Esophageal adenocarcinoma

Esophageal adenocarcinoma, also adenocarcinoma of the esophagus, is a common malignant epithelial-derived tumour of the distal esophagus, that classically arises in the context of Barrett's esophagus.

Esophageal adenocarcinoma
Diagnosis in short
Esophageal adenocarcinoma. H&E stain.
LM	"invading" cell clusters or glands (gland cribriforming (more than rare) or desmoplasia or submucosa invasion); nuclear atypia of malignancy (variation of size, shape, staining), +/-mitoses
LM DDx	high-grade columnar dysplasia of the esophagus, squamous cell carcinoma of the esophagus,gastric adenocarcinoma
IHC	CK7 +ve, CK20 +ve, p63 -ve
Site	esophagus
Associated Dx	Barrett's esophagus, high-grade columnar dysplasia of the esophagus
Symptoms	dysphagia
Prevalence	uncommon
Prognosis	often poor - as typically high stage at diagnosis
Treatment	EMR (early), surgery - esophagectomy

General

• Often a prognosis poor - as diagnosed in a late stage.
• May be difficult to distinguish from adenocarcinoma of the stomach.
  • By convention (in the CAP checklist) gastroesophageal junction carcinomas are staged as esophageal carcinomas.

Symptoms:

• Dysphagia - difficulty swallowing.

Associations:

• Barrett's esophagus.
  • Gastroesophageal reflux disease.
• Hiatal hernia.
• Family history - prostate cancer.

Treatment

• Adenocarcinoma in situ (AIS) - may be treated with endoscopic mucosal resection & follow-up.
• Surgery - esophagectomy.

Esophagus versus stomach

The convention is it's esophageal if both of the following are true:

1. Epicenter of tumour is in the esophagus.
2. Barrett's mucosa is present.

Microscopic

Features:

• Adenocarcinoma:
  • "Invading" cell clusters or glands.
    • Cribriforming (more than rare) or desmoplasia or "deep" invasion (into submucosa).
  • Nuclear atypia of malignancy:
    • Size variation.
    • Shape variation.
