Narrow band imaging of adenocarcinoma arising from ectopic gastric mucosa in the upper esophagus

Cervical esophageal adenocarcinoma of intestinal type in ectopic gastric mucosa

A 45‐year‐old man underwent esophagogastroduodenoscopy because of symptoms of laryngopharyngeal discomfort. We found a protruded reddish lesion adjacent to the ectopic gastric mucosa (EGM) in the cervical esophagus, and a biopsy revealed that it was a tubular adenocarcinoma. We diagnosed the patient with intramucosal cancer and performed endoscopic submucosal dissection. Esophageal endoscopic submucosal dissection was performed under general anesthesia using a conventional procedure. The resected tumor measured 23 × 14 mm and was adjacent to the EGM. Histologically, the tumor cells showed moderately well‐differentiated adenocarcinoma confined to the muscularis mucosa with no lymphovascular infiltration. Immunohistochemically, the tumor cells were positive for intestinal markers, namely MUC2 and CD10, and negative for gastric markers, namely MUC5AC and MUC6. The patient had no post‐endoscopy submucosal dissection stenosis and remained disease‐free without local recurrence. EGM of the cervical esophagus develops from the columnar epithelium during embryonic development. There are few reports on endoscopic submucosal dissection for mucosal cancer. Of these, immunostaining was performed in three cases. All were positive for MUC5AC and MUC6 and negative for MUC2 and CD10. Usually, EGM shows gastric type epithelium, but occasional cases with intestinal metaplasia, which show positivity for MUC2 and CD10, have been reported. Therefore, we consider this to be an extremely rare case of esophageal adenocarcinoma arising from intestinal metaplasia within the EGM.

Lymph node metastasis after endoscopic submucosal dissection of a superficial esophageal adenocarcinoma arising from the ectopic gastric mucosa of the cervical esophagus: A case report

Esophageal adenocarcinoma derived from the ectopic gastric mucosa of the cervical esophagus is very rare. Little is known about the efficacy of endoscopic treatment of these superficial lesions. Herein, we report the first case of lymph node metastasis after endoscopic submucosal dissection of a lesion with invasion into the muscularis mucosa. A 46-year-old man underwent esophagogastroduodenoscopy during a health checkup. Endoscopy revealed a 10-mm-sized nodular and a 5-mm-sized depressed lesion within the ectopic gastric mucosa of the cervical esophagus. The biopsy specimen confirmed the presence of adenocarcinoma. The entire ectopic gastric mucosa was resected by endoscopic submucosal dissection, and pathological examination showed invasion of the muscularis mucosa. A follow-up computed tomography scan revealed lymph node metastasis 12 months post-treatment. The patient underwent surgical mediastinal lymphadenectomy. The patient has been regularly followed up with a computed tomography scan and endoscopy for 2 years post-surgery with no evidence of recurrence. Close follow-up or additional treatment after endoscopic submucosal dissection should be considered and discussed with the patient if invasion into the muscularis mucosa is observed on pathological examination.

Early Esophageal Adenocarcinoma with Non-Barrett's Columnar Epithelium Origin: Two Case Reports and a Literature Review

We herein report two cases of early esophageal adenocarcinoma derived from non-Barrett's columnar epithelium. Both patients, a 65-year-old woman and 60-year-old man, had elevated lesions on white-light imaging. Magnifying endoscopy revealed slightly irregular surface and vessel patterns, and both patients were successfully treated with endoscopic submucosal dissection. Histopathologically, both lesions comprised of well-differentiated gastric mucin phenotype adenocarcinoma. One lesion was accompanied by ectopic gastric mucosa, but the other was speculated to be ectopic gastric mucosa according to the tumor locus at the upper thoracic esophagus. Despite its rarity, endoscopists should consider the existence of adenocarcinoma derived from non-Barrett's columnar epithelium.

Cervical squamous cell carcinoma coexisting with ectopic gastric mucosa treated by endoscopic submucosal dissection: A case report

A 69-year-old Japanese man underwent an endoscopic submucosal dissection (ESD) for early gastric cancer 2 years prior to admission at Fukuchiyama City Hospital. A follow-up esophagogastroduodenoscopy (EGD) revealed a butterfly-shaped brownish area in the cervical esophagus. A successful endoscopic submucosal dissection of the esophageal lesion was performed for total biopsy. Histopathological analysis of the resected specimen revealed moderately differentiated squamous cell carcinoma of the esophagus, cervical esophagus tumor type 0-IIb, a tumor diameter of 14x8 mm, T1b pathological findings (invading into submucosa), infiltrative growth α, lymphatic invasion (-), venous invasion (-), a horizontal tumor free margin and a vertical tumor free margin. The results demonstrated that the squamous cell carcinoma had invaded into the submucosal layer under the ectopic gastric mucosa. After endoscopic treatment, chemoradiation therapy was administered to the patient.

Gastric inlet patches: symptomatic or silent?

PURPOSE OF REVIEW

The purpose of this review is to assess recent literature on the clinical relevance of the gastric inlet patch with particular focus on endoscopic diagnosis and treatment, the relationship of the inlet patch to laryngopharyngeal reflux disease and the association of proximal esophageal adenocarcinoma with inlet patch.

RECENT FINDINGS

Recent studies suggest endoscopic diagnosis of inlet patch increases with endoscopist awareness (up to 10-fold) and when using enhanced imaging techniques such as narrow band imaging (up to three-fold). The literature remains mixed on the association of inlet patch with laryngopharyngeal symptoms or globus sensation. Studies of endoscopic ablation, using argon plasma coagulation or radiofrequency ablation have shown improved laryngopharyngeal reflux symptom scores posttreatment. Proximal esophageal adenocarcinomas are rare but often associated with inlet patch when they occur. Case studies have described endoscopic resection of malignant lesions related to inlet patch, using endoscopic mucosal resection or submucosal dissection.

SUMMARY

Prospective, multicenter studies of symptom association with inlet patch using validated symptom questionnaires and blinded sham-controlled treatments are needed to further clarify the role of such treatments, which to date are limited to a small numbers of centers with a special interest.

A 14-Year Study of 398 Esophageal Adenocarcinomas Diagnosed Among 156,256 EGDs Performed at Two Large Hospitals: An Inlet Patch Is Proposed as a Significant Risk Factor for Proximal Esophageal Adenocarcinoma

BACKGROUND

An association between inlet patches and proximal esophageal adenocarcinomas is currently suspected because of numerous case reports of simultaneous occurrence of both diseases.

AIMS

To analyze whether inlet patches are significantly associated with proximal esophageal adenocarcinomas in a large population.

METHODS

Computerized search of pathology and EGD reports revealed 398 cases of esophageal adenocarcinomas among 156,236 EGDs (performed on 106,510 patients) diagnosed by histopathology performed at Royal Oak/Troy, William Beaumont Hospitals, 2003-2016. Adenocarcinomas localized as distal, middle, or proximal; and characterized as associated versus unassociated with inlet patches. Medical records were reviewed. Endoscopic photographs, radiologic images, and pathologic slides were re-reviewed. Two researchers independently performed systematic computerized literature searches; cases of simultaneous diseases identified by consensus.

RESULTS

Adenocarcinoma locations included: distal-381, middle-14, and proximal esophagus-3. Five patients had inlet patches with esophageal adenocarcinomas located at: distal-2, middle-0, and proximal esophagus-3 (relative frequency of inlet patches with cancers of distal/middle esophagus = 2/395 [.5%] vs. proximal esophagus = 3/3 [100%], p < .000001, 95% OR CI > 50.1, Fisher's exact test). Cases of proximal esophageal adenocarcinomas within inlet patches included: (1) Seventy-eight-year-old man presented with dysphagia. Neck CT showed proximal esophageal mass. EGD revealed semi-circumferential, multinodular, 3.0 × 1.5 cm mass within inlet patch. Histopathology of biopsies revealed moderately-to-poorly differentiated adenocarcinoma. Patient received chemoradiotherapy and expired 2 years later. (2) Seventy-nine-year-old man presented with anorexia and weight loss. EGD demonstrated proximal esophageal mass within inlet patch. Histopathology of biopsies revealed poorly differentiated, signet ring cell adenocarcinoma. Chest CT revealed 3.4 × 2.1-cm-proximal esophageal mass. Patient expired 4 months later. (3) Sixty-year-old man presented with dysphagia. EGD revealed 4-cm-long, semi-circumferential, proximal esophageal mass within inlet patch. Histopathology of biopsies revealed poorly differentiated adenocarcinoma. Patient underwent emergency esophagectomy for esophageal perforation 2 weeks after initiating chemoradiotherapy, and died shortly thereafter. Literature review revealed 39 cases of simultaneous disease.

STUDY LIMITATIONS

Potential underreporting by endoscopists of inlet patches at EGD.

CONCLUSIONS

Study supplements 39 previously reported cases of simultaneous disease, by adding three new cases, and by novel report of statistically significant association between these two entities, which has important implications in the pathophysiology of proximal esophageal adenocarcinoma.

Gastric adenocarinoma of the upper oesophagus: A literature review and case report

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Upper oesophageal adenocarcinomas are rare, and can occur in the setting of ectopic gastric mucosa (EGM).

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Adenocarcinomas arising within EGM have been treated successfully via a wide range of approaches (including endomucosal resection and open surgical resection) depending upon their clinical staging.

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The patient in our case report was successfully treated with no detectable disease recurrence at 18months follow up with neoadjuvant chemotherapy and surgical resection.

Background

Ectopic gastric mucosa (EGM) otherwise termed gastric heterotopia or gastric inlet patch occurs in approximately 2.5% of the population. Adenocarcinoma uncommonly involves the upper oesophagus, rarely arising from gastric heterotopia or submucosal glands. Currently, there are 58 cases in the literature of oesophageal adenocarcinoma arising within areas of EGM. To date no paper has differentiated between gastric or intestinal type adenocarcinoma. This case, which describes adenocarcinoma arising within EGM, exhibited a different immunophenotype reminiscent of gastric type glands, in the absence of intestinal metaplasia. This case should be regarded as a different type of carcinoma, consistent with a non-Barrett’s oesophagus-associated adenocarcinoma.

Clinical presentation

A 63 year old female presented with a three month history of progressive cervical dysphagia with no associated weight loss or general malaise. Gastroscopy revealed a suspicious lesion at the cricopharyngeus. Positron emission tomography demonstrated a metabolically active primary lesion without evidence of distant disease. The patient received neo-adjuvant chemotherapy followed by a three stage total oesophagectomy. Histology demonstrated a moderately differentiated adenocarcinoma with gastric immunophenotype and background changes of gastric heterotopia.

Conclusion

EGM is common but scarcely biopsied for evidence of dysplasia or adenocarcinoma. Whilst malignant progression is rare it is important that endoscopists are aware of the potential. Determining the exact type of adenocarcinoma may have implications for therapeutic approaches.

Recognition of EGM at endoscopy may identify patients at greater risk of developing adenocarcinomas of the proximal oesophagus, however, this relationship and the necessity for screening requires more study.

Adenocarcinoma of the cervical esophagus arising from ectopic gastric mucosa: report of two cases and review of the literature

Esophageal adenocarcinoma arising from ectopic gastric mucosa (EGM) is extremely rare. We describe here two Japanese patients with adenocarcinoma of the cervical esophagus arising from EGM. Case 1 is a 62-year-old man who had slightly red EGM in the cervical esophagus on upper gastrointestinal endoscopy (UGE). Because the biopsy showed atypical glands that were suspicious for adenocarcinoma, endoscopic submucosal dissection was performed. Histopathological examination revealed that the lesion was a well-differentiated adenocarcinoma (pT1a MM). Lymphovascular invasion was absent, and the margins were free from carcinoma. Case 2 is a 57-year-old man who had an elevated lesion with a bleeding tendency in an area of EGM in the cervical esophagus on UGE. Adenocarcinoma was diagnosed in the biopsy. Because of the presence of enlarged lymph nodes (#106recL), preoperative chemoradiotherapy was performed to reduce the size of the adenocarcinoma and lymph nodes prior to resection of the cervical esophagus and reconstruction with free jejunal grafts. Histopathological examination revealed moderately differentiated adenocarcinoma (0-I, pT2N1M0, pStage II). In both cases, adenocarcinoma was surrounded by EGM, which led to the diagnosis of EGM-derived esophageal adenocarcinoma. Here, we report its immunohistochemical characteristics in the present cases and discuss the histogenesis.

Esophageal adenocarcinoma arising in cervical inlet patch with synchronous Barrett's esophagus-related dysplasia

Esophageal adenocarcinomas usually develop in Barrett's esophagus, typically through the metaplasia-dysplasia-carcinoma sequence, but adenocarcinomas can occur from heterotopic gastric mucosa in cervical esophagus (inlet patch). This report describes the first case of synchronous presentation of adenocarcinoma arising from cervical inlet patch and Barrett's esophagus-related dysplasia in a 76-year-old man. Surveillance CT detected a 3-cm polypoid mass in the cervical esophagus. Endoscopic biopsies confirmed a diagnosis of adenocarcinoma of the cervical esophagus. Barrett's esophagus was present also in the lower esophagus. Histologic examination of the surgically resected specimen revealed the polypoid mass as composed of tubular adenocarcinoma, and was associated with non-neoplastic columnar mucosa representing pre-existing inlet patch. Another isolated cervical inlet patch with intestinal metaplasia was also recognized. In the lower esophagus, high-grade dysplasia was noted within the Barrett's esophagus. Immunohistochemically, the adenocarcinoma associated with inlet patch had intestinal immunophenotype (CDX2-, CD10- and MUC2-positive), whereas the Barrett's esophagus-related high-grade dysplasia showed mixed immunophenotype (MUC5AC- and MUC6-positive, with scattered MUC2-positive goblet cells). Previous studies and our findings suggest that intestinal metaplasia might predispose to the development of adenocarcinoma in the inlet patch. Therefore, endoscopists and pathologists should be aware of rare malignant transformation of inlet patches, especially those with intestinal metaplasia.

Mixed adeno(neuro)endocrine carcinoma arising from the ectopic gastric mucosa of the upper thoracic esophagus

We report a case of mixed adenoendocrine carcinoma of the upper thoracic esophagus arising from ectopic gastric mucosa. A 64-year-old man who had been diagnosed with an esophageal tumor on the basis of esophagoscopy was referred to our hospital. Upper gastrointestinal endoscopy revealed the presence of ectopic gastric mucosa and an adjacent pedunculated lesion located on the posterior wall of the upper thoracic esophagus. Subtotal esophagectomy with three-field lymph node dissection was performed. A microscopic examination revealed that there was a partially intermingling component of neuroendocrine carcinoma adjacent to a tubular adenocarcinoma which was conterminous with the area of the ectopic gastric mucosa. Although the tubular adenocarcinoma was confined to the mucosa and submucosa, the neuroendocrine carcinoma had invaded the submucosaand there was vascular permeation. Each component accounted for 30% or more of the tumor, so the final histopathological diagnosis was mixed adenoendocrine carcinoma of the upper thoracic esophagus arising from ectopic gastric mucosa. Adjuvant chemotherapy was not performed, because the postoperative tumor stage was IA. The patient was well and had no evidence of recurrence 16 months after surgery.