Paget Cells in the Esophagus: Assessment of Their Histopathologic Features and Near-universal Association With Underlying Esophageal Adenocarcinoma

A case of endoscopic submucosal dissection of esophageal acantholytic Paget's disease with discontinuously spreading and unclear neoplastic extension

BACKGROUND

Paget's disease (PD) is a carcinoma, in which irregular atypical cells with abundant cytoplasm proliferate mainly within the epithelium and is classified into PD occurring in the breast and extramammary Paget's disease (EMPD) occurring outside the breast. Essentially, extramammary PD is reported as a tumor for which it is difficult for surgeons to properly determine the line of resection.

CASE PRESENTATION

An 83-year-old male was admitted to our hospital because of roughness of the esophageal epithelium during the follow-up examination for a gastric ulcer. A preoperative biopsy revealed squamous cell carcinoma; therefore, endoscopic submucosal dissection (ESD) was performed.

CONCLUSIONS

The characteristic feature in this patient was the distribution of tumor cells and, accordingly, the difficulty in identifying the neoplastic distribution. In this patient, the odd distribution and growth pattern of the tumor cells made it difficult for the operator to identify the distribution of the lesion preoperatively.

Esophageal squamous cell carcinoma with pagetoid spread: a clinicopathologic study

Pagetoid spread in esophageal squamous epithelium associated with underlying esophageal adenocarcinoma (EAC) has been well studied. Case reports describing pagetoid spread of esophageal squamous cell carcinomas (ESCC) also exist in the literature. The latter, however, has not been systematically studied. In this study, we report seven cases of pagetoid spread associated with ESCC. The clinical, morphologic, and immunophenotypic profiles of pagetoid spread in the context of ESCC and EAC are compared. Cases of pagetoid spread of ESCC were identified through computerized search of pathology archives at five institutions. Additional cases were identified through manual review of surgical resection cases of treatment naive ESCC in Mass General Brigham (MGB) pathology archive. Clinical history was collected via chart review. Immunohistochemistry for CK7, CK20, CDX2, p53, p63, and p40 was performed on selected cases. A computerized search of pathology archives of five institutions revealed only two cases. A manual review of 76 resected untreated ESCC revealed five additional cases with unequivocal pagetoid spread of ESCC, indicating the condition was not uncommon but rarely reported. Patient age ranged from 54 to 78 years (median, 65). There were six women and one man. One case had in situ disease, five had pT1 (1 pT1a and 4 pT1b), and one had pT3 disease. One of the patients with pT1 tumor had a positive lymph node, while the remaining six patients were all N0. Four tumors were in the proximal to mid esophagus, and three in the distal esophagus. Patient survival ranged from 25 months to more than 288 months. The pagetoid tumor cells demonstrated enlarged, hyperchromatic nuclei with variable amounts of eosinophilic cytoplasm. The cytoplasm was often condensed to the perinuclear area, creating peripheral clearing. By immunohistochemistry, the pagetoid cells were positive for p40 (6/6) and p63 (7/7) and negative for CDX2 (7/7). The tumor cells showed mutant-type staining for p53 in five of seven cases. One of the patients had pagetoid tumor cells at the resection margin and subsequently had recurrent disease 2 years later. All other patients had negative resection margins and did not have local recurrence. Four cases of pagetoid spread in the context of EAC were used as a comparison group. Previously published studies were also analyzed. These tumors were all located in the distal esophagus or gastroesophageal junction. All cases were associated with underlying invasive EAC. Pagetoid spread associated with EAC often had cytoplasmic vacuoles or mucin. They were more frequently positive for CK7 than pagetoid ESCC (p = 0.01). Both ESCC and EAC may give rise to pagetoid spread of tumor cells within surface squamous epithelium. Pagetoid spread from ESCC and EAC have overlapping morphologic features. P40 and p63 immunostains can facilitate the distinction between ESCC and EAC. P53 immunostain can aid in confirmation of malignancy. Understanding their overlapping pathologic features will help pathologists avoid pitfalls and diagnose these lesions correctly on biopsy specimens.

Paget cells of the esophagus: A clinicopathologic and immunohistochemical study of 10 cases

OBJECTIVES

Extramammary Paget's disease (EMPD) of the esophagus is very rare and the clinicopathologic features are not well characterized.

DESIGN

We analyzed 10 cases with reported presence of Paget or Pagetoid tumor cells in the esophageal specimens collected between 2005 and 2018 at our institution.

