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

Occurrence and Prognosis of Mixed Subtype Adenocarcinoma and Adeno-Squamous Carcinoma in Esophageal Cancer

Purpose: To gain a deeper understanding of the incidence and survival rates of rare esophageal mixed adenoacanthoma (EAM) and esophageal mixed adeno-squamous carcinoma (EASC) to promote a more comprehensive understanding of these two subtypes. Background: EAM and EASC are rare subtypes of esophageal cancer with limited literature available. Extensive research has been conducted on the clinical and pathological characteristics of gastric and colorectal mixed adenoacanthomas, but there is relatively little literature on esophageal mixed adenoacanthomas. Therefore, this study aims to investigate the incidence and survival rates of these two subtypes in depth. Methods: Patients diagnosed with EAM and EASC between 2000 and 2019 were selected from the SEER database for the study. Joinpoint software was used to calculate the incidence rates of esophageal AM and ASC patients, and differences in cancer overall survival (OS) and cancer-specific survival (CSS) based on Kaplan-Meier curves were compared. Multivariate Cox regression analysis was employed to identify independent prognostic factors for OS and CSS, and a prognostic model was established and validated for accuracy. Results: The study found that the incidence of EAM increased until 2014, followed by a decline, while the incidence of EASC decreased until 2017, followed by an increase. Both of these subtypes were more common in male patients and those over the age of 65. For EAM patients, preoperative chemoradiotherapy was associated with better survival rates, while for EASC patients, preoperative radiotherapy combined with adjuvant chemotherapy improved survival. Finally, we constructed nomograms for predicting the overall survival of EAM and EASC patients by incorporating identified risk factors, which demonstrated good sensitivity and specificity. Conclusion: EAM and EASC are rare subtypes of esophageal cancer, and an in-depth exploration of their incidence and survival rates provides valuable data and insights for understanding these rare esophageal cancer subtypes. This information can assist clinical decision-making for healthcare professionals.

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.

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.

Esophageal superficial adenosquamous carcinoma resected by endoscopic submucosal dissection: A rare case report

BACKGROUND

Adenosquamous carcinoma (ASC), which is comprised of squamous cell carcinoma (SCC) and adenocarcinoma elements, is a rare histological type of esophageal carcinoma. Few reports have focused on the endoscopic findings and the effectiveness of the endoscopic treatment of early ASC.

CASE SUMMARY

A 77-year-old man underwent esophagogastroduodenoscopy for heartburn. A flat lesion with an uneven and slightly elevated central portion was found in the distal esophagus. Magnifying endoscopy with narrow-band imaging showed a well-demarcated brownish area with dendritically branched abnormal vessels and highly irregular intrapapillary capillary loops. A histopathological diagnosis of SCC was obtained by endoscopic biopsy. Endoscopic ultrasonography revealed a hypoechoic mass confined to the mucosa layer. The lesion was suspected to be SCC with invasion into the muscularis mucosa. The lesion was resected en bloc by endoscopic submucosal dissection and histologically diagnosed as esophageal ASC limited within the muscularis mucosa, which was completely resected without lymphovascular or neural invasion. The SCC element was the pre-dominant element. The adenocarcinoma element formed ductal and nested structures distributed in a focal pattern. The patient underwent only endoscopic submucosal dissection and has been under annual endoscopic and radiographic surveillance for 3 years without recurrence.

CONCLUSION

For early ASC confined within the mucosal layer, complete endoscopic resection might also be a curative treatment.

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.

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.

