Esophageal cancer imaging - reporting and data system (ECI-RADS) and post-therapy ECI-RADS (pECI-RADS): Comprehensive synoptic reporting formats for esophageal cancer imaging: A narrative review : Cancer Research, Statistics, and Treatment

Secondary Logo

Journal Logo

Health Systems and Quality Improvement

Esophageal cancer imaging - reporting and data system (ECI-RADS) and post-therapy ECI-RADS (pECI-RADS): Comprehensive synoptic reporting formats for esophageal cancer imaging: A narrative review

Chakrabarty, Nivedita; Mahajan, Abhishek

Author Information
Cancer Research, Statistics, and Treatment: Jul–Sep 2022 - Volume 5 - Issue 3 - p 562-568
doi: 10.4103/crst.crst_97_22
  • Open



Structured synoptic reporting is an effective and accurate means of conveying imaging findings to the clinician/surgeon by a radiologist, which can significantly impact patient management. The origin of the Reporting and Data System (RADS) dates back to the late 1980s with the development of the Breast Imaging RADS (BI-RADS) by the American College of Radiology, which was aimed at introducing uniformity in mammography reporting.[12] Since then, many such reporting templates have come into practice, but till date, there is no such reporting template for esophageal cancer. Synoptic reporting in a standardized manner eliminates any ambiguity in reporting, maintains uniformity across various hospitals/diagnostic centers, and enables the radiologist to effectively convey the relevant information pertaining to the staging of a cancer in a precise manner, thus minimizing any chance of missing pertinent findings.[3]

Esophageal cancers are divided into those located in the cervical, upper thoracic, middle thoracic, and lower thoracic esophagus.[4] Esophageal cancers involving the esophagogastric junction and the proximal 2 cm of the gastric cardia are treated as per the established guidelines for the lower thoracic esophagus.[4] The predominant pathology in the upper-third and middle-third of the esophagus is squamous cell carcinoma, whereas adenocarcinoma predominates in the distal esophagus.[56] Cervical esophageal cancers are usually of the squamous cell carcinoma subtype and comprise 2%-10% of all esophageal cancers.[78]

Overall survival of esophageal cancer is dismal, ranging from 5%-30%.[9] Cervical esophageal cancer most commonly presents at the locally advanced stage with involvement of the surrounding structures and lymph nodal metastasis.[710]

In this manuscript, we have provided two separate synoptic reporting templates for recording the imaging findings in esophageal cancers: one for recording the baseline findings at initial staging and the other for conveying post-treatment changes. Our goal in providing these two separate reporting templates is to positively impact patient management in esophageal cancers as they will enable the radiologists to convey the relevant findings effectively and comprehensively to the surgeons/treating physicians.


The contents for this review article were obtained by performing an internet search using Google. The search terms used were “esophageal cancer imaging,” “AJCC staging,” “NCCN guidelines,” “CT in esophageal cancer,” and “post-therapy imaging”. All articles that had been published in the preceding 25 years were assessed for inclusion. In addition, one article published in 1984 (on cervical esophageal cancer) was included, as relevant articles from recent years were not available. All the articles that contained information relevant to our manuscript were included. We excluded articles for which the full text was not available. We manually searched all the references of the selected articles. We also referred to the recent National Comprehensive Cancer Network version 2.2022.[11] Our search strategy is depicted in a flow diagram in Figure 1.

Figure 1:
Flow diagram for the selection of articles for the review on the synoptic reporting format for esophageal cancer imaging.


Currently, the eighth edition of the American Joint Committee on Cancer staging system is used for staging esophageal and esophagogastric junction cancers and it provides imaging-based clinical tumor-node-metastasis descriptors as shown in Table 1.[412] As per the National Comprehensive Cancer Network guidelines, surgical resection is the treatment of choice for low-risk (well differentiated <3 cm) thoracic esophageal cancers up to T2 category without nodal metastasis.[11] Neoadjuvant chemotherapy or chemoradiation is administered for thoracic esophageal cancers and definitive chemoradiation is given for cervical esophageal cancers in the following settings: High risk (≥3 cm, poorly differentiated with lymphovascular invasion) T2 category primary without nodal metastasis, T1b to T2 node positive esophageal cancer, and T3 to T4a categories of esophageal cancer.[1113] For T4b category primaries, definitive chemoradiation is the treatment of choice, unless there is involvement of the trachea, great vessels, vertebra, or heart, in which case, palliative chemotherapy is the only option.[1112] Systemic therapy in metastatic disease can be decided based upon the human epidermal growth factor receptor 2 (HER2) overexpression (for adenocarcinomas) and programmed death-ligand 1 (PD-L1) expression.[1112]]