RESULTS

The cohort included 7 males and 3 females with a median age of 67 years. Histologically, 7 cases were secondary Pagetoid spread of tumor cells directly from an underlying invasive adenocarcinoma (pADC) located at the distal esophagus, all CK7 + with variable intracytoplasmic mucin. The clinical course of those secondary cases was dependent on the underlying malignancies. Only 3 cases were primary, including 2 Pagetoid squamous cell carcinoma in-situ (pSqCCis) and 1 Pagetoid adenocarcinoma in-situ (pADCis) with focalstromal invasion. The primary cases showed similar clinical and endoscopic presentations. Immunohistochemically, the singly dispersed Paget or Pagetoid tumor cells frequently showed loss of E-cadherin and gain of vimentin expression. Seven cases, including 5 pADC, 1 pSqCCis and the pADCis showed aberrant p53 expression. Four patients, all pADC, died of disease at a median follow-up of 10 months, while the others were alive.

CONCLUSIONS

Paget or Pagetoid tumor cells in the esophagus can be primary or secondary to an invasive carcinoma. The clinical outcomes depend on the underlying malignancy and extensiveness of disease. Frequent p53 aberrancies and epithelium-mesenchymal transition likely play a role in the pathogenesis.

Paget's disease derived in situ from reserve cell hyperplasia, squamous metaplasia, and squamous cell carcinoma of the esophagogastric junction: a case report

Background

Extramammary Paget’s disease (EMPD) of the esophagus is a rare tumor, with most cases originating from invasive adenocarcinoma of the esophagus. Pure esophageal Paget’s disease, in which no underlying invasive carcinoma component is present, is extremely rare. In this report, we describe a case of EMPD of the esophagogastric junction with no evidence of invasive carcinoma.

Case presentation

An 81-year-old Japanese woman with a 2-week history of abdominal distension presented to our hospital for assessment. Endoscopic examination revealed a mild elevated granular lesion, with a slightly depressed irregular mucosa, in the distal esophagus, with EMPD confirmed by biopsy. Thoracoscopic esophagectomy with lymph node dissection was performed, with Paget cells observed on microscopic examination in the lower part of the esophageal epithelium. Only a few Paget cells stained positively for PAS/Alcian blue. Immunohistochemically, negative staining for CK5 and p63 were identified in the Paget cells, with positive staining for CK7. Furthermore, an intraepithelial squamous cell carcinoma, with squamous metaplasia and reserve cell hyperplasia, was observed in the gastric mucosa of the esophagogastric junction, adjacent to the Paget cells.

Conclusions

EMPD of the esophagus is a rare disease. We report a case of EMPD that was probably derived from a gastric squamous cell carcinoma, with squamous cell metaplasia and reserve cell hyperplasia, in the esophagogastric junction, which, to our knowledge, is the first report of this type of EMPD in the clinical literature.

Diagnosis and Management of Barrett-Related Neoplasia in the Modern Era

Whereas in the past, pathologists were hesitant to diagnose high-grade dysplasia in patients with Barrett esophagus, because this diagnosis prompted esophagectomy, current international consensus is that endoscopic treatment is the management for high-grade dysplasia and intramucosal carcinoma. Furthermore, many centers advocate endoscopic ablation for low-grade dysplasia. As such, establishing a diagnosis of dysplasia has become the key step; separation between the grades of dysplasia is less critical. This article offers some criteria for separating dysplasia from reactive changes, discusses pitfalls in interpreting endoscopic mucosal resection specimens, and outlines management strategies.

Esophageal adenosquamous carcinoma mimicking acantholytic squamous cell carcinoma

Herein is described a unique case of esophageal cancer mimicking acantholytic squamous cell carcinoma (SCC). The patient succumbed to the disease within one month of diagnosis. Autopsy revealed a 10-cm esophageal tumor, characterized by prominent acantholysis-like areas composed of discohesive cancer cells, along with nested growth of SCC. These discohesive cancer cells focally exhibited pagetoid extension into adjacent esophageal epithelium, comprised ~60% of the esophageal tumor volume and had widely metastasized to the lungs, chest wall, liver, spleen, right adrenal gland, bones and lymph nodes. No metastases of SCC were observed. SCC cells were immunohistochemically positive for keratin 5/6 and E-cadherin and were negative for mucin and carcinoembryonic antigen (CEA). However, the discohesive cancer cells exhibited negativity for keratin 5/6, positivity for mucin and CEA, and diminished or no immunostaining for E-cadherin. Thus, these discohesive cells represented true adenocarcinomatous differentiation rather than acantholytic SCC cells. It was concluded that this tumor was an esophageal adenosquamous carcinoma with 'pseudo'-acantholytic adenocarcinoma components, which should be considered as a rare but distinctive type of aggressive cancer.

