Significance of thickening of the upper gastrointestinal tract on cross sectional imaging: Endoscopic correlation

Abstract

Aim: To report the endoscopic findings for a cohort of patients referred for discussion at a specialist oesophago-gastric multi-disciplinary team (MDT) meeting, on the basis of CT mural thickening. Patients and methods: The records of patients discussed at a regional oesophago-gastric MDT during the time 1st April 2014 to 5th February 2016 were reviewed in order to identify patients who were endoscopy naïve at the time of CT and scans re-reviewed to measure maximum wall thickness. Results: 456 patients were referred for discussion, 126 met the inclusion criteria. Endoscopy confirmed malignancy in 50/126 patients (40%); by site, oesophagus (21/67, 31%), stomach (25/50, 50%), duodenum (4/9, 44%). Malignancy was confirmed for 10/48 (21%) patients with isolated wall thickening, for 11/33 (33%) when regional lymphadenopathy was identified, and for 28/44 (64%) when possible metastatic disease was identified. The commonest source of diagnostic uncertainty was thickening around the gastro-oesophageal junction in the presence of a hiatal hernia. Wall thickening >20 mm was strongly associated with malignancy compared to thickening =<20 mm (p < 0.0001). Using this threshold would have resulted in a sensitivity of 32/50 (64%), a specificity of 55/76 (72%), a positive predictive value of 32/53 (60%) and a negative predictive value of 55/73 (75%) in this cohort. Conclusions: The cancer pick-up rate of 40% and the medicolegal consequences of a missed cancer suggest that endoscopy should be performed in all patients with CT identified mural thickening. In the presence of isolated mural thickening and a normal endoscopy, no formal MDT discussion is required.