Table 1:
The American Joint Committee on Cancer tumor-node-metastasis staging of esophagus and esophagogastric junction, eighth edition[4 12]


Computed tomography imaging

The computed tomography (CT) scan cannot differentiate between T1 and T2 category tumors.[149101112131415] Only if periesophageal fat infiltration is seen on the CT, it is labelled as T3 category. CT has a 75% sensitivity and 78% specificity for diagnosing T3 category tumors.[15] The importance of the CT lies in the detection of infiltration of the surrounding structures (pleura, pericardium, azygous vein, diaphragm, peritoneum, aorta, trachea, or vertebra), in which case the disease will be designated as T4 category.[41415] Table 2 describes the CT features suggestive of involvement of adjacent structures.[4514] The CT is most accurate in providing the craniocaudal length of the tumor (along with the corresponding vertebral level) which is imperative for deciding the surgical resection margins.[45] The CT is commonly used for detecting metastases to distant sites like the liver and lungs[5] and also plays an important role in the assessment of any postsurgical complications or acute emergencies.[4]

Table 2:
CT signs of invasion of periesophageal structures[4 5 14]

Owing to the key role that imaging plays in deciding the management, we have developed a comprehensive standardized synoptic reporting template for esophageal cancer. Such a reporting template will equip the treating physician/surgeon with the necessary details for chalking out the treatment plan.

The synoptic reporting template 1 [Figure 2] includes the pretreatment reporting template for esophageal cancer termed, “Esophageal and esophagogastric junction Cancer Imaging–Reporting and Data System (ECI-RADS)”.

Figure 2:
Synoptic reporting template 1 on pretreatment Esophageal and esophagogastric junction Cancer Imaging–Reporting and Data System (ECI-RADS) based on contrast enhanced computed tomography or Fluorodeoxyglucose Positron Emission Tomography-CT

Additional imaging

Endoscopic ultrasound (EUS) is the only modality that can differentiate the various layers of the esophageal wall, but it has low accuracy for differentiating cT1a from cT1b tumors, for which endoscopic resection is required.[11] The sensitivity of EUS increases with an increasing T category and is reported to be 82% for cT1 tumors and 92% for cT4 tumors.[1215] The accuracy of CT scan for N categorization is low, with a reported sensitivity of 30%-60%, specificity of 60%-80%, and an accuracy of 27%-86% for lymph nodes with a short-axis diameter of more than 1 cm.[15] The sensitivity of EUS is better at 85% than either CT or positron emission tomography (PET)-CT for the detection of nodal involvement.[11] Fluorodeoxyglucose (FDG)-PET/CT can detect any metastasis that is occult on CT.[11] The sensitivity and specificity of FDG-PET/CT are 69% and 93%, respectively, for detecting metastases.[12] Magnetic resonance imaging can be used as a problem-solving tool in case it is unclear on CT whether the esophageal mass is involving the aorta and/or the heart. In addition, in case of tumors that are infiltrating the vertebral bodies, magnetic resonance imaging is essential to evaluate for the presence of intraspinal extension and cord compression.


This includes post-surgical, post-neoadjuvant therapy, and post-chemoradiation imaging.

Immediate post-therapy

CT is the modality of choice for the postoperative evaluation of patients with esophageal cancer. Fistula formation between the neoesophagus and airway and anastomotic leaks are the predominant postsurgical complications to look for on the CT.[4] Verstegen et al. reported that anastomotic leaks are seen in 30% of patients after surgery for esophageal cancer.[16] Recurrent pneumonia and empyema requiring surgical intervention can occur following fistulization of the neoesophagus into the airway (trachea/bronchus).[4] A frequent acute adverse effect of definitive concurrent chemoradiation is esophageal edema which can be evaluated well with contrast enhanced CT (CECT), on which it appears as non-enhancing esophageal thickening.[17]

Delayed post-therapy

Recurrence of the carcinoma may be seen as a frank mass on CECT with an increased FDG uptake on PET. However, areas of radiation-induced esophagitis can also take up FDG, giving a false-positive result.[4] The incidence of stricture formation is high in patients with anastomotic leaks and can occur as an early or late complication.[4] Herniation of the abdominal contents, pleural injury causing pleural effusion, and atelectasis are some of the other postoperative complications that can be visualized on CT.[4] Esophageal stricture is a common delayed complication of radiotherapy, occurring 3 to 8 months after the completion of radiotherapy and can appear as narrowing of the esophageal lumen with proximal dilatation and air fluid-levels on the CT.[418]

The sensitivity and specificity of CT for evaluation of response following neoadjuvant chemoradiotherapy are 33%-55% and 50%-71%, respectively.[1519]

The synoptic reporting template 2 [Figure 3] includes the post-therapy reporting template for esophageal cancer termed, “Post-therapy Esophageal and esophagogastric junction Cancer Imaging–Reporting and Data System (pECI-RADS).”