Endoscopic Findings of Esophageal Adenosquamous Carcinoma Diagnosed by Endoscopic Mucosal Resection

Adenosquamous carcinoma (ASC) is a rare histological type of esophageal carcinoma. Esophagogastroduodenoscopy for the health checkup of a 71-year-old male revealed the presence of a slightly elevated lesion like a submucosal tumor at the lower part of the esophagus. The center of it was slightly depressed, and the depressed area was not stained by iodine. Magnifying endoscopy with narrow-band imaging revealed reticular pattern vessels in the depressed area, whereas no irregularity of the microvascular pattern of the surrounding area was evident. One of the biopsied specimens taken from the depressed area was diagnosed as squamous intraepithelial neoplasia, but a malignant tumor with submucosal invasion was suspected based on the findings of endoscopic ultrasonography. Endoscopic mucosal resection using a cap-fitted endoscope was performed, and the lesion was diagnosed as esophageal ASC histologically. Carcinomas that formed nested and ductal structures existed in the lamina propria and invaded to the submucosa. Almost all of them were covered by non-invasive intraepithelial neoplasia, whereas small erosion was seen in the central depressed area. The growing pattern of ASC was quite different from that of typical differentiated squamous cell carcinomas. When we do endoscopic examination for an esophageal lesion like submucosal tumor, we have to consider the possibility of an esophageal carcinoma that has a similar growing pattern. If reticular pattern vessels are seen with magnifying endoscopy, the existence of an invasive carcinoma is suspected, and additional endoscopic ultrasonography is recommended. Possible efforts to gain histological findings have to be made using bowling biopsy, endoscopic resection, and so on.

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.

Cullin7 promotes epithelial‑mesenchymal transition of esophageal carcinoma via the ERK‑SNAI2 signaling pathway

Cullin7 (CUL7) is a member of Cullin protein family and exhibits a tumor‑promoting role in several types of tumors, including breast, liver and ovarian. However, its roles in esophageal carcinoma (EC) have not yet been reported. In the present study, CUL7 expression in EC tissue was revealed to be significantly higher compared with nontumoral tissues, as detected by immunohistochemistry (IHC; P=0.000). χ2 analysis confirmed that CUL7 expression was positively associated with invasion depth (P=0.000), lymph node involvement (P=0.033) and advanced clinical stage (P=0.000). Survival analysis demonstrated that CUL7 was positively associated with poor overall survival (P=0.001) and poor disease‑free survival (P=0.0019). An association of CUL7 with endothelial‑mesenchymal transition (EMT) was examined, and IHC results indicated that high CUL7 expression was associated with increased zinc finger protein SNAI2 (SNAI2) expression (P=0.000) and decreased E‑cadherin (P=0.000). Western blot analysis demonstrated that short hairpin RNA silencing CUL7 in EC1 cells increased epithelial (E)‑cadherin protein expression level, and decreased expression of Vimentin and SNAI2; cell migration was also reduced. Western blot analysis demonstrated that over expression of CUL7 in EC9706 cells increased Vimentin and SNAI2 protein expression, but decreased E‑cadherin expression, and the number of migratory cells. Investigation into the potential molecular mechanisms demonstrated that over expressing CUL7 in EC9706 cells stimulated the phosphorylation of ERK. Inhibiting ERK through treatment with U0126 significantly abrogated CUL7‑induced alterations in Vimentin, SNAI2 and E‑cadherin expression levels. Results from the present study demonstrated that CUL7 expression was associated with EC progression and poor prognosis. CUL7 may promote EMT via the ERK‑SNAI2 pathway in EC. These data may improve our understanding of the role of CUL7 in tumors and provide supporting evidence for the development of novel therapeutic targets for EC.

Histopathological Assessment for Esophageal Adenocarcinoma

In the World Health Organization (WHO) classification, adenocarcinoma of esophagus comprises preinvasive type (dysplasia), adenocarcinoma, adenoid cystic carcinoma, adenosquamous carcinoma, and mucoepidermoid carcinoma. For adenocarcinoma, it is important to determine the grading of the cancer and histological variants such as signet ring adenocarcinoma. In the current day management of esophageal adenocarcinoma by neoadjuvant therapy, the histology of the cancer and the lymph nodal status may change after the therapy. Tumor regression grading systems could be used to assess the response to the neoadjuvant therapy in esophageal adenocarcinoma.

Esophageal adenosquamous carcinoma mimicking acantholytic squamous cell carcinoma

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