Malignant transformation of esophageal columnar epithelium

Abstract

This report describes two patients with esophageal columnar epithelium (Barrett's esophagus) in which microinvasive adenocarcinoma developed. Case 1 had multiple foci of carcinoma rn u!u contiguous with epithelium resembling gastric and intestinal mucosa. Case 2 had signet-ring type adenocarcinoma. Surveillance for malignant transformation in columnar esophageal epithelium should be routinely performed, and because of its focal nature, multiple biopsies and cytologic examination should be carried out. T h e presence of carcinoma 01 i r / t r should lead to consideration of excision of the affected esophagus.Cancer 41 CASE REPORTS Case 1A 47-year-old white male executive had a 20-year history of intermittent epigastric pain exacerbated by spicy foods ilnd recumbency and relieved by antacids. In Ilecembw 1973, his epigastric pain increased in intensity and duration, radiated to the back and awakened him from s1ec.p. L!pper gastrointestinal radiography revealed a sliding hiatal hernia with esophaqeal reflux and tertiary contractions. Antacid treatment was intensified and the head of his bed elevated, but minimal relief was obtained. In April 1975. fiberoptic endoscopy revealed a deep stellate 1.2 cm ulcer associated with edema and stiffening in the distal esophagus. Multiple biopsies revealed benign squamous epithelium. Since "Barrett's esophagus" was suspected, endosco:)y was repeated and biopsies were obtained at the ulcer site and proximally to the level of the aortic arch. Biopsies from the ulcer were processed for routine light-microscopic examination; the proximal biopsies were immediately placed in gluteraldehyde, pH 7.4, and processed for ultrastructural study as previously de~cribed.~Carcinoma ~n si!u was demonstrated at the ulcer site. Following refcrral to the Department of Surgery at the Llniversity of Chicago, esophageal manometry and pH measurements showcd a low distal esophageal sphincter pressure and free reflux in erect and supine positions. An esophageal acid-saline perfusion test was positive. A radical posterior medi;istinectomy was performed with resection of the distal 11.5 cm of the esophagus and the proximal half of the stomach. An isoperistaltic left colon segment was interposed between the normal esophagus and stomach, and a pyloroplasty was performed to facilitate gastric emptying.The proximal resected margin of the esophagus was lined by hyperplastic epithelium and contained foci of reflux esophagitis as described by Ismail-Beigi

Histological and histochemical changes in the columnar lined (Barrett's) oesophagus.

“…From our results it would appear that the presence of sulphomucins in oesophageal biopsies of columnar mucosa is not sufficiently discriminating to allow detection of a subgroup of patients at particular risk of malignant transformation. The neoplastic potential of the columnar lined oesophagus is well recognised,9 11 34 3 however, and the frequent finding of sulphomucins within this metaplastic epithelium supports the suggestion that production of these mucins may represent a marker of incompletely differentiated metaplastic epithelia in the upper gastrointestinal tract which have a propensity for malignant transformation. '8 22 29 It has been suggested that sulphomucin secretion within the stomach may not so much be the product of early malignant change but rather represents an important cytoprotective mechanism to a carcinogenic microenvironment,36 and it is possible that its presence in the columnar lined oesophagus has the same significance.…”

“…Observations that adenocarcinoma appears to develop directly from dysplastic mucosa provides evidence in support of the neoplastic nature of this epithelium" 34 and, in view of the lack of discrimination afforded by the detection of sulphomucins, dysplasia would appear to be the most valuable and specific indicator of potential malignant transformation.…”

The relevance and implications of signet-ring cell adenocarcinoma of the oesophagus

“…SRCs have been noted in oesophageal cancer biopsies with the first case study found in our literature search published in 1978 7. Less is known about the genetic and molecular mechanisms involved in SRC pathology in oesophageal compared with gastric adenocarcinomas.…”

Pathogenesis, Diagnosis, and Management of Reflux Esophagitis

“…Experimental studies in dogs show that if the mucosal ulcerations are continuously bathed by the refluxed contents, they tend to heal, partially or completely, with a metaplastic mixed epi thelium (Barrett's epithelium) (48), which is characterized by a combina tion of gastric, fundic, pyloric, or intestinal glands (49). There is increasing evidence that this metaplastic epithelium is premalignant predisposing to development of adenocarcinoma (50,51). In contrast, when the GER is controlled or prevented, the ulcerations tend to heal with a normal squa mous epithelium.…”