Figure 3:
Synoptic reporting template 2 for Post-therapy Esophageal and esophagogastric junction Cancer Imaging–Reporting and Data System (pECI-RADS) based on CECT or FDG-PET/CT


Pretreatment and post-therapy synoptic reporting templates “ECI-RADS” and “pECI-RADS” for esophageal cancer will help radiologists to effectively convey the relevant imaging findings in a comprehensive manner without missing out on any pertinent finding, and thus, enable the treating surgeon/physician to make well-informed therapeutic decisions and take timely actions.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1. Mahajan A Synoptic reporting in lung cancers using Lung Cancer Reporting and Data System (LC-RADS):The road ahead for standardization of imaging in lung cancer staging Cancer Res Stat Treat 2021 4 61 6
2. Burnside ES, Sickles EA, Bassett LW, Rubin DL, Lee CH, Ikeda DM, et al. The ACR BI-RADS®Experience:Learning From History J Am Coll Radiol 2009 6 851 60
3. Vaidya T, Desai S, Mahajan A 8th edition AJCC and imaging TNM:Time to break-in and assert in the staging process! Indian J Cancer 2019 56 271 3
4. Jayaprakasam VS, Yeh R, Ku GY, Petkovska I, Fuqua JL, Gollub M, et al. Role of imaging in esophageal cancer management in 2020:Update for radiologists AJR Am J Roentgenol 2020 215 1072 84
5. Kim TJ, Kim HY, Lee KW, Kim MS Multimodality assessment of esophageal cancer:Preoperative staging and monitoring of response to therapy RadioGraphics 2009 29 403 21
6. Daly JM, Fry WA, Little AG, Winchester DP, McKee RF, Stewart AK, et al. Esophageal cancer:Results of an American College of Surgeons patient care evaluation study J Am Coll Surg 2000 190 562 72
7. Hoeben A, Polak J, Van De Voorde L, Hoebers F, Grabsch HI, de Vos-Geelen J Cervical esophageal cancer:A gap in cancer knowledge Ann Oncol 2016 27 1664 74
8. Ding-Jen L, Anthony H, Arve G, Louis M, Haskins K Carcinoma of the cervical esophagus:Diagnosis, management, and results South Med J 1984 77 1365 7
9. Available from: Last accessed on 2022 Aug 21
10. Grass GD, Cooper SL, Armeson K, Garrett-Mayer E, Sharma A Cervical esophageal cancer:A population-based study Head Neck 2015 37 808 14
11. Available from: Last accessed on 2022 Jan 30
12. Rice TW, Patil DT, Blackstone EH 8th edition AJCC/UICC staging of cancers of the esophagus and esophagogastric junction:Application to clinical practice Ann Cardiothorac Surg 2017 6 119 30
13. Dora TK, Aeron T, Chatterjee A, Deshmukh J, Goel A, Bose S, et al. Neoadjuvant chemoradiotherapy followed by surgery for operable carcinoma esophagus:Ground reality in a tertiary care center of rural India-A retrospective audit Cancer Res Stat Treat 2021 4 647 55
14. Iyer R, Dubrow R Imaging of esophageal cancer Cancer Imaging 2004 4 125 32
15. Elsherif SB, Andreou S, Virarkar M, Soule E, Gopireddy DR, Bhosale PR, et al. Role of precision imaging in esophageal cancer J Thorac Dis 2020 12 5159 76
16. Verstegen MHP, Bouwense SAW, Van Workum F, Ten Broek R, Siersema PD, Rovers M, et al. Management of intrathoracic and cervical anastomotic leakage after esophagectomy for esophageal cancer:A systematic review World J Emerg Surg 2019 14 17
17. Zeng C, Zhai T, Chen J, Guo L, Huang B, Guo H, et al. Imaging biomarkers of contrast-enhanced computed tomography predict survival in oesophageal cancer after definitive concurrent chemoradiotherapy Radiat Oncol 2021 16 8
18. Park JH, Kim KY, Song HY, Cho YC, Kim PH, Tsauo J, et al. Radiation-induced esophageal strictures treated with fluoroscopic balloon dilation:Clinical outcomes and factors influencing recurrence in 62 patients Acta Radiologica 2018 59 313 21
19. Qiu B, Wang D, Yang H, Xie W, Liang Y, Cai P, et al. Combined modalities of magnetic resonance imaging, endoscopy and computed tomography in the evaluation of tumor responses to definitive chemoradiotherapy in esophageal squamous cell carcinoma Radiother Oncol 2016 121 239 45

ECI-RADS; esophageal cancer; pECI-RADS; reporting format

Copyright: © 2022 Cancer Research, Statistics, and Treatment