High-grade esophageal dysplasia: long-term survival and quality of life after esophagectomy

BACKGROUND

Esophagectomy for high-grade dysplasia in Barrett's esophagus has been advocated. Although long-term survival data exist, little is known about functional outcome and quality of life in this particular subset of patients.

METHODS

The records of all patients who underwent esophageal resection for high-grade dysplasia from June 1991 through July 1997 were reviewed. Long-term functional outcome and quality of life were assessed using a two-part written survey.

RESULTS

There were 54 patients (48 men, 6 women). Median age was 64 years (range, 36 to 83 years). Ivor Lewis esophagogastrectomy was performed in 34 patients (63%), transhiatal esophagectomy in 10 (18%), extended esophagectomy in 8 (15%), and other in 2 (4%). Invasive carcinoma was found in 19 patients (35%). Five patients (9%) were stage 0, 7 (13%) stage I, 3 (6%) stage IIA, 1 (2%) stage IIB, and 3 patients (6%) stage III. There was one operative death (1.8%). Complications occurred in 31 patients (57%). Median hospitalization was 13 days (range, 11 to 44 days). Follow-up was complete in all patients and ranged from 6 months to 9 years (median, 63 months). Overall 5-year survival was 86% and did not differ significantly from a population matched for age and gender. Five-year survival for patients with only high-grade dysplasia was 96% and 68% for patients with cancer (p = 0.017). Quality of life was measured by the Medical Outcomes Study 36-Item Short-Form Health Survey. For patients with only high-grade dysplasia, the role-physical and role-emotional scores were better than for the control population (p < 0.03). For patients with cancer, the health perception score was worse than for the control population (p < 0.03). Scores measuring physical-function, social function, mental health, bodily pain, and energy/fatigue were similar.

CONCLUSIONS

Although perioperative morbidity is significant, surgical resection of high-grade dysplasia in Barrett's esophagus provides excellent long-term survival with acceptable function and quality of life.

[Progress in oncological visceral surgery--esophageal carcinoma]

Compared to adenocarcinoma of the esophagus (Barrett cancer) the prevalence of esophageal squamous cell cancer is decreasing. Patients with squamous cell cancer have a less favorable risk profile for surgical therapy, a higher prevalence of lymphatic spread in early tumor stages, and more frequently an invasion of lymphatic vessels (lymphangiosis carcinomatosa) than patients with adenocarcinoma. A transthoracic en-bloc esophagectomy is therefore the procedure of choice for squamous cell esophageal cancer. The prognosis after surgical resection is worse for squamous cell esophageal cancer as compared to adenocarcinoma. In patients with early Barrett cancer a limited surgical approach is possible. The results of radical transmediastinal esophagectomy compare favorably to transthoracic esophagectomy in patients with locoregional Barrett cancer.

[Multimodality therapy concepts in esophageal carcinoma]

The role of preoperative chemotherapy for esophageal cancer still remains controversial. Only one study of the recently published, randomized controlled trials in potentially resectable esophageal cancer has shown improvement in survival by preoperative chemotherapy compared to surgery alone. Nevertheless, there has been a consistent observation that in patients who respond to preoperative therapy survival was significantly prolonged. Therefore, a diagnostic test that allows prediction of response is considered to be crucial for the future use of preoperative chemotherapy in patients with esophageal cancer. Molecular markers for response prediction and reliable non-invasive techniques such as FDG-PET are not yet established. At the moment therefore responder should undergo esophagectomy for definitive curative treatment, whereas non-responder may undergo individualized salvage therapy.

Surveillance and survival in Barrett's adenocarcinomas: a population-based study

BACKGROUND & AIMS

Guidelines recommend periodic endoscopic surveillance of Barrett's esophagus (BE) patients to detect and treat early esophageal adenocarcinomas; however, no trials or population-based studies exist. We evaluated the association between endoscopic surveillance of BE and survival among esophageal/gastric cardia adenocarcinoma patients.

METHODS

We studied a cohort of 23 BE patients, among 589 esophageal or gastric cardia adenocarcinoma patients diagnosed between 1990-1998 at Northern California Kaiser Permanente (a large health maintenance organization). We measured the presence of BE, detection of cancer by endoscopic surveillance, cancer stage, mortality, and potential confounders.

RESULTS

BE was diagnosed in 135 of 589 adenocarcinoma patients, with 23 BE patients diagnosed greater than 6 months before cancer was diagnosed. Among these 23 patients, 73% of the surveillance-detected cancer patients (n = 15) were alive at the end of follow-up, compared with none of the patients without surveillance-detected cancers (n = 8; P = 0.001). All surveillance-detected cancer patients had low-stage disease and none died directly from cancer. The surveillance/survival association was not substantially altered by stratification for age at BE diagnosis or other potential confounders.

CONCLUSIONS

Surveillance-detected BE-associated adenocarcinomas were associated with low-stage disease and improved survival. Additional studies are needed to evaluate potential biases and whether screening/surveillance programs decrease mortality among all patients in surveillance. Few patients (3.9%) had a BE diagnosed before their cancer. Thus, even if current surveillance techniques are effective, they are unlikely to substantially impact the population's mortality from esophageal cancer; better methods are needed to identify at risk patients.

Long-term survival after esophagectomy for Barrett's adenocarcinoma in endoscopically surveyed and nonsurveyed patients

There is growing controversy over the cost-effectiveness of surveillance endoscopy for patients with Barrett's esophagus. A retrospective review was performed of 80 patients who underwent resection for Barrett's adenocarcinoma to assess the influence of endoscopic surveillance on long-term survival. Twelve patients initially were diagnosed with benign Barrett's esophagus and were followed with endoscopic surveillance. The remaining 68 patients had the diagnosis of Barrett's esophagus made at the time of their cancer diagnosis or resection. Patients in surveillance programs were younger (53 vs. 64 years; P = 0.008), had better performance status (8.9 vs. 8.2; P = 0.04), had less weight loss (0.3 vs. 5.5 kg; P < 0.001), had a similar incidence of gastroesophageal reflux disease symptoms (75% vs. 60%), and were less likely to undergo preoperative chemotherapy and/or radiation therapy (8% vs. 28%). Pathologic stage was 0 or I in 9 (75%) of 12 patients in the surveillance group compared to 12 (18%) of 68 of those in the no surveillance group (P < 0.001). Median survival for patients in the surveillance group was 107 months compared to 12 months for those in the no surveillance group (P < 0.001). Stratifying for stage, surveillance (hazard ratio = 3.05; confidence interval = 1.09 to 8.57; P = 0.034) was the only predictor of survival. Surveillance endoscopy permits early diagnosis of adenocarcinoma in patients with Barrett's esophagus and contributes substantially to long-term survival.

Preventing death of Barrett's cancer: does frequent surveillance endoscopy do it?

Patients experiencing gastroesophageal reflux may be predisposed to developing Barrett's esophagus, which is thought to be a precursor for the development of esophageal cancer. Currently, endoscopic surveillance is recommended for patients with Barrett's esophagus in the hope that esophageal cancer may be detected or even prevented. However, the frequency of endoscopic evaluations is a matter of debate. This article will examine whether regular endoscopic surveillance can prevent death of Barrett's cancer. The issues that are evaluated include the death rate from esophageal cancer, the need to scope all patients with reflux, the need to perform surveillance on all patients with Barrett's esophagus, survival data for Barrett's patients, and the incidence of nonsymptomatic Barrett's cancer.

Transthoracic esophagectomy with radical mediastinal and abdominal lymph node dissection and cervical esophagogastrostomy for esophageal carcinoma

BACKGROUND

Several techniques for esophageal resection have been reported. This study examines the morbidity, mortality, and early survival of patients after transthoracic esophagectomy for esophageal carcinoma using current staging techniques and neoadjuvant therapy. The technique includes right thoracotomy, laparotomy, and cervical esophagogastrostomy (total thoracic esophagectomy) with radical mediastinal and abdominal lymph node dissection.

METHODS

Three hundred forty-two patients had surgery for esophageal carcinoma between 1989 and 2000 at our institution. Two hundred fifty consecutive patients had esophagectomy using this technique. Kaplan-Meier curves and univariate and multivariate analyses were performed by postsurgical pathologic stage.

RESULTS

Median age was 62.7 years (31 to 86 years). Fifty-nine were female. Eighty-one percent (202) had induction chemotherapy (all patients with clinical T3/4 or N1). Early postoperative complications included recurrent laryngeal nerve injury (14% [35]), chylothorax (9%, [22]), and leak (8%, [19]). Median length of stay was 13 days (5 to 330 days). In-hospital or 30-day mortality was 3.6% (9). Overall survival at 3 years was 44%; median survival was 25 months, and 3-year survival by posttreatment pathologic stage was: stage 0 (complete response) (n = 60), 56%; stage I (n = 32), 65%; stage IIA (n = 67), 41%; stage IIB (n = 30), 46%; and stage III (n = 49), 17%. Mean follow-up was 24 months (SEM 1.6, 0 to 138 months). Five patients with tumor in situ, 6 patients with stage IV disease, and 1 patient who could not be staged (12 pts) were excluded from survival and multivariate calculations. In univariate and different models of multivariate analysis, age more than 65 years, posttreatment T3, and nodal involvement were predictive of poor survival. For univariate analysis, p = 0.002, p = 0.004, p = 0.02, respectively; for multivariate analysis, p = 0.001, p = 0.003, p = 0.02, respectively.

CONCLUSIONS

Total thoracic esophagectomy with node dissection for esophageal cancer appears to have acceptable morbidity and mortality with encouraging survival results in the setting of neoadjuvant therapy. Patients who show complete response after induction chemoradiotherapy appear to have improved long-term survival.

Accuracy of EUS in the evaluation of Barrett's esophagus and high-grade dysplasia or intramucosal carcinoma

BACKGROUND

Nonoperative therapy with intent to cure may be considered for patients with Barrett's esophagus and high-grade dysplasia or intramucosal carcinoma. However, a more advanced stage of disease must be precluded before such treatment. The potential of EUS for this purpose was evaluated.

METHODS

EUS was performed in patients with Barrett's esophagus and high-grade dysplasia or intramucosal carcinoma based on endoscopy, endoscopic biopsies, and CT before esophagectomy. EUS findings were compared with surgical/pathologic evaluation.

RESULTS

EUS suggested submucosal invasion in 6 patients and lymph node involvement in 5 patients. By surgical/pathologic evaluation, 5 of 22 patients (23%) had unsuspected submucosal invasion and 1 had lymph node involvement. EUS detected all 5 instances of submucosal invasion and the single instance of lymph node involvement. EUS was falsely positive for submucosal invasion in 1 patient and for lymph node involvement in 4 patients. Sensitivity, specificity, and negative predictive values of preoperative EUS for submucosal invasion were 100%, 94%, and 100%, and for lymph node involvement were 100%, 81%, and 100%, respectively. A nodule or stricture noted by endoscopy was associated with an increased likelihood of submucosal invasion.

CONCLUSIONS

In patients with Barrett's esophagus and high-grade dysplasia or intramucosal carcinoma, EUS detected otherwise unsuspected submucosal invasion and lymph node involvement. Patients should be evaluated with EUS when nonoperative therapy is contemplated.

Combined endoscopic mucosal resection and photodynamic therapy for esophageal neoplasia within Barrett's esophagus

BACKGROUND

Endoscopic mucosal resection (EMR) and photodynamic therapy have been proposed as treatments for early stage cancers. EMR is limited by its focal nature whereas photodynamic therapy is dependent on precise staging. The combination of EMR and photodynamic therapy were studied in the treatment of superficial cancer in patients with Barrett's esophagus.

METHODS

Seventeen consecutive nonsurgical patients with superficial cancers underwent EMR followed by photodynamic therapy with a porphyrin photosensitizer. Photoradiation was performed at 630 nm for a total dose of 200 J/cm of diffuser.

RESULTS

Seventeen patients (15 men; mean age 69 +/- 13 years) underwent EMR. The mean diameter of mucosal resection was 1 cm. The margins were involved by cancer in 3 cases. EMR improved staging in 8 patients (47%). Sixteen (94%) patients remained in remission (median follow-up 13 months). Complications included minor bleeding after EMR in 1 patient (6%), stricture in 5 (30%), cutaneous phototoxicity in 2 (12%), and supraventricular tachycardia in 1 patient (6%).

CONCLUSIONS

Combined EMR and photodynamic therapy appears to be an effective and safe therapy for superficial esophageal cancer within Barrett's esophagus. This combination improves cancer staging, removes the superficial cancer, and eliminates remaining mucosa at risk for cancer development.

A majority of patients with Barrett's oesophagus are unlikely to benefit from endoscopic cancer surveillance

BACKGROUND

Endoscopic cancer surveillance has been advocated for patients with Barrett's oesophagus. However, only a small minority of patients dies from adenocarcinoma in Barrett's oesophagus. It has been calculated that endoscopic cancer surveillance will only add to the quality of life of individuals in whom the incidence of adenocarcinoma in Barrett's oesophagus is greater than 1/200 patient-years.

OBJECTIVE

To determine the proportion of a consecutive cohort of patients, in whom Barrett's oesophagus was diagnosed over a 5-year period, likely to benefit from endoscopic cancer surveillance.

METHODS

All patients who had died during the observation period or were over 75 years old and those with diseases likely to impair survival were excluded. Next, all patients in whom the risk of developing adenocarcinoma in Barrett's oesophagus fell below 1/200 patient-years were excluded (including all women, all men under the age of 60 and all men with Barrett's oesophagus of < 3 cm in length). Patients with dysplasia of any degree and/or presence of an ulcer or stricture in Barrett's oesophagus were reinstated.

RESULTS

Of 335 adult patients diagnosed with Barrett's oesophagus but without adenocarcinoma or high-grade dysplasia, 75 had died from unrelated causes, 47 had other diseases limiting survival and 59 were over 75 years old. After exclusion of all women, all men with Barrett's oesophagus of < 3 cm in length and all men under 60 years old, 15 patients were left. However, 32 were reinstated because of risk factors and another five because of insufficient data, resulting in 52 of the original 335 patients (15.5%) being eligible for endoscopic cancer surveillance.

CONCLUSION

This study suggests that less than 20% of patients identified with Barrett's oesophagus at routine endoscopy would benefit from endoscopic cancer surveillance. Prospective surveillance programmes should be limited to patients with an increased cancer risk and a good health profile.

[Surgical treatment of Barrett carcinoma]

Barrett-carcinoma is a type of adenocarcinoma of the distal esophagus and the cardia. Barrett-esophagus is defined by the histologic presence of specialized epithelium with intestinal metaplasia. As a consequence Barrett-carcinoma has a close relationship to the adenocarcinoma of the cardia and is very often part of the cardiacarcinoma type I. The aim of the surgical therapy is a radical R0-resection of the tumor including the lymphatic drainage area. This aim is accomplished among different authors by different surgical concepts. One is the radical transhiatal subtotal esophagectomy with lymphadenectomy in the lower mediastinum and the upper abdominal compartments. The other concept is a transthoracic en-bloc esophagectomy. Both resection procedures are usually completed by gastric pull up reconstruction. Currently a sophisticated preoperative staging is followed by distinguished indication and therapy depending on tumor status, risk factors of the patient and on the international classification of the cardia carcinoma (Siewert). When a R0-resection is impossible, a neoadjuvant radiochemotherapy should be performed.

Adenocarcinoma of the esophagus with and without Barrett mucosa

HYPOTHESIS

Previous studies have demonstrated an improved prognosis in patients with Barrett adenocarcinoma as compared with esophageal adenocarcinoma without Barrett. It has been suggested that an earlier presentation due to gastroesophageal reflux disease (GERD) may lead to detection of adenocarcinoma at an earlier stage.

DESIGN

The records of 178 patients with esophageal adenocarcinoma presenting to Roswell Park Cancer Institute (Buffalo, NY) between 1991 and 1996 were reviewed.

MAIN OUTCOME MEASURES

The clinical presentation, work-up, therapy, and outcome were compared between patients with Barrett esophagus (n = 66) and those without endoscopic or pathologic evidence of Barrett esophagus (n = 112).

RESULTS

There were several favorable prognostic signs in the Barrett group, including smaller tumors, lower grade, and earlier stage. More patients in the Barrett group had surgically resectable tumors, resulting in an improved overall survival. However, there were no differences in the type or duration of symptoms. Overall, very few patients presented because of GERD, and only slightly more in the Barrett group (14% vs 4%). While survival greatly improved in patients diagnosed with Barrett due to GERD, this did not account for the difference in prognosis.

CONCLUSIONS

Improved prognosis and survival for the Barrett group is not due to earlier presentation due to symptoms of GERD. It is more likely that all esophageal adenocarcinoma arises from Barrett esophagus, and that it is obscured by larger tumors. Reviews limited to resected patients greatly overestimate the number of adenocarcinoma cases diagnosed due to GERD. Increased efforts to identify high-risk patients and initiate screening are necessary to diagnose adenocarcinoma at an earlier stage.

Intestinal metaplasia is the probable common precursor of adenocarcinoma in barrett esophagus and adenocarcinoma of the gastric cardia

BACKGROUND

Intestinal metaplasia in the tubular esophagus is the recognized precancerous lesion of adenocarcinoma in Barrett esophagus. However, it is not yet clear whether adenocarcinoma of the gastric cardia arises from the same premalignant lesion, i.e., intestinal metaplasia of the gastric cardia. The purpose of this study was to compare adenocarcinomas in Barrett esophagus and adenocarcinomas of the gastric cardia at an early stage, when it was more likely that intestinal metaplasia had not been completely overgrown by the tumor.

METHODS

The authors compared the epidemiologic, clinical, and pathologic features of early stage adenocarcinoma in Barrett esophagus and adenocarcinoma of the gastric cardia from 42 patients who underwent resection surgery. The presence of intestinal metaplasia was assessed in the resected specimens by using Alcian blue (pH 2.5) staining.

RESULTS

Intestinal metaplasia was detected in the mucosa adjacent to neoplasia in 25 of 26 patients with adenocarcinoma in Barrett esophagus and in 11 of 16 (69%) patients with adenocarcinoma of the gastric cardia. Patient and tumor characteristics and survival were comparable in both groups.

CONCLUSIONS

Intestinal metaplasia is a very common finding in the mucosa adjacent to early stage adenocarcinoma of the gastric cardia. Adenocarcinoma in Barrett esophagus and adenocarcinoma of the gastric cardia may represent the same disease; the former arises from longer segments of intestinal metaplasia and the latter from intestinal metaplasia of the cardia.

Perforation of Barrett's ulcer: a challenge in esophageal surgery

BACKGROUND

Barrett's ulcer, which develops within Barrett's esophagus, is frequently responsible for bleeding. Perforation is a rare complication constituting a great challenge for diagnosis and management.

METHODS

Three personal cases and 31 published reports of perforated Barrett's ulcer were reviewed retrospectively. The site of perforation, clinical presentation, management, and outcome were assessed.

RESULTS

The clinical presentation proved to be heterogeneous and was determined by the site of perforation: this was the pleural cavity (20% of cases), mediastinum (20%), left atrium (16.6%), tracheobronchial tract (13.3%), aorta (13.3%), pericardium (10%), or pulmonary vein (6.6%). Early esophagectomy and esophageal diversion-exclusion were the most frequent procedures, and overall mortality was 45%.

CONCLUSIONS

The poor prognosis of perforated Barrett's ulcer should be improved by earlier diagnosis and adequate emergent operation. Although early esophagectomy constitutes the recommended procedure, esophageal diversion-exclusion, which allows control of both sepsis and bleeding, is also of interest.

Prognostic significance and effect of chemoradiotherapy on microvessel density (angiogenesis) in esophageal Barrett's esophagus-associated adenocarcinoma and squamous cell carcinoma

Previous studies have shown that intratumoral microvessel density (IMD) correlates with clinical outcome in a variety of human neoplasms, such as those that arise in the breast, colon, and stomach, suggesting that angiogenesis is important in cancer progression. The aims of this study were to evaluate the prognostic utility of IMD in esophageal Barrett's-associated adenocarcinoma (AdCa) and squamous cell carcinoma (SCC), and to determine the effect of preoperative chemoradiotherapy (chemrad) on this process. Tissue sections of tumor from 67 patients with esophageal carcinoma (45 with Barrett's-associated AdCa, 22 with SCC) were stained with the vascular marker CD31. The IMD was calculated by evaluating at least 5 different 200 x fields of tumor hot spot areas to obtain the mean microvessel count (MVC). The data then were correlated with the clinical and pathological features, chemrad status, and patient survival. The MVC was significantly higher in AdCa (143 +/- 63.2) compared with SCC (77.2 +/- 38.6, P = 0.0001). In AdCa, no correlation was noted between the MVC and any of the clinical or pathological features, including chemrad status. In contrast, in SCC, a statistically significant higher MVC was detected in patients who did not receive chemrad (97.2 +/- 37.3) compared with those who did (48.3 +/- 15.9, P = .002) and in tumors that were larger in size (P = .02). However, the MVC did not correlate with survival in either AdCa or SCC (P > .05). The degree of angiogenesis is not a significant prognostic indicator in either esophageal AdCa or SCC. Preoperative chemrad has a positive effect on reducing the degree of angiogenesis in esophageal carcinoma, particularly SCC.

Beta 1 integrin expression in adenocarcinoma of Barrett's esophagus

BACKGROUND/AIMS

In vitro and in vivo studies did not show that beta 1 integrin expression is associated with malignant transformation or that it is of prognostic value in some malignant tumors. There are no data on the expression or prognostic value of beta 1 integrins in adenocarcinoma of Barrett's esophagus.

METHODOLOGY

We assessed the expression pattern and the prognostic impact of beta 1 integrins in paraffin-embedded specimens of 41 patients with adenocarcinoma of Barrett's esophagus by immunochemistry. At the time of investigation, neither histomorphological parameters nor the survival time were known.

RESULTS

There was no correlation between histomorphological parameters and the expression of beta 1 integrins. The expression of beta 1 integrins had no influence on long- term survival. There was a relationship between the prognosis and the following histopathological parameters: pT, pN and pM category, the UICC stage, the presence of lymphangiosis, and the DNA content of the tumor cells.

CONCLUSIONS

The preliminary results obtained in this study did not show that the expression of beta 1 integrins was of prognostic value in patients with adenocarcinoma of Barrett's esophagus. Further studies in a larger number of patients are required to confirm the results obtained in this investigation.

[Surgical treatment of adenocarcinoma in Barrett's esophagus and prognosis]

There is no consensus regarding the surgical approach to adenocarcinoma in Barrett's esophagus. From 1980 to 1988, 8 patients with adenocarcinoma in Barrett's esophagus were treated at the National Cancer Center Hospital. Seven patients underwent subtotal esophagectomy with extended lymph node dissection, and one transhiatal esophagogastrectomy with regional lymph node dissection. In 4 patients tumor invasion was limited within the submucosa and in 4 within the muscularis propria. Four of 8 patients had stage I disease. The 5-year survival rate for the 8 patients was 64.3%. Some reports have indicated that endoscopic survey for Barrett's esophagus is important for early diagnosis. We conclude that survival after esophagectomy for adenocarcinoma in Barrett's esophagus is dependent on the method of operation, and that patients with early lesions may expect significantly better survival after extended lymph node dissection.

[Barrett and stomach carcinoma: surgical guidelines]

The aim of surgical therapy of adenocarcinoma in Barrett's esophagus and gastric carcinoma is an R0 resection of the infiltrated organ including regional lymphadenectomy. In Barrett's carcinoma these requirements can be achieved by radical transhiatal subtotal esophagectomy and lymphadenectomy of the lower mediastinum and compartment I and II. In case of adenocarcinoma of the thoracic esophagus, a transthoracic en bloc esophagectomy is indicated because of the probability of mediastinal lymph node metastasis. In gastric cancer the criteria for the luminal extent of resection are localization, depths of infiltration, and histological type according to Laurén. In carcinoma of the antrum of intestinal type and stage T1, T2 (T3) and in distal T1-carcinoma of diffuse type a subtotal gastric resection is possible. All other carcinomas require total gastrectomy which, in case of infiltration of the cardia, should be extended to the distal esophagus. A local excision of gastric carcinoma in curative intention can only be performed in mucosal carcinoma (pT1a) of intestinal type. As several studies have shown an improvement of prognosis by D2-lymphadenectomy, especially in UICC-Stages II and IIIa, a D2 lymphadenectomy is suggested in order to achieve, aside from a better staging, a possible prognostic gain for special subgroups of patients with beginning lymph-node metastasis. Principle splenectomy in case of gastrectomy increases morbidity and is more disadvantageous concerning prognosis. Therefore, splenectomy only is suggested in case of proximal gastric carcinoma because of the special type of lymph-node metastasis.

[Barrett carcinoma as a tumor entity with special therapy consequences]

The development of columnar lined epithelium with intestinal metaplasia in the distal esophagus is a possible, but not a necessary, end stage of advanced gastroesophageal reflux disease. Currently, research is focused on the carcinogenesis of Barrett's carcinoma and the metaplasia-dysplasia carcinoma sequence, since it is a malignoma with the highest increasing incidence in Western industrial countries. Possible causes of the above-mentioned sequence are excessive acid, duodenogastric reflux, and genetic factors. A curative surgical approach is the radical R-0 resection. Some centers prefer the transmediastinal esophagectomy. Others prefer the transthoracic en bloc esophagectomy. Reconstruction can be done with the stomach and the colon. Patients with advanced disease probably benefit best from multimodal therapy with neoadjuvant radiochemotherapy.

[Adenocarcinoma in Barrett esophagus: its recurrence and long-term survival]

Adenocarcinoma arising in ectopic gastric mucosa has been reported more than 40 years ago. This report reviews our experience with Barrett's adenocarcinoma over 8 years. The definition remains subject to controversy. More than 50% of patients in our study had unfavorable course of disease. The hope for cure lies almost in early detection of tumors at which point a truly curative resection could be done. There is no difference in terms of survival comparing to the adenocarcinoma arising on normal esophagus.

[Treatment of esophageal adenocarcinoma]

Surgical treatment of adenocarcinoma of the esophagus is of topical interest because an increasing rate of incidence. The main purpose of this study was to determine the surgical management of adenocarcinoma in Barrett's esophagus, non Barrett's adenocarcinoma, early adenocarcinoma, high-grade dysplasia in Barrett's esophagus and to precise whether multi modality therapy after a survival advantage.

Expression of beta-catenin, alpha-catenin, and E-cadherin in Barrett's esophagus and esophageal adenocarcinomas

Loss of expression and function of the E-cadherin/catenin membrane complex can result in loss of cell adhesion and contribute to invasive or metastatic potential in carcinomas. The aim of this study was to examine the expression of alpha- and beta-catenin and E-cadherin in Barrett's esophagus with and without dysplasia and in esophageal adenocarcinomas and to identify any relationship with tumor growth pattern and clinical outcome. Immunoperoxidase staining for alpha- and beta-catenin and E-cadherin was performed on specimens of Barrett's esophagus with and without dysplasia and on 54 esophageal adenocarcinoma specimens. Membranous staining for all of the components was seen in normal gastric and esophageal mucosa. Abnormal expression of beta-catenin, alpha-catenin, and E-cadherin was significantly associated with higher degrees of dysplasia in Barrett's esophagus. Fourteen of 16 cases of high grade dysplasia and 7 of 7 cases of intramucosal carcinoma showed abnormal expression of beta-catenin, compared with 3 of 6 cases indefinite for dysplasia and 11 of 17 cases with low grade dysplasia (P = 0.022). Similar results were seen for expression of alpha-catenin (P < .01) and E-cadherin (P = .049). In esophageal adenocarcinomas, preserved expression of these proteins occurred more frequently in well-differentiated tumors; abnormal expression was more common in diffusely infiltrative poorly differentiated tumors that did not form glands. Focal nuclear staining for beta-catenin was present in two high-grade dysplasias, two intramucosal carcinomas, and five adenocarcinomas. No survival advantage was demonstrated for patients whose tumors retained expression of these cell adhesion components. In conclusion, abnormal expression of the E-cadherin/catenin membrane complex is common in esophageal adenocarcinoma and occurs early in the dysplasia/carcinoma sequence in Barrett's esophagus, indicating that disturbances in this cell adhesion complex might be important in tumorigenesis and tumor progression in this disorder.