The dichotomy in carcinogenesis of the distal esophagus and esophagogastric junction: intestinal-type vs cardiac-type mucosa-associated adenocarcinoma

Abstract

Adenocarcinoma of the distal esophagus and esophagogastric junction continues to rise in incidence. An intestinal metaplasia (Barrett esophagus)-dysplasia-carcinoma sequence induced by gastroesophageal reflux disease is well established. However, a significant number of adenocarcinomas in the vicinity of the esophagogastric junction are seen in the background of gastric/cardiac-type mucosa without intestinal metaplasia. Thus, the aim of this study was to investigate the role of Barrett esophagus (intestinal-type mucosa) in the classification and prognosis of tumors of the distal esophagus and esophagogastric junction. Clinicopathological and molecular characteristics were examined in 157 consecutively resected adenocarcinomas of the distal esophagus and esophagogastric junction and were compared between tumors arising in association with intestinal-type and cardiac-type mucosa. Intestinal-type mucosa-associated adenocarcinomas were more likely to be associated with younger age (P ¼ 0.0057), reflux symptoms (Po0.0001), proximal location (P ¼ 0.0009), lower T stage (Po0.0001), fewer nodal metastases (P ¼ 0.0001), absence of lymphatic (Po0.0001), venous (P ¼ 0.0060) or perineural (Po0.0001) invasion. Histologically, intestinal-type mucosa-associated tumors were more likely to be low-grade glandular tumors (P ¼ 0.0095) of intestinal or mixed immunophenotype (P ¼ 0.015) and express nuclear b-catenin (P ¼ 0.0080), whereas tumors arising in a background of cardiac-type mucosa were more frequently associated with EGFR amplification (P ¼ 0.0051). Five-year overall survival rate was significantly higher in patients with intestinal-type mucosa-associated tumors (28 vs 9%, P ¼ 0.0015), although no survival benefit was seen after adjusting for potential confounders. Our findings support the theory that multiple distinct pathways of tumorigenesis exist in the vicinity of the esophagogastric junction, including one in which tumors arise from dysplastic intestinal metaplasia (intestinal pathway), and one potentially involving dysplasia of the cardiac-type mucosa (non-intestinal pathway). Additional studies are warranted to further clarify their pathogenesis and the molecular mechanisms involved.

SATB1 is an independent prognostic factor in radically resected upper gastrointestinal tract adenocarcinoma

“…Interestingly, SATB1 expression was significantly lower in primary tumors associated with IM than in primary tumors not associated with IM. This is in line with at least two different pathways of gastroesophageal carcinogenesis, one intestinal (arising from dysplasia in IM) and one non-intestinal (arising from cardia-type mucosa), the former being associated with better overall survival [32]. Our cohort showed a similar trend, which is in agreement with SATB1 expression as a negative prognostic factor.…”

Barrett's oesophagus diagnostic criteria: endoscopy and histology

“…Recognition of gastric foveolar and serrated dysplasia in BE may indicate the presence of distinct pathways of carcinogenesis in BE: an intestinal pathway that involves intestinal metaplasia versus a gastric pathway that involves foveolar dysplasia, but this theory has not been well-investigated [87][88]. In a recent study of 156 patients that underwent resection of BE associated adenocarcinoma, Agoston et al…”

Barrett’s Esophagus

“…94 Thus, some authorities have proposed that there are, at minimum, two distinct mechanisms of cancer development in BE, one with an intestinal precursor and one with a gastric epithelium precursor. 94–96 In a recent study of 156 patients that underwent resection of BE associated adenocarcinoma, Agoston et al found that 122 patients (78%) showed dysplasia in background mucosa and that, in general, the type of dysplasia (i.e. intestinal, foveolar or mixed) correlated with the type of adenocarcinoma that was present in the esophagus.…”