The changing role of the pathologist in the management of Barrett's oesophagus

Pathological specimens from columnar-lined oesophagus (CLO) comprise a considerable proportion of the workload of gastrointestinal pathologists in Western countries. There remain controversies concerning the diagnostic role of pathology. More recently, in the UK at least, the diagnosis has been regarded as primarily an endoscopic endeavour, with pathology being corroborative and only diagnostic when endoscopic features are equivocal or when there are additional features that make the endoscopic diagnosis unclear. There is also recognition that demonstration of intestinalisation or 'goblet cells' is not paramount, and should not be required for the diagnosis. There have been notable changes in the management of CLO neoplasia: pathologists are centrally involved in its management. Pathological assessment of endoscopic mucosal resection (EMR) specimens provides the most useful means of determining the management of early neoplasia and of determining indications for surgery. This represents an extraordinarily rapid change in management, in that, <10 years ago, laborious Seattle-type biopsy protocols were recommended, and high grade dysplasia was an indication for resectional surgery. Now, individual patient management is paramount: multi-professional meetings determine management after biopsy and EMR assessment. One significant change is that major resections are undertaken less often, in Western countries, for CLO neoplasia.

Barrett esophagus: diagnostic challenges

The incidence of esophageal adenocarcinoma and associated mortality has risen dramatically over the past several decades, and, thus, it is increasingly important to understand its pathogenesis and risk factors. Barrett esophagus is the established precursor to esophageal adenocarcinoma that progresses through a metaplasia-dysplasia-carcinoma sequence. Its risk of transforming to carcinoma is not as high as previously reported and there appears to be a biological heterogeneity among patients with this disease. The overall prevalence of Barrett esophagus in the United States ranges from 1% to 25% and is closer to 5% in patients with gastroesophageal reflux disease. Because of the frequency of Barrett esophagus and associated implications, it is important for the practicing pathologist to have a thorough understanding of this disease and its diagnostic pitfalls. In this review, we will discuss issues associated with the diagnosis of Barrett esophagus, including the definition of Barrett esophagus and its distinction from carditis with intestinal metaplasia. We will also discuss challenges in the grading of dysplasia and new variants of dysplasia, including crypt dysplasia and foveolar-type dysplasia. Finally, we will touch upon the evaluation of dysplasia in endoscopic mucosal resection specimens.

A Clinical and Histopathologic Focus on Barrett Esophagus and Barrett-Related Dysplasia

Context.—Barrett esophagus is a metaplastic, premalignant lesion associated with approximately 0.5% annual incidence of progression to esophageal adenocarcinoma. Diagnosis and screening of Barrett esophagus and Barrett-related dysplasia relies on histologic evaluation of endoscopic mucosal biopsies, a process that is burdened with interobserver variability.

Objectives.—To review the histologic features and classification of Barrett esophagus and Barrett-related dysplasia, to discuss the underlying difficulties in diagnosis and pitfalls, and to provide a brief review of new developments related to therapeutic modalities for patients diagnosed with dysplasia.

Data Sources.—Sources include a review of relevant literature indexed in PubMed (US National Library of Medicine).

Conclusions.—In spite of interobserver variability, histologic assessment of dysplasia is currently the accepted method of surveillance, and subsequent patient management is dictated by this evaluation. Although not universal, endoscopic therapy is increasingly important in replacing esophagectomy for patients with high-grade dysplasia or early carcinoma.

New treatments, new challenges: pathology's perspective on esophageal carcinoma

While frank esophageal carcinoma rarely presents a diagnostic challenge, early lesions are often tricky to assess. This difficulty stems in part from drawbacks in the classification systems designed to stratify early lesions as a guide for deciding treatment. These systems are complex and wrought with specific pathologic challenges brought on by new treatment modalities. Such interventions as endoscopic mucosal resection, photodynamic therapy, and chemotherapy/radiation combinations present the pathologist with new histologic challenges that have a direct impact on patient care. In this article, we discuss staging issues pertinent to early cancers, histologic sequelae of various treatments, and how these factors affect the pathologist's role in evaluating esophageal carcinoma.