Radiation-induced esophagitis

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Radiation-induced esophagitis is a consequence of radiotherapy toxicity over the esophagus resulting in both acute or chronic complications:

  • acute esophagitis: usually 2 to 4 weeks after radiotherapy start  extending within ≤ 3 months after completion of the radiotherapy
  • chronic esophagitis: > 3 months after completion of the radiotherapy

Epidemiology

Patients receiving external-beam radiation therapy to treat bronchogenic carcinoma, mediastinal lymphomas, or tumors involving the thoracic spine are at risk . The method of radiation delivery (eg. conventional radiotherapy vs. 3D-CRT), the total radiation dose, and the concurrent administration of chemotherapy are variants that may increase the risk for radiation-induced esophagitis . Simultaneous treatment with doxorubicin hydrochloride (Adriamycin) greatly accentuates esophageal inflamation .

Clinical presentation

  • acute: dysphasia, odynophagia, and chest pain
  • chronic: pending

Pathology

The radiation is known to cause cell death via pro-inflammatory cytokines triggered by direct DNA damage. The esophagus mucosa has a high cell turnover and, therefore, is extremely vulnerable to radiation . The acute toxicity will manifest as mucosal inflammation, which may complicate with further ulceration or superimposed infection .  If the inflammation overtakes the capacity of repair of the mucosa, esophageal fibrosis will progressively develop and manifest later with strictures.

Radiographic features

Fluoroscopy

Given the superficial involvement in acute radiation-induced esophagitis, most of the cases will show a normal esophagogram. When there is a severe acute esophagitis, fluoroscopy findings may include :

  • abnormal peristalsis
  • serrated contour due to wall edema
  • granular appearance without discrete ulcers 
  • mucosal ulceration: multiple, small, and within the radiation portal
  • sloughing of the mucosa
  • focal luminal narrowing: due to spasm and edema
  • perforation or fistulation: rare

In the late phase, a radiation-induced stricture may be demonstrated, characterized by a long stenotic segment of smooth contours correlating with the radiation portal .

CT

Both acute or chronic phases may show a focal esophageal wall thickening along the irradiated esophagus .

Nuclear medicine
PET/CT

In the acute phase, FDG PET/CT will demonstrate an extensive linear uptake within the irradiated esophagus , reflecting inflammation.

Treatment and prognosis

Most of the acute radiation-induced esophagitis tends to be self-limiting in most cases and managed clinically without further investigations .

Severe cases of acute esophagitis can potentially complicate with perforation or fistulation, but these are rare findings nowadays.

Differential diagnosis

In the acute phase, consider: