Primary esophageal adenosquamous carcinoma: a retrospective analysis of 24 cases

Clinical predictors of special type of esophageal cancer

BACKGROUND

Esophageal cancers with a histological type other than the two major types, squamous cell carcinoma (SCC) and adenocarcinoma, are referred to as "special type of esophageal cancer" (STEC). STEC is rare and difficult to diagnose preoperatively. Therefore, we aimed to clarify the clinicopathological findings of STEC, including magnifying endoscopy with narrow band imaging (ME-NBI).

METHODS

We reviewed 1133 lesions in 936 consecutive cases who underwent endoscopic resection or surgical resection for primary esophageal cancer. Patients were classified into the SCC group and the STEC group, respectively. Factors that predict STEC endoscopically, as well as clinicopathologic features of STEC compared to SCC, were examined.

RESULTS

Twenty-eight STECs were diagnosed in 28 patients: 15 with basaloid squamous cell carcinoma, 6 with adenosquamous carcinoma, 4 with mucoepidermoid carcinoma, 1 with carcinosarcoma, 1 with salivary duct-type carcinoma, and 1 with neuroendocrine cell carcinoma. There was significantly more pT1b or deeper cancer (60.7% vs. 12.8%), lymphovascular invasion (50.0% vs. 11.1%) and elevated type (53.6% vs. 16.1%) in the STEC group. The proportion of lesions with type R vessels on ME-NBI was significantly higher in the STEC group (46.4% vs. 3.9%). The STEC group had significantly lower accuracy of ME-NBI for prediction of depth (64.3% vs. 83.5%) and a greater proportion of underestimated lesions (32.1% vs. 9.3%). In the multivariate analysis, the histopathology of STEC was associated with type R vessels on ME-NBI.

CONCLUSION

Type R vessels and submucosal tumor-like elevation might be the clinical predictors of STEC.

Clinical-Pathological Characteristics of Adenosquamous Esophageal Carcinoma: A Propensity-Score-Matching Study

There are few studies on esophageal adenosquamous carcinoma (ADSC). Our study intended to investigate the clinical and survival features of ADSC. We included esophageal cancer (EC) data from the Surveillance, Epidemiology, and End Results program database to explore clinical and survival traits. Propensity score matching (PSM), the multivariate Cox regression model, and survival curves were used in this study. A total of 137 patients with ADSC were included in our analysis. The proportion of ADSC within the EC cohort declined from 2004 to 2018. Besides, results indicated no significant difference in survival between ADSC and SCC groups (PSM-adjusted HR = 1.249, P = 0.127). However, the survival rate of the ADSC group was significantly worse than that of the ADC group (PSM-adjusted HR = 1.497, P = 0.007). For the ADSC group, combined treatment with surgery had a higher survival rate than other treatment methods (all P < 0.001). Surgical resection, radiotherapy, and chemotherapy were independent protective prognostic factors (all P < 0.05). The proportion of ADSC has been declining from 2004 to 2018. The prognosis of ADSC is not significantly different from that of SCC but is worse than that of ADC. Surgery, radiotherapy, and chemotherapy could improve the prognosis of patients. Comprehensive treatment with surgery as the main treatment is more beneficial for some patients.

Surgical resection for esophageal adenosquamous carcinoma: an analysis of 56 cases

BACKGROUND

Esophageal adenosquamous carcinoma (EASC) is a rare disease. The biological behavior and treatment of this malignancy are not well studied.

METHODS

Data from 56 patients with EASC who underwent esophagectomy were retrospectively analyzed and compared with 5028 patients with esophageal squamous cell carcinoma (ESCC). The impact of clinicopathological factors on the survival of patients with EASC was analyzed. The survival differences between patients with EASC and ESCC were also compared.

RESULTS

There were 43 males and 13 females with a mean age of 59.7 ± 1.3 years (range, 39-79 years). Only 1 of the 43 patients who received preoperative esophagoscopic biopsy was diagnosed with EASC. The median survival time for patients with EASC was 32.0 months, and the 1-, 3-, and 5-year overall survival rates were 78.3%, 46.1%, and 29.6%, respectively. Resection margin, pN category, and adjuvant chemotherapy were found to be independent predictors. After 1:1 propensity score matching, the 5-year overall survival rate of 29.6% for patients with EASC was similar to that of 42.5% for patients with ESCC (P = 0.179).

CONCLUSIONS

EASC is a rare disease and is easily misdiagnosed by esophagoscopic biopsy. The prognosis of EASC was similar to that of ESCC. Postoperative adjuvant chemotherapy may improve the survival of patients with EASC after esophagectomy.

A case report of adenosquamous carcinoma of the esophagogastric junction

BACKGROUND

Many types of tumors can arise in the esophagogastric junction (EGJ). Squamous cell carcinoma (SCC) arising from the esophageal epithelia, adenocarcinoma arising from the gastric mucosa, or Barrett's esophageal mucosa are frequently observed in the EGJ. However, adenosquamous carcinoma (ASC) has been rarely observed in this area. We herein report a rare case of ASC of the EGJ.

CASE PRESENTATION

An 81-year-old man visited our hospital complaining of dysphagia. Esophagogastroduodenoscopy detected an elevated tumor in the gastric cardia. Biopsy specimens taken from the tumor showed SCC. Computed tomography revealed a tumor located in the EGJ and node metastases surrounding the EGJ. The tumor was diagnosed as SCC, overhanging in the stomach, of the EGJ. The patient underwent a proximal gastrectomy with a lower esophagectomy and node dissection for the metastases surrounding the EGJ, and esophagogastrostomy in the lower mediastinum. Histopathologic examination showed the tumor consisted of SCC and adenocarcinoma. The adenocarcinoma consisted of nests scattered in the SCC. We observed adenocarcinoma component in 35% of the tumor and epithelial spread of SCC in the lower esophagus. Thus, we diagnosed the tumor as ASC of the EGJ. Eight metastatic nodes were dissected; both SCC and adenocarcinoma were observed in seven.

CONCLUSIONS

In the present case, SCC may be originated from the squamous epithelia of the lower esophagus and grew into the stomach, and the adenocarcinoma may have differentiated from SCC through the infiltration.

A Review: PI3K/AKT/mTOR Signaling Pathway and Its Regulated Eukaryotic Translation Initiation Factors May Be a Potential Therapeutic Target in Esophageal Squamous Cell Carcinoma

Esophageal squamous cell carcinoma (ESCC) is a malignant tumor developing from the esophageal squamous epithelium, and is the most common histological subtype of esophageal cancer (EC). EC ranks 10th in morbidity and sixth in mortality worldwide. The morbidity and mortality rates in China are both higher than the world average. Current treatments of ESCC are surgical treatment, radiotherapy, and chemotherapy. Neoadjuvant chemoradiotherapy plus surgical resection is recommended for advanced patients. However, it does not work in the significant promotion of overall survival (OS) after such therapy. Research on targeted therapy in ESCC mainly focus on EGFR and PD-1, but neither of the targeted drugs can significantly improve the 3-year and 5-year survival rates of disease. Phosphatidylinositol 3-kinase (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR) pathway is an important survival pathway in tumor cells, associated with its aggressive growth and malignant progression. Specifically, proliferation, apoptosis, autophagy, and so on. Related genetic alterations of this pathway have been investigated in ESCC, such as PI3K, AKT and mTOR-rpS6K. Therefore, the PI3K/AKT/mTOR pathway seems to have the capability to serve as research hotspot in the future. Currently, various inhibitors are being tested in cells, animals, and clinical trials, which targeting at different parts of this pathway. In this work, we reviewed the research progress on the PI3K/AKT/mTOR pathway how to influence biological behaviors in ESCC, and discussed the interaction between signals downstream of this pathway, especially eukaryotic translation initiation factors (eIFs) and the development and progression of ESCC, to provide reference for the identification of new therapeutic targets in ESCC.

Squamous Neoplasia in the Esophagus

CONTEXT.—

Squamous lesions of the esophagus encompass a spectrum of disorders ranging from reactive changes and benign papilloma to squamous dysplasia and squamous cell carcinoma, which may pose diagnostic challenges especially in superficial biopsies.

OBJECTIVE.—

To provide a review on the typical features of squamous neoplasia in the esophagus, with an emphasis on the key diagnostic features as well as differential diagnosis from mimicking lesions.

DATA SOURCES.—

Data sources include published peer-reviewed literature and personal experiences of the authors.

CONCLUSIONS.—

Accurate diagnosis of squamous neoplasia requires adherence to established diagnostic criteria, attention to subtle histologic features, and correlation with clinical and imaging findings. In difficult cases, multiple biopsies may be necessary to reach a definitive diagnosis.

Clinical Characteristics, Prognosis, and Nomogram for Esophageal Cancer Based on Adenosquamous Carcinoma: A SEER Database Analysis

Objective: Esophageal adenosquamous carcinoma (ASC) is a rare pathological type of cancer. Its clinical features and prognosis is poorly understood. The purpose of this study was to identify the characteristics of ASC patients and analyze the risk factors of esophageal carcinoma.

Methods: Patients with esophageal cancer in the SEER database diagnosed from 1975–2016 were obtained. The epidemiology, clinical characteristics, and outcomes between these three groups were compared. The nomogram and online dynamic nomogram were constructed according to the Cox proportional hazard model.

Results: The age-adjusted incidences of AC (1975–1999), AC (1999–2016), and ASC (1975–1989) increased over time (p < 0.05). Age-adjusted incidences of SqCC (1986–2012) and ASC (1989–2016) decreased (p < 0.05). Survival of patients with ASC was significantly worse when compared to AC and SqCC (ASC vs. AC, p < 0.001, ASC vs. SqCC, p = 0.01). ASC, older age, black race, male, overlapping site, higher tumor grade, lymph node metastasis, and a higher summary stage or AJCC stage were considered to be risk factors for a poor survival in the multivariate Cox analysis. The ROC curves and AUC indicated that the model has a good discrimination ability (AUC were 0.774 for a 3-year OS and 0.782 for a 5-year OS). An online dynamic nomogram was built based on the Cox proportional hazard model for convenient clinical use.

Conclusions: ASC is somewhat closer to AC rather than SqCC in terms of the demographics and tumor site, but has a worse OS than both AC and SqCC.

Adenosquamous carcinoma of the digestive system: a literature review

Adenosquamous carcinoma (ASC), containing both adenocarcinoma and squamous cell carcinoma components, is rare in the digestive system. Limited data is available on ASC of the digestive system (AS-ASC), and the current evidence is available mainly in the form of case reports and case series. We performed a thorough search of the available literature and compiled a review on the epidemiology, histopathology, pathogenesis, clinical manifestations, diagnosis, treatment, and prognosis of AS-ASC. Non-specific clinical and imaging presentations and low diagnostic accuracy of biopsy lead to difficulties in preoperative diagnosis in a high proportion of patients and high malignancy. The pathogenesis remains obscure. Surgery remains the mainstay of treatment for AS-ASC. The role of chemoradiotherapy as an adjuvant treatment is still inconclusive. Key messages Metastatic linings and the lack of efficacious treatments lead to an unfavorable outcome in AS-ASC patients. Further research could help us understand the pathophysiology of AS-ASCand the unique needs of AS-ASC patients.

Should adenosquamous esophageal cancer be treated like adenocarcinoma or squamous cell carcinoma?

BACKGROUND

Esophageal adenocarcinoma (AC) and squamous cell carcinoma (SCC) have distinct outcomes, treatment strategies, and response profiles to therapy. Adenosquamous carcinoma (ASC) is thought to behave more aggressively than each of its counterparts. The aim of this study is to determine ifASC is best managed as AC or SCC.

METHODS

National Cancer Database (2004-2015) was queried for patients with nonmetastatic esophageal ASC. The analysis was stratified by clinical node-negative (cN0) or clinical node-positive (cN1-3). Treatment was categorized into chemoradiation alone, surgery alone, or preoperative chemoradiation followed by surgery. The primary outcome was 5-year overall survival (OS).

RESULTS

Among 352 patients, 43% were cN0 (n = 151), 57% were cN1-3 (n = 201) and 55% had chemoradiation alone (n = 194), 15% surgery alone (n = 53), and 30% preoperative chemoradiation (n = 105). Among patients who had preoperative chemoradiation, 20% had pathologic complete response (n = 17). For either cN0 or cN1-3, Charlson-Deyo Comorbidity Index did not differ among the treatment groups(all p > 0.05). On Kaplan-Meier analysis for cN0, treatment with surgery alone had comparable OS to preoperative chemoradiation (47% vs 34%; P = .5) and each had improved OS compared to chemoradiation alone (30%; P = .02; P = .06). On univariate analysis for cN0, clinical T category was not associated with OS. For cN1-3, however, preoperative chemoradiation was associated with improved OS when compared to chemoradiation alone or surgery alone (27% vs 19% vs 0%; P < .001). This persisted when accounting for age and clinical T category (hazard ratio: 0.45; P < .001).

CONCLUSION

Esophageal ASC behaves more like AC in response to chemoradiation and survival based on treatment modality. A complete response to chemoradiation is only 20% unlike what has been shown for SCC, where chemoradiation is an acceptable definitive therapy. Esophageal ASC should be managed more like AC.

A Primary Barrett's Adenocarcinoma with a Squamous Cell Carcinoma Component

The present report describes an extremely rare case of Barrett's adenocarcinoma (BAC) with a squamous cell carcinoma (SCC) component. A 55-year-old man was diagnosed with esophageal adenocarcinoma on Barrett's esophagus. The patient underwent endoscopic submucosal dissection, but the pathology revealed deep submucosal invasive, moderately differentiated tubular adenocarcinoma and focal SCC with vascular invasion. In addition, morphological transition between adenocarcinoma and SCC components was confirmed. The patient underwent additional surgery, which revealed lymph node metastasis, and then received S-1 adjuvant chemotherapy. Based on the pathological findings, the transdifferentiation process may have a role in the histogenesis of this tumor.

Identification of Adenosquamous Carcinoma as a Rare Aggressive HER2-negative Subgroup of Esophageal/Gastroesophageal Junction Adenocarcinoma

BACKGROUND

Our purpose was to evaluate the prognostic impact of pathologically confirmed esophageal adenosquamous carcinoma (ASC) and its association with HER2 status and clinicopathologic characteristics.

METHODS

Among 796 patients with esophageal or gastroesophageal junction adenocarcinoma who underwent curative resection, surgical pathology reports were reviewed, and suspected ASC was confirmed utilizing p63 and CK5/6 immunostaining. HER2 status was determined using immunohistochemistry and fluorescence in situ hybridization. Cox models were used to assess the impact of ASC on disease-specific survival and overall survival.

RESULTS

Overall, 2.0% (16/796) of patients had esophageal ASC, mostly demonstrating a close intermingling of squamous and adenocarcinoma cells within the same tumor. The percentage of squamous versus adenocarcinoma cells in the primary was generally recapitulated in nodal metastases, and intrapatient internodal heterogeneity was uncommon. Patients with esophageal ASC were statistically significantly more likely to be female (vs. male), have normal (vs. excess) body mass index, and harbor HER2-negative (vs. positive) tumors, as compared with patients with adenocarcinoma only. No ASC tumor was HER2-positive as compared with 16% of adenocarcinoma only tumors (P=0.018). Compared with patients with adenocarcinoma only, those with ASC demonstrated profoundly worse disease-specific survival (5-year event-free rate, 34% vs. 6%; multivariate hazard ratio, 2.87 [95% confidence interval, 1.59-4.76]; P=0.0010) and overall survival (P=0.0027) that was independent of known prognostic factors and HER2 status.

CONCLUSION

ASC identifies a rare aggressive HER2-negative subgroup of esophageal/gastroesophageal junction adenocarcinoma.

Adenosquamous Carcinoma of the Esophagus: A Literature Review

Adenosquamous carcinoma (ASC) of the esophagus is an uncommon type of esophageal cancer that contains both adenocarcinoma and squamous cell carcinoma elements. Data on this biologically unique type of cancer are limited and mainly stem from case reports and small case series. We performed an audit of the available literature and synthesized a review on the epidemiology, pathogenesis, histopathology, clinical manifestations, diagnosis, treatment and prognosis of ASCs. Adenosquamous carcinoma of the esophagus is a rare type of esophageal cancer. Histological examination is necessary to confirm the diagnosis of ASC and patients usually receive multimodal treatment. Patient outcomes are not well defined and further research could help us better understand the pathophysiology and unique needs of patients with this rare malignancy.

Clinical characteristics of adenosquamous esophageal carcinoma

BACKGROUND

Current published information of adenosquamous carcinoma (ASC) of the esophagus in the United States is limited to isolated case reports. We sought to study the clinical characteristics of this tumor using the Surveillance, Epidemiology and End Results (SEER) database.

METHODS

Relevant data of all patients with esophageal cancer in the SEER database diagnosed from 1998-2010 was obtained. Demographic, grade, stage, treatment and survival characteristics of patients with ASC were summarized and compared to those patients with adenocarcinoma (ACA) and squamous cell carcinoma (SqCC). Univariate analyses across comparison groups were performed using Wilcoxon rank sum test for continuous covariates and the Pearson Chi-square test for categorical covariates. To evaluate the association of selected covariates to survival by histology, unadjusted and adjusted proportional hazards models were generated for the entire study population. To further control for the difference in covariates among the histology groups, propensity weighted Cox regression modeling was performed using the inverse propensity to treat weighting (IPTW) approach.

RESULTS

Of 29,890 patients with the histological subgroups, only 284 patients had ASC (1%). Patients with ACA had a higher grade (72.9% with grade III/IV) and presented with advanced stage (48.2% distant disease) than their comparison group. Patients with ASC had worse overall survival compared to ACA but not SqCC in both univariate and multivariate analyses (OR =0.76; P<0.05 and OR =0.86; P<0.05 respectively). These results were further confirmed by the propensity weighted Cox regression analysis. Analysis of the ASC population alone demonstrated that decreasing stage, radiation therapy (OR =0.59; P<0.001) and surgery (OR =0.86; P<0.001) were associated with better overall survival, but grade was not.

CONCLUSIONS

ASC of the esophagus is a rare histological variant comprising 1% of esophageal ACA in the Unites States. This histological subtype presents in later stages, at a higher grade and portends a poorer survival than the more common ACA. Radiation therapy and surgical resection of appropriate stage patients provide the best chance of survival.

Primary adenosquamous carcinoma of the esophagus: an analysis of 39 cases

BACKGROUND

Adenosquamous carcinoma (ASC) of the esophagus is an uncommon type of malignant esophageal neoplasm containing both squamous cell carcinoma (SCC) and adenocacinoma (AC) components. The aim of this study was to explore the clinical characteristics and prognosis of esophageal ASC.

METHODS

A retrospective review of esophageal ASC patients who underwent transthoracic esophagectomy with lymphadenectomy in our hospital from July 2007 to April 2014.

RESULTS

A total of 39 (1.0%) esophageal ASC patients among 3855 patients with esophageal cancers were collected to analyze. There were 34 men and 5 women with a median age of 61.0 years (range from 39-85). Median follow-up time was 30.0 months and median survival time was 44.4 months. The 1-, 3- and 5-year overall survival rates were 82.1%, 51.6% and 37.5%, respectively. Compared to esophageal SCC and AC, there were no significant difference in survive time (P=0.616). Thirty five (92.1%) of the 38 patients who underwent preoperative endoscopic biopsy were misdiagnosed, mostly as SCC. Fifteen patients (38.5%) were found to have lymph node metastasis. Thirty two patients (82.1%) had a poorly differentiated or undifferentiated tumor. According to the 2009 American Joint Committee on Cancer (AJCC) staging system for esophageal squamous cell carcinoma, 3 patients were at Stage I, 21 patients at Stage II and 15 patients at Stage III. In univariate analysis, pT stage, lymph node metastasis and pTNM Stage significantly influenced survive time. In multivariate analysis, however, only lymph node metastasis (P=0.003; 95% CI: 1.626-10.972) was found to be the independent prognostic factor.

CONCLUSIONS

Primary ASC of the esophagus is a rare disease with difficultly to be histologically confirmed by endoscopic biopsy. The prognosis of esophageal ASC was no worse than esophageal SCC and AC. Lymph node metastasis is the most influent prognostic factor. The TNM staging system of esophageal SCC is applicable for esophageal ASC.

A Nation-Wide Cancer Registry-Based Study of Adenosquamous Carcinoma in Taiwan

BACKGROUND

Adenosquamous carcinoma (ASC) is a rare disease involving various organs, yet there are no large-scale population-based comparative studies on ASC among different organs.

METHODS

The incidence and overall survival of ASC among various organs in cases diagnosed in Taiwan from January 1, 2003 to December 31, 2010 were calculated and compared using data from the Taiwan Cancer Registry (TCR). The various organs were classified and divided into three different systems: the female reproductive, respiratory, and alimentary systems. Survival analysis were also compared among 30,850 patients diagnosed as ASC, adenocarcinoma (AC) or squamous cell carcinoma (SCC) in organs with frequent ASC.

RESULTS

During the study period, a total of 576 ASC cases were diagnosed in Taiwan. The most common primary system was respiratory (73.8%), followed by alimentary (16.2%) and female reproductive (10%). The overall survival were significantly higher for cases involving the female reproductive system, followed by the respiratory and alimentary systems (P = 0.016). The median overall survival were worse in males than females for cases involving the respiratory system (22.4 vs. 31.8 months, P = 0.044). Multivariate analysis showed that age ≧ 65, more advanced T and N categories were independent unfavorable prognostic factors of overall survival in ASC. ASC histology is an independent unfavorable prognostic factor compared with AC and SCC.

CONCLUSIONS

ASC at an old age and more advanced T and N categories were found to be associated with a poor prognosis.

Adenosquamous Carcinoma of the Esophagus and Esophagogastric Junction: Clinical Manifestations and Treatment Outcomes

BACKGROUND/AIMS

The aim of this study is to understand the clinicopathological manifestations, treatment, and prognostic factors of adenosquamous carcinoma (ASC) of the esophagus and esophagogastric junction, a rare malignancy.

METHODS

From 1981 to 2011, 26 out of 4704 patients (23 males, 3 females; mean age: 65.8 years) with ASC of the esophagus and esophagogastric junction who received surgical resection were analyzed.

RESULTS

Only one (4.2%) patient was diagnosed with ASC by preoperative endoscopic biopsy. Three patients received Ivor-Lewis operation with intrathoracic esophagogastrostomy, seven received gastrectomies, and the other 16 underwent transthoracic esophagectomies. Median follow-up time was 30.6 months (interquartile range, 17.9-95.1 months). At study end, there were 12 (46.2%) patients with tumor relapse, all within 3 years postoperatively. The 5-year disease-free survival (DFS) rate was 46.2%. Tumor length and no postoperative adjuvant treatment were the independent prognostic factors for DFS. The 5-year overall survival (OS) rate was 30.8%. On multivariate analysis, the resection type, tumor length, and perineural invasion were independent prognostic factors for OS.

CONCLUSION

ASC is a rare cell type of the esophagus and esophagogastric junction that is easily misdiagnosed at endoscopic biopsy. OS rate was no worse than that reported for squamous cell carcinoma (SCC). Tumor length was the independent prognostic factor for both DFS and OS.