meniscoid ulcer surrounded by a radiolucent rind of tumor [127] (Figure 6.68). Finally, varicoid carcinomas are those in which submucosal spread of tumor produces thickened, tortuous longitudinal defects, mimicking the appearance of varices [128]. However, varicoid tumors have a fixed configuration, whereas varices tend to change in size and shape at fluoroscopy. Also, varices rarely cause dysphagia because they are soft and compressible. Thus, it is usually possible to differentiate varices from varicoid tumors on the basis of the clinical and radiographic findings.
Squamous cell carcinomas and adenocarcinomas of the esophagus cannot be reliably differentiated on esophagography. Nevertheless, squamous cell carcinomas tend to involve the upper or mid esophagus, whereas adenocarcinomas are located predominantly in the distal esophagus (Figure 6.69). Unlike squamous cell carcinomas, esophageal adenocarcinomas also have a marked tendency to invade the gastric cardia or fundus, comprising as many as 50% of all malignant tumors involving the GEJ [129, 130].
Figure 6.58 Squamous papilloma. Single‐contrast view shows a small, lobulated mass (arrows) in the distal esophagus. A small esophageal cancer could produce similar findings.
Esophageal carcinomas tend to metastasize to other parts of the esophagus via a rich network of submucosal lymphatic channels. These lymphatic metastases may appear as polypoid, plaque‐like, or ulcerated lesions separated from the primary lesion by normal intervening mucosa [123]. Tumor may also spread subdiaphragmatically to the proximal portion of the stomach via submucosal esophageal lymphatic vessels. These metastases to the gastric cardia and fundus may appear as large submucosal masses, often containing central areas of ulceration [131].
Appropriate treatment strategies for esophageal carcinoma depend on accurate staging of the tumor. Various imaging techniques such as CT, MRI, and endoscopic sonography are used for staging esophageal carcinoma [123]. The tumor stage is assessed by evaluating the depth of esophageal wall invasion and the presence or absence of lymphatic or distant metastases.
Figure 6.59 Glycogenic acanthosis. Double‐contrast view shows multiple small, rounded plaques and nodules in the mid esophagus. Although Candida esophagitis could produce similar findings, this elderly patient was not immunocompromised and had no esophageal symptoms. The clinical history therefore is extremely helpful for differentiating these conditions.
Source: Reproduced from Levine MS. Radiology of the esophagus. Philadelphia: WB Saunders; 1989, with permission.
Other malignant tumors
Non‐Hodgkin’s lymphoma and, rarely, Hodgkin’s lymphoma may involve the esophagus. Esophageal lymphoma may be manifested on barium studies by submucosal masses, polypoid lesions, enlarged folds, or strictures [132]. Spindle cell carcinoma is another rare tumor characterized by a bulky, polypoid intraluminal mass that expands the lumen of the esophagus without causing obstruction [133]. Other rare malignant tumors involving the esophagus include leiomyosarcomas and malignant melanomas [132].
Lower esophageal rings
Lower esophageal rings are a common finding on esophagography, but only a small percentage of patients are symptomatic. The term Schatzki ring should be reserved for lower esophageal rings in symptomatic patients who present with dysphagia. These rings almost always occur at the GEJ. Histologically, the superior surface of the ring is lined by stratified squamous epithelium and the inferior surface by columnar epithelium. The exact pathogenesis of Schatzki rings is uncertain, but some rings are thought to develop as a result of scarring from reflux esophagitis.
Figure 6.60 Leiomyoma. Double‐contrast view shows a submucosal mass (arrows) in the upper thoracic esophagus. Note how the lesion has a smooth surface and forms slightly obtuse angles with the adjacent esophageal wall. These features are characteristic of a submucosal mass.
Figure 6.61 Giant fibrovascular polyp. (A) Double‐contrast view shows a smooth, expansile, sausage‐shaped mass in the upper thoracic esophagus (arrow denotes tip of polyp). (B) Computed tomography (CT) scan also shows an expansile mass (arrow) in the esophagus, with a thin rim of contrast surrounding the lesion, confirming its intraluminal location. Also note the predominantly fat density of the polyp. This CT finding is characteristic of fibrovascular polyps containing abundant adipose tissue.
Source: Reproduced from Levine et al. [121], with permission.
Schatzki rings typically appear on barium studies as 2–3 mm high, symmetric, web‐like constrictions (usually <13 mm in diameter) at the GEJ above a hiatal hernia (Figure 6.70). The rings can be missed if the distal esophagus is not adequately distended at fluoroscopy (Figure 6.70A), so it is important to obtain prone views of the esophagus during continuous drinking of a low‐density barium suspension in order to visualize these structures (Figure 6.70B). Studies have shown that biphasic esophagography is a sensitive technique for the diagnosis of Schatzki rings, occasionally detecting rings that are missed on endoscopy [134].
Diverticula
Esophageal diverticula may be classified as pulsion or traction diverticula. The more common pulsion diverticula result from esophageal dysmotility with increased intraluminal pressures in the esophagus, whereas traction diverticula are caused by scarring in the soft tissues surrounding the esophagus. Diverticula most commonly occur in the region of the pharyngoesophageal junction (i.e. Zenker’s diverticulum), mid esophagus, and distal esophagus above the GEJ (i.e. epiphrenic diverticulum). Other patients may develop tiny outpouchings from the esophagus, known as esophageal intramural pseudodiverticula.
Figure 6.62 Communicating esophageal duplication cyst. Single‐contrast view shows a branching, tubular outpouching (arrows) from the midesophagus. This is a rare type of esophageal duplication cyst.
Source: