Esophageal Duplication Cyst -- A Guest Case in Robotic and Computer-Assisted Surgery From the University of Nebraska Medical Center

Chad Ringley, MD; Victor Bochkarev, MD; Dmitry Oleynikov, MDSeries Editors: Brant K. Oelschlager, MD; Carlos A. Pellegrini, MD


November 02, 2006

Diagnostic Imaging

On chest x-ray, benign mediastinal cysts appear as sharply marginated, round, or oval areas of increased opacity. Their appearance is similar to that of other cystlike lesions, but the location in the mediastinum can suggest the diagnosis and guide subsequent imaging procedures. However, many midline midsize lesions located in the lower mediastinum may not be seen on chest x-ray.

Because most adult patients with esophageal duplication cysts are asymptomatic or present with mild dysphagia, the best initial radiologic intervention is upper gastrointestinal barium studies. Barium examination of the upper digestive tract will show extrinsic or intramural compression due to close contact with the esophagus.

Esophagogastroscopy would be the next logical step in diagnostic work-up, although duplication cysts are often difficult to see on initial endoscopy. Repeat esophagogastroscopy with biopsy will exclude an esophageal mucosa-originated malignancy and other comorbidities, as well as possible communication with the cyst cavity. This modality will help define the degree of stenosis (extraluminal compression) and location of the mass in relation to the gastroesophageal junction.

Benign mediastinal cysts have the following features on a CT scan: a smooth, oval or, tubular mass with a well-defined thin wall that usually enhances after intravenous contrast, and no infiltration of adjacent mediastinal structures. However, esophageal duplication cysts contain nonserous fluid; because its thick mucinous content can have high attenuation on CT exam, it may be mistaken for a solid lesion.[19]

MRI can be useful in showing the cystic nature of these masses because these lesions continue to have characteristically high signal intensity when imaged with T2-weighted sequences, regardless of the nature of the cyst contents. However, the appearance of esophageal duplication cysts on CT or MRI exam is identical to that of bronchogenic cysts, except that the wall of the lesion may be thicker and in more intimate contact with the esophagus.[17,18]

Esophagogastroscopy and EUS can facilitate accurate preoperative diagnosis of an esophageal duplication cyst, differentiating the lesion from other mediastinal cysts. In most patients, the cyst lumen appears to be filled with a relatively echogenic material. Most important, EUS can accurately demonstrate contiguity of the muscularis propria of the esophagus with the muscle layer of the cyst wall. Esophagogastroscopy usually can suggest a fullness but cannot make the diagnosis alone.

This most reliable nonsurgical method for the diagnosis of this lesion should be used as a final preoperative test, not as an initial approach.[1,6,16,18]

PET imaging is highly accurate in the restaging of esophageal cancer. Overall, it compares favorably to anatomic imaging in the evaluation of tumor recurrence because metabolic abnormalities usually precede a structural change. Initial imaging of mediastinal cystic lesions, which are usually benign, with PET is inappropriate and costly. However, this study may be used in patients with confirmed malignization of the cyst to exclude local invasion and lymph node spread.

Radionuclide scanning with Tc-99m sodium pertechnetate may be helpful in pediatric patients, in 50% of whom thoracic duplication cysts contain ectopic gastric mucosa.[19] There is no evidence for using radionuclide scanning in the diagnosis of mediastinal cystic lesions in adults.

Which of the following strategies is the treatment of choice for a patient with an esophageal duplication cyst?

  1. Observation, because the vast majority of esophageal duplication cysts are benign

  2. EUS-guided fine-needle aspiration; if no malignancy, then observation

  3. CT scan-guided biopsy; if no malignancy, then observation

  4. Surgery if symptomatic; observation if asymptomatic

  5. Surgery in all cases

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