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Staging and Follow-up of Esophageal Cancer

Variant: 1   Newly diagnosed esophageal cancer. Pretreatment clinical staging. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
CT chest and abdomen with IV contrast Usually Appropriate ☢☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Appropriate ☢☢☢☢
MRI chest and abdomen without and with IV contrast May Be Appropriate O
FDG-PET/MRI skull base to mid-thigh May Be Appropriate ☢☢☢
CT chest abdomen pelvis with IV contrast May Be Appropriate (Disagreement) ☢☢☢☢
Radiography chest Usually Not Appropriate ☢
Fluoroscopy upper GI series Usually Not Appropriate ☢☢☢
MRI chest and abdomen without IV contrast Usually Not Appropriate O
CT chest abdomen pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest abdomen pelvis without IV contrast Usually Not Appropriate ☢☢☢☢
CT chest and abdomen without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest and abdomen without IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 2   Esophageal cancer. Imaging during treatment.
Procedure Appropriateness Category Relative Radiation Level
FDG-PET/CT skull base to mid-thigh Usually Appropriate ☢☢☢☢
MRI chest and abdomen without and with IV contrast May Be Appropriate O
FDG-PET/MRI skull base to mid-thigh May Be Appropriate ☢☢☢
Radiography chest Usually Not Appropriate ☢
Fluoroscopy upper GI series Usually Not Appropriate ☢☢☢
MRI chest and abdomen without IV contrast Usually Not Appropriate O
CT chest abdomen pelvis with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest abdomen pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest abdomen pelvis without IV contrast Usually Not Appropriate ☢☢☢☢
CT chest and abdomen with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest and abdomen without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest and abdomen without IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 3   Esophageal cancer. Posttreatment imaging. No suspected or known recurrence.
Procedure Appropriateness Category Relative Radiation Level
CT chest and abdomen with IV contrast Usually Appropriate ☢☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Appropriate ☢☢☢☢
CT chest abdomen pelvis with IV contrast May Be Appropriate ☢☢☢☢
Radiography chest Usually Not Appropriate ☢
Fluoroscopy upper GI series Usually Not Appropriate ☢☢☢
MRI chest and abdomen without and with IV contrast Usually Not Appropriate O
MRI chest and abdomen without IV contrast Usually Not Appropriate O
FDG-PET/MRI skull base to mid-thigh Usually Not Appropriate ☢☢☢
CT chest abdomen pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest abdomen pelvis without IV contrast Usually Not Appropriate ☢☢☢☢
CT chest and abdomen without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest and abdomen without IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 4   Esophageal cancer. Posttreatment imaging. Suspected or known recurrence.
Procedure Appropriateness Category Relative Radiation Level
CT chest and abdomen with IV contrast Usually Appropriate ☢☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Appropriate ☢☢☢☢
CT chest abdomen pelvis with IV contrast May Be Appropriate (Disagreement) ☢☢☢☢
Radiography chest Usually Not Appropriate ☢
Fluoroscopy upper GI series Usually Not Appropriate ☢☢☢
MRI chest and abdomen without and with IV contrast Usually Not Appropriate O
MRI chest and abdomen without IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRI head without IV contrast Usually Not Appropriate O
FDG-PET/MRI skull base to mid-thigh Usually Not Appropriate ☢☢☢
CT chest abdomen pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest abdomen pelvis without IV contrast Usually Not Appropriate ☢☢☢☢
CT chest and abdomen without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest and abdomen without IV contrast Usually Not Appropriate ☢☢☢☢

Panel Members
Summary of Literature Review
Introduction/Background
Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

  • There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).
Discussion of Procedures by Variant
Variant 1: Newly diagnosed esophageal cancer. Pretreatment clinical staging. Initial imaging.
Variant 1: Newly diagnosed esophageal cancer. Pretreatment clinical staging. Initial imaging.
A. CT Chest and Abdomen
Variant 1: Newly diagnosed esophageal cancer. Pretreatment clinical staging. Initial imaging.
B. CT Chest, Abdomen, and Pelvis
Variant 1: Newly diagnosed esophageal cancer. Pretreatment clinical staging. Initial imaging.
C. FDG-PET/CT Skull Base to Mid-Thigh
Variant 1: Newly diagnosed esophageal cancer. Pretreatment clinical staging. Initial imaging.
D. FDG-PET/MRI Skull Base to Mid-Thigh
Variant 1: Newly diagnosed esophageal cancer. Pretreatment clinical staging. Initial imaging.
E. Fluoroscopy Upper GI Series
Variant 1: Newly diagnosed esophageal cancer. Pretreatment clinical staging. Initial imaging.
F. MRI Chest and Abdomen
Variant 1: Newly diagnosed esophageal cancer. Pretreatment clinical staging. Initial imaging.
G. Radiography Chest
Variant 2: Esophageal cancer. Imaging during treatment.
Variant 2: Esophageal cancer. Imaging during treatment.
A. CT Chest and Abdomen
Variant 2: Esophageal cancer. Imaging during treatment.
B. CT Chest, Abdomen, and Pelvis
Variant 2: Esophageal cancer. Imaging during treatment.
C. FDG-PET/CT Skull Base to Mid-Thigh
Variant 2: Esophageal cancer. Imaging during treatment.
D. FDG-PET/MRI Skull Base to Mid-Thigh
Variant 2: Esophageal cancer. Imaging during treatment.
E. Fluoroscopy Upper GI Series
Variant 2: Esophageal cancer. Imaging during treatment.
F. MRI Chest and Abdomen
Variant 2: Esophageal cancer. Imaging during treatment.
G. Radiography Chest
Variant 3: Esophageal cancer. Posttreatment imaging. No suspected or known recurrence.
Variant 3: Esophageal cancer. Posttreatment imaging. No suspected or known recurrence.
A. CT Chest and Abdomen
Variant 3: Esophageal cancer. Posttreatment imaging. No suspected or known recurrence.
B. CT Chest, Abdomen, and Pelvis
Variant 3: Esophageal cancer. Posttreatment imaging. No suspected or known recurrence.
C. FDG-PET/CT Skull Base to Mid-Thigh
Variant 3: Esophageal cancer. Posttreatment imaging. No suspected or known recurrence.
D. FDG-PET/MRI Skull Base to Mid-Thigh
Variant 3: Esophageal cancer. Posttreatment imaging. No suspected or known recurrence.
E. Fluoroscopy Upper GI Series
Variant 3: Esophageal cancer. Posttreatment imaging. No suspected or known recurrence.
F. MRI Chest and Abdomen
Variant 3: Esophageal cancer. Posttreatment imaging. No suspected or known recurrence.
G. Radiography Chest
Variant 4: Esophageal cancer. Posttreatment imaging. Suspected or known recurrence.
Variant 4: Esophageal cancer. Posttreatment imaging. Suspected or known recurrence.
A. CT Chest and Abdomen
Variant 4: Esophageal cancer. Posttreatment imaging. Suspected or known recurrence.
B. CT Chest, Abdomen, and Pelvis
Variant 4: Esophageal cancer. Posttreatment imaging. Suspected or known recurrence.
C. FDG-PET/CT Skull Base to Mid-Thigh
Variant 4: Esophageal cancer. Posttreatment imaging. Suspected or known recurrence.
D. FDG-PET/MRI Skull Base to Mid-Thigh
Variant 4: Esophageal cancer. Posttreatment imaging. Suspected or known recurrence.
E. Fluoroscopy Upper GI Series
Variant 4: Esophageal cancer. Posttreatment imaging. Suspected or known recurrence.
F. MRI Chest and Abdomen
Variant 4: Esophageal cancer. Posttreatment imaging. Suspected or known recurrence.
G. MRI Head
Variant 4: Esophageal cancer. Posttreatment imaging. Suspected or known recurrence.
H. Radiography Chest
Summary of Recommendations
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information
References
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Disclaimer
The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document.  The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged.  The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination