Rat tail tapering of the lower esophagus with a lobulated mass extending into gastric bubble in barium swallow is seen in:

Ans: C (Ca esophagus) Explanation:Ref- Oesophageal carcinoma is relatively uncommon. It tends to present with increasing dysphagia, initially to solids and progressing to liquids as the tumour increases in size, obstructing the lumen of the oesophagus. Epidemiology Oesophageal cancer is responsible for <1% of all cancers and 4-10% of all GI malignancies. There is recognised male preponderance with the squamous cell subtype, M:F 4:1. Blacks are more susceptible than caucasians, 2:1. The incidence of the subtypes has regional variation. The squamous cell subtype has the greatest worldwide incidence (~90%), but the adenocarcinoma subtype is more common in many parts of North America and Europe. In addition, there are certain regions where individuals are at particularly high risk of developing oesophageal cancer, e.g. Iran, parts of Africa, Italy and China. Predisposing factors include 8: alcohol and smoking: for squamous cell carcinoma and adenocarcinoma achalasia asbestosis Barrett oesophagus: for adenocarcinoma coeliac disease ionising radiation caustic stricture/lye stricture Plummer-Vinson syndrome obesity: for adenocarcinoma history of oral or pharyngeal cancer human papilloma virus (HPV) tylosis (Howel-Evans syndrome): rare AD disease with hyperkeratosis of palm and sole with a high incidence of oesophageal cancer Clinical presentation Patients present with progressive dysphagia, weight loss, chronic worsening gastroesophageal reflux and hoarseness, cough, vocal cord paralysis, or other signs and symptoms of mediastinal invasion. Pathology Histological types squamous cell carcinoma of oesophagus: 81-95% (worldwide) adenocarcinoma of oesophagus: 4-19% (worldwide) arising from mucosal/submucosal glands, heterotopic gastric mucosa, or columnar-lined epithelium >90% related to Barrett oesophagus tend to occur at the gastro-oesophageal junction other types mucoepidermoid carcinoma adenoid cystic carcinoma (ACC) spindle-cell squamous carcinoma leiomyosarcoma rhabdomyosarcoma fibrosarcoma malignant lymphoma * in western world adenocarcinoma is as common or even slightly more common than SCC Macroscopic appearance polypoid/fungating (most common) sessile/pedunculated tumour lobulated surface protruding irregular, polycyclic, overhanging, step-like "apple core" lesion ulcerating: large ulcer niche within bulging mass infiltrating: gradual narrowing with a smooth transition superficial spreading carcinoma Staging See main article: oesophageal cancer staging. Metastases lymphatic anterior jugular chain and supraclavicular nodes (primary in upper 1/3) para-oesophageal and subdiaphragmatic nodes (primary in middle 1/3) mediastinal and paracardial and coeliac trunk nodes (primary in lower 1/3) haematogenous: lung, liver, adrenal glands Radiographic features A combination of CT scan, transoesophageal ultrasound and PET/CT scan are used for staging of the disease. CT is the best initial modality for detection of the distant metastasis, gross direct invasion, and enlarged lymph nodes. Ultrasound is the most sensitive modality for assessment of the depth of invasion and regional enlarged lymph nodes. PET can be useful for re-staging after the initial neoadjuvant therapy 7. Chest radiograph Many indirect signs can be sought on a chest radiograph and these include: widened azygo-oesophageal recess with convexity toward right lung (in 30% of distal and mid-oesophageal cancers) thickening of posterior tracheal stripe and right paratracheal stripe >4 mm (if tumour located in the upper third of oesophagus) tracheal deviation or posterior tracheal indentation/mass retrocardiac or posterior mediastinal mass oesophageal air-fluid level lobulated mass extending into gastric bubble (Kirklin sign) repeated aspiration pneumonia (with tracheo-oesophageal fistula) Fluoroscopy/Barium Swallow irregular stricture pre-stricture dilatation with 'hold up' shouldering of the stricture Endoscopic US It is the most accurate imaging modality for the T staging of oesophageal cancer It defines the layers of the oesophageal wall hence can differentiate T1, T2, and T3 tumors The oesophagus consists of five layers. the first hyperechoic layer represents the interface between the balloon and the superficial mucosa. the second hypoechoic layer represents the lamina propria and muscularis mucosae. the third hyperechoic layer represents the submucosa the fourth hypoechoic layer represents the muscularis propria the fifth layer represents the interface between the adventitia and surrounding tissues CT eccentric or circumferential wall thickening >5 mm peri-oesophageal soft tissue and fat stranding dilated fluid- and debris-filled oesophageal lumen is proximal to an obstructing lesion tracheobronchial invasion appears as a displacement of the airway (usually the trachea or left mainstem bronchus) as a result of mass effect by the oesophageal tumour aortic invasion FDG PET/CT PET/CT is useful for detecting oesophageal primary tumors yet it has little role in helping determine the specific T classification because it provides limited information about the depth of tumor invasion. PET/CT is also superior to CT for detecting lymph node metastases and can depict metastases in normal-sized lymph nodes through the uptake of FDG. PET/CT has a primary role in the depiction of distant sites of metastatic disease. The most common sites of distant metastases detected at PET (but frequently missed at CT) are the bones and liver. Complications fistula formation to trachea (5-10%), bronchi or mediastinum: can be either due to direct tumour progression or iatrogenic effects (e.g. radiation therapy) oesophageal perforation Treatment and prognosis The 5-year mortality depends on the stage of the tumour. Unfortunately, most cases present with regional or distant metastatic disease (30% and 40%, respectively. localised disease: ~40% 5-year survival distant metastatic disease: ~5% 5-year survival Endoscopic mucosal resection, without or with localised ablation is an option for localised (T1a) disease. These epithelial tumours are usually <2 cm, asymptomatic, and noncircumferential. For T1b tumours and above, surgical options are mostly limited to oesophagectomy (including sometimes with palliative colonic interposition (see case 19)) Differential diagnosis Imaging differential considerations include: benign tumours of oesophagus oesophageal leiomyoma oesophageal leiomyomatosis non-malignant conditions (e.g. diffuse inflammation) X-Ray Findings - Abdomen (Contrast) A. Barium - Bird's Beak deformity of the lower esophagus - Achalasia cardia (Barium Swallow) Rattail tapering of the lower esophagus - Carcinoma esophagus (Barium Swallow) Corkscrew esophagus - Diffuse oesophageal spasm (Barium Swallow) The commonest radiological appearance of gastric carcinoma (in barium meal follow through) is - filling a defect in antrum/ body of stomach Trifoliate duodenum - Chronic duodenal ulcer with scarring {Barium Meal) Hour Glass stomach - Peptic ulcer Cup & Spill / Cascade stomach - Volvulus of stomach Construction of transverse duodenum - superior mesenteric artery syndrome Bull's eye lesion (in barium meal) - Leiomyosarcoma Single-bubble appearance - Pyloric stenosis Double-bubble sign - Duodenal atresia, duodenal stenosis, annular pancreas Triple-bubble sign - Jejunal atresia Coffee bean sign - Strangulation of the incompletely obstructed loop of small intestine A string of Beads - Small bowel obstruction Coiled spring appearance-intussusception Pincer-shaped ending in barium enema - Intussusception Bird of Prev sign - Sigmoid volvulus Moulage sign (flocculation of barium, with mucosal thickening) - seen in - malabsorption syndrome String sign of Kantor - Crohn's disease Pipe-stem appearance (Loss of haustrations}- Ulcerative Colitis (Barium Enema) Saw-tooth appearance and I or diverticula - Diverticular disease / Diverticulosis (Barium Enema) Scalloping of the edge of the sigmoid colon on barium enema - Ulcerative colitis Napkin ring sign - Annular carcinoma of the colon Porcelain gallbladder - Carcinoma of the gallbladder Pad sign - Carcinoma pancreas (Barium Meal) ERCP (Endoscopic retrograde cholangiopancreatography) Scrambled-egg appearance - Carcinoma of the pancreas Chain of Lakes appearance - Chronic pancreatitis Double duct sign - Carcinoma of the pancreas PTC (Percutaneous transhepatic cholangiography) Meniscus sign - Choledocholithiasis