Adenocarcinoma of the oesophagus

A Case of Adenocarcinoma of the Upper Third of the Esophagus Arising on Ectopic Gastric Tissue

A case of adenocarcinoma of the upper third of the esophagus, arising from ectopic mucosa of gastric type, is described. The possible origins, from ectopic islets of gastric mucosa, tracheobronchial rests or esophageal glands, are discussed. The precence of ectopic gastric mucosa on the surface of the esophagus adjacent to the tumor suggests that this esophageal adenocarcinoma arose from ectopic gastric mucosa.

Adenocarcinoma of the esophagogastric junction: incidence, characteristics, and treatment strategies

The incidence of adenocarcinoma of the esophagogastric junction (AEG) is dramatically increasing in Western countries, while it is not increasing in Eastern countries. Siewert type I tumors are observed less frequently in Eastern countries in comparison to Western countries. On the other hand, other clinicopathological features of AEG, including age, male-to-female ratio, pathological grade, tumor progression, and prognosis, are similar in Western and Eastern countries. Two surgical phase III trials have indicated that AEG type I should be treated surgically as esophageal cancer, while types II and III should be regarded as true gastric cancer. No phase III trials have demonstrated a significant interaction comparing hazard ratios for death between AEG and true gastric cancer in the subset analyses with regard to chemotherapy.

Columnar-lined esophagus: time to drop the eponym of "Barrett": Historical review

There can be few medical conditions that have been surrounded by as much confusion about their definition or terminology as columnar-lined esophagus (CLE); approximately 30 different terms and eponyms have been used to describe this condition. The history of this condition can be divided into five stages: (i) descriptive stage, 1906-1950; (ii) "argument" stage, 1950-1963; (iii) "significant" stage, 1963-1973; (iv) surveillance stage, 1973-1990; and (v) refined research stage, 1990-present. The use of the eponym "Barrett's" to describe CLE is not justified from a historical point of view. Lining of the lower esophagus by columnar epithelium was termed "Barrett's esophagus" after the presentation by Barrett in 1957. Although this finding has been attributed to Barrett, the work of others, including Tileston, Lortat-Jacob, and Allison and Johnstone, preceded Barrett's description. The historical aspects of CLE were reviewed to show how little Norman Barrett had contributed to the core concept of this condition in comparison to the contributions of other investigators, particularly the contribution of Philip Allison. Based on many discussed historical facts, we are not in favor of retaining the term "Barrett's esophagus" and we propose that CLE be henceforth referred to as "columnar-lined esophagus".

The management of patients with advanced cancer (II)

In this second article in the series, obstruction of hollow viscera in patients with advanced malignant disease is discussed. The obstruction of such structures can be associated with the development of painful and incapacitating symptoms, often in patients who have a limited life expectancy. This obstruction may be caused by the primary tumour, compression from adjacent tumour-draining lymph nodes, the presence of metastases distant from the site of the primary tumour or to adhesions within the abdominal compartment (usually as a result of previous surgery). The organs most often affected are the oesophagus, the intestine (small and large), the biliary tree and the genito-urinary tract. Obstruction of each of these organs and its management is discussed in more detail below.

Preoperative high-dose radiation and chemotherapy in adenocarcinoma of the esophagus and esophagogastric junction

BACKGROUND

Esophageal adenocarcinoma (EA) incidence is rising. Defining optimal management is essential because median survival after surgery alone is only approximately 12 months. High-dose radiation (> 5000 cGy) and chemotherapy (HDRCT) preoperatively for patients with EA has not been fully investigated. We evaluated tumor response, resectability, and survival following HDRCT in patients with localized EA.

METHODS

Thirty patients with American Joint Committee on Cancer (AJCC) clinical stage I or II EA were prospectively treated with HDRCT. The treatment consisted of 60 Gy radiation at 2 Gy per fraction with concurrent infusional 5-fluorouracil (5-FU) and a bolus of mitomycin C followed by esophagogastrectomy. The range of follow-up was 7 to 69 months, with a median of 31 months.

RESULTS

Twenty of 30 patients (67%) received full-course HDRCT. Severe esophagitis precluded full-dose radiation in 10 patients. Three patients developed neutropenia and fever requiring admission to a hospital. Two patients died preoperatively of treatment-related complications. Nine patients were not explored. Eighteen patients were resected with curative intent; the remaining three had metastatic disease at laparotomy. Seven of 18 resected patients (39%), or 7/30 (23%) of all patients treated, had a pathologic complete response. There was one operative death. Overall local control was seen in 25/30 patients (83%). Median overall survivals for resected and for all patients were 23 and 13 months, respectively.

CONCLUSIONS

Preoperative HDRCT in patients with EA results in encouraging local tumor response and local control. Overall survival, however, may not be improved, and the treatment-related mortality of 10% is higher than reported with surgery alone or with preoperative chemotherapy.

Primary oesophageal carcinoma in teens

Seven teenaged patients with primary oesophageal carcinoma, treated at our hospital in the last 6 years are presented and their management discussed. Five patients had localised disease. Three of them underwent total oesophagectomy, one was given radical radiotherapy, and one was lost to follow-up. Two patients had metastatic disease at presentation. The primary oesophageal carcinoma in this age group may not be so rare as reported in the literature and must be considered in the differential diagnosis of dysphagia. Like their older counterparts, the outcome depends on the stage of the disease and is not influenced by age per se.

Adenocarcinoma of the cervical oesophagus arising from ectopic gastric mucosa. The histochemical determination of its origin

A case of adenocarcinoma of the cervical oesophagus was examined by employing a battery of histochemical techniques and was demonstrated to arise from ectopic gastric mucosa. The patient was a 66-year-old Japanese male. Endoscopy revealed an ulcerated tumour on the right anterior wall of the cervical oesophagus, approximately 16 cm from the incisor teeth. Pathological examination of surgically removed specimens showed well-differentiated tubular adenocarcinoma. Ectopic gastric mucosa was found in the oesophageal mucosa adjoining the carcinoma. Histochemical stains for characterizing mucosubstances and immunostains for various antigens were used. In addition to this carcinoma, ectopic gastric mucosa in the oesophagus and normal oesophageal, cardiac, tracheal and bronchial mucosa were also examined. The results showed that the carcinoma contained mucins, which showed reactivities characteristic of the gastric surface mucous cell (galactose oxidase-cold thionin Schiff reactive) and gland mucous cell (paradoxical concanavalin A staining reactive). Ectopic gastric mucosa consistently contained these mucins, but other tissue sites lacked them.

Treatment of adenocarcinoma of the cardia with synchronous chemotherapy and radiotherapy

Twenty-nine evaluable patients with adenocarcinoma of the cardia were treated with synchronously administered chemotherapy (two cycles of 5-fluouracil and cisplatin and 30-36 Gy of radiation to determine whether these tumours are responsive to such treatment. Complete regression of tumour was observed endoscopically in 19 patients, and partial regression in four. Fourteen patients had their tumours resected and in six no microscopic tumour was found in the specimen. Nine patients received additional radiotherapy to a total dose of 54-60 Gy instead of surgery. Tumour response was associated with rapid reversal of dysphagia. Only one patient required subsequent intervention for relief of dysphagia due to fibrous stricture. Enhanced survival was associated with a complete endoscopic response to initial chemotherapy and radiotherapy, and a tumour of less than 5 cm in length. The median survival of responding patients was 15 months. Synchronous chemotherapy and radiotherapy was of major palliative benefit in this series and merits further evaluation.

Adenocarcinoma of the esophagus and esophago-gastric junction: the effects of single and combined modalities on the survival and patterns of failure following treatment

One hundred sixty-five patients with localized adenocarcinomas of the esophagus or esophago-gastric (EG) junction were treated with surgery alone, radiation therapy alone, chemotherapy alone, surgery followed by post-operative radiation therapy, chemotherapy, or chemosensitized radiation therapy, and chemosensitized radiation therapy alone. Patients were retrospectively evaluated for survival, control of tumor within the mediastinum, post-operative swallowing function, patterns of failure, and treatment-related morbidity. Follow-up of survivors ranges from 9-88 months (median 23 months). Chemotherapy and radiation therapy as single modalities were associated with a recurrence rate of 100%. Combined modality therapy significantly reduced the risk of local recurrence in all patient groups. Chemosensitized radiation therapy alone reduced the local recurrence rate to 48%, and surgery followed by radiation therapy reduced the local failure rate to 24%. When chemotherapy or chemosensitization was added to surgery plus radiation, the risk was further reduced to 15%. The use of combined modality therapy was also found to extend the survival of patients without excessive toxicity. Median survival was shortest among the group treated with radiation alone (5 months) and intermediate among patients following chemosensitized radiation alone (10 months) or complete surgical resection alone (15 months). Patients treated with all three modalities had the longest median survival (21 months). Based on this experience, the optimum treatment of these patients appears to include aggressive attempts at surgical resection with chemosensitized radiation therapy. Excellent palliation can also be achieved in unresectable patients with chemosensitized radiation therapy with a smaller chance for long term survival.

The increasing frequency of adenocarcinoma of the esophagus

Adenocarcinoma of the esophagus has been considered an uncommon tumor, accounting for fewer than 8% of all cases of esophageal cancer. To determine the current frequency of adenocarcinoma of the esophagus, we reviewed data from the tumor registries of the Commonwealth of Massachusetts, the University Hospital (UH), and the Boston VA Medical Center (BVAMC). From 1982 to 1984, 868 esophageal cancers were reported in Massachusetts, of which 231 (27%) were adenocarcinomas. In comparison with squamous cell carcinomas of the esophagus, esophageal adenocarcinomas occurred more frequently in males (P less than 0.01) and were uncommon among blacks (P less than 0.01). From 1980 to 1986, 262 cases of esophageal cancer were seen at the UH and the BVAMC, of which 81 (31%) were adenocarcinomas. An analysis of the latter group to identify true esophageal adenocarcinomas (tumors confined to the esophagus without gastric involvement) yielded 47 cases. Thus, true esophageal adenocarcinoma accounted for 18% of esophageal malignancies at our hospitals, a frequency threefold to fivefold higher than that found in four prior studies that used comparable anatomic diagnostic criteria. We conclude that adenocarcinoma of the esophagus is now being recognized at a substantially higher frequency than reported in the past.

Combined radiation and chemotherapy as primary management of adenocarcinoma of the esophagus and gastroesophageal junction

Between January 1981 and December 1986, 20 patients with adenocarcinoma of the esophagus and gastroesophageal junction were entered into a prospective study involving combined radiation therapy and chemotherapy (5-fluorouracil [5-FU] and mitomycin) as primary management. Nine patients with Stage I or II disease received definitive treatment consisting of 6000 cGy in 6 to 7 weeks and 5-FU (1000 mg/m2/24 hours) as a continuous intravenous (IV) infusion for 96 hours starting on days 2 and 29. Mitomycin (10 mg/m2) was administered as a bolus injection on day 2. Ten patients with extraesophageal and disseminated disease (Stages III and IV) and one patient with an unresectable anastomotic recurrence were considered palliative. Generally the palliative regimen did not differ from the definitive except for the radiation dose which in seven of the 11 patients was less than 6000 cGy (4000-5600 cGy). The range of follow-up was 6 to 74 months and no patient was lost to follow-up. Seven of the eight evaluable definitively treated patients were complete responders. The median relapse-free survival was 10 months and the median survival was 15 months in this group. In the palliative group, six of nine evaluable patients had relief of dysphagia until death or last follow-up with a median duration of 8 months. Our results indicate that combined modality treatment with infusional 5-FU, mitomycin, and radiation is an effective and well-tolerated treatment for adenocarcinoma of the esophagus and gastroesophageal junction. This treatment regimen offers palliation and some chance for cure to those patients who are inoperable, unresectable, or who refuse surgery.

Primary adenocarcinoma of the esophagus

Of 163 patients with carcinomas of the esophagus seen between 1975 and 1982, 11 (6.7%) had a primary adenocarcinoma. Although the high ratio of men to women (10:1) was similar to that seen in patients with squamous cell carcinoma of the esophagus, the mean age of those with adenocarcinoma was younger (57 years). In contrast to squamous cell carcinomas, which predominantly involve blacks, esophageal adenocarcinomas in these patients involved only Caucasians. The great majority of lesions were found in the lower third of the esophagus. Only 3 (27%) of the patients with adenocarcinomas gave a history of a large daily alcohol consumption and only 2 (18%) had a Barrett's esophagus. Although various combinations of surgery, chemotherapy, and radiotherapy could control the primary tumor rather well, the final results were poor. All patients have now expired; median survival time was 16 months.

Cancer of the distal esophagus and cardia. Incidence, tumorous infiltration, and metastatic spread

The report concerns the findings of autopsies performed at the Institute of Pathology, The University of Düsseldorf, where 68 patients with cancer of the distal esophagus and 117 patients with cancer of the cardia were observed between 1950 and 1982. The total number of autopsies during this 33-year observation period was 46,593. The male:female ratio was 5.8:1 in cancer of the distal esophagus, and 4.3:1 in cancer of the cardia. During the observation period, cancer of the distal esophagus accounted, on average, for about 40% of all esophageal cancers, whereas the percentage of cancers of the cardia among all gastric cancers was 15.4% on average. While the incidence of gastric cancer has decreased overall, a relative increase in cancers of the cardia has been found, especially in the last 8 years. In histological terms, most of the malignomas of the distal esophagus were squamous cell carcinomas (84%), and most of the cancers of the cardia were adenocarcinomas (96%). Tumor spread and lymphogenous and hematogenous metastasizing are discussed, and the findings are compared with the literature.

Dysplasia and reserve cell hyperplasia-like change in human esophagus

The esophagus was totally examined in 264 autopsied cases and 61 operated cases, for a total of 325 cases, to clarify the histogenesis of squamous cell carcinoma of the esophagus. Epithelial dysplasia of the mucosa was present in 27% and subclinical carcinoma was found in 2.4%. Hyperplasia of the duct of the esophageal gland proper was present in 34% and cysplasia of the ductal epithelium in 3%. Reserve cell hyperplasia-like change of the islet of the ectopic gastric mucosa was found in 4% and reserve cell hyperplasia-like change of the esophagogastric junction zone in 13%. Of the seven cases of microcarcinoma, two showed dysplasia and gradual transition and one presented dysplasia and abrupt transition. Another two were considered to have originated in the ductal epithelium. These findings suggested that they could all be the sites of origin of cancer development.

"Barrett's esophagus" adenocarcinoma: a case report

A case of signet ring cell carcinoma of the lower thoracic esophagus of Barrett type without association of hiatus hernia is reported. The patient is doing well more than five years after esophagectomy combined with esophagogastrostomy. On the base of histological findings of the operative material, this tumor appears to have originated from the gastric type of mucosa with parietal cells, accessory cells and chief cells as it is lining the segment of the esophagus directly distal to the tumor. The basic anomaly in this case is believed to be misdifferentiation of the embryonic columnar epithelium to a gastric fundic type instead of a normal squamous type.

Adenocarcinoma of the esophagus

The relevant literature is reviewed in an attempt to clarify the true frequency of intraesophageal adenocarcinoma and to evaluate the different treatment modalities and survival of this uncommon type of tumor. The incidence of intraesophageal adenocarcinoma in reported clinical series is about 1%, and data from cancer registries show the incidence to be about 2% for upper and the middle thirds, a more reliable figure than that for the lower third in which lesions of cardia, or stomach infiltrating the lower esophagus have been included. The benefits of any particular treatment modality are difficult to evaluate in view of the rarity of this type of tumor, and the treatment results are as poor as those obtained in the treatment of squamous cell carcinoma.

Primary adenocarcinoma of the upper oesophagus

Adenocarcinoma of the upper one-third of the oesophagus is an uncommon entity. A review of the literature reveals 20 reported cases. This paper reports an additional case. The lesion may arise from oesophageal glands, foci of ectopic gastric mucosa, or a Barrett's oesophagus. In contrast with squamous cell carcinomas submucosal spread is not prominent; however, transverse penetration through the oesophageal wall is common. The prognosis is grave. Treatment modalities that have been employed include supportive care, surgery alone, pre-operative radiation therapy and surgery and radiation therapy alone. Survival statistics produced by these various regimens are similar. There is little documented evidence for the radioresponsiveness of primary adenocarcinoma of the oesophagus. The case described demonstrates marked tumour regression following a course of external radiotherapy as shown by serial oesophagrams. Optimum treatment for adenocarcinoma of the upper oesophagus remains to be determined. It is felt that the role of radiation therapy should be further evaluated.

Adenocarcinoma of the oesophagus and of the oesophagogastric junction

The clinical and pathological features of 52 adenocarcinomas invading the oesophagus and the oesophagogastric junction are reviewed. The relationship of these tumours to the presence of a concomitant hiatal hernia and the histogenesis of primary oesophageal adenocarcinomas are discussed. Adenocarcinomas of the cardio-oesophageal junction appear to have distinctive prognostic and pathological features and there may be a case for their classification into a separate category of alimentary neoplasms.

Diagnosis of Barrett's esophagus by pertechnetate radionuclide

In Barrett's esophagus the normal stratified squamous epithelium of esophagus is replaced by columnar epithelium and other charcteristics of gastric mucosa. Barrett's esophagus has an increased tendency to bleed and is more prone to undergo malignant change. There are many procedures used to diagnose this entity, but only by serial and multiple esophageal mucosal biopsies can the diagnosis be confirmed. Harper et al (2) demonstrated an early and intense uptake of 99m Tc pertechnetate by the stomach in animals. Since the Barrett's esophagus is lined by gastric mucosa, pertechnetate scintigraphy was used as a screening procedure. The criteria for a postive scan was an area of increased uptake of technetium extending above the normal dense uptake of stomach configuration. Pertechnetate scintigraphy was performed in 4 patients with Barrett's esophagus and 6 controls with only one false negative result. Thus pertechnetate scintigraphy is a rapid, safe, and atraumatic screening procedure.

Adenocarcinima in the columnar epithelial lined lower (Barret) oesophagus

Hawe, A., Payne, W. S., Weiland, L. H., and Fontana, R. S. (1973).Thorax, 28, 511-514. Adenocarcinoma in the columnar epithelial lined lower (Barrett) oesophagus. At the Mayo Clinic, five patients with Barrett oesophagus developed adenocarcinoma of the oesophagus at sites cephalad from the anatomic cardia but separated from it by a definite segment of columnar lined oesophagus. Twelve similar cases have been reported in the literature, including one from this institution. Of 85 Mayo Clinic patients in whom a clinical diagnosis of benign Barrett oesophagus was made in the 20-year period 1950-69, two subsequently developed oesophageal cancer. Since its description in 1950 by Barrett, the columnar epithelial lined lower oesophagus has been encountered with increasing frequency. The full clinical implications of this unusual condition are only partially appreciated at this time, and the present report, as well as previous ones, suggest that the condition may be premalignant.

Primary adenocarcinoma of the esophagus: 18-year review and review of literature

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Intraoesophageal adenocarcinoma

A study of 87 cases of carcinoma involving the gastro-oesophageal region included seven cases of adenocarcinoma confined to the anatomical limits of the oesophagus. Six of these intraoesophageal adenocarcinomas appear to have arisen in "oesophagi lined by columnar epithelium". The seventh, a carcinoma of double histological pattern associated with a sliding hiatus hernia, showed a complex mixture of epithelial structures in the lower oesophagus. The histogenesis of intraoesophageal adenocarcinoma is discussed, and it is stressed that its prognosis may be relatively favourable.