1912, Sgalitzer (6) described the delineation of the tumor shadow by contrast with the tracheal air shadow. Teschendorff (8), in 1928, stated that a tumor shadow might frequently be seen if the roentgen technic was adequate. However, he deals with the problem academically and does not offer details. Palugyay (4) assumed that only in the case of a tumor-forming carcinoma (not in the infiltrative types) could a direct shadow be obtained, and then only if the growth were large. In the majority of textbooks and articles, the direct roentgen demonstration of esophageal cancer is not mentioned. No detailed comprehensive presentation of the subject could be found, nor any stressing the routine utilization of this roentgen sign. It thus seemed advisable to compile and describe our related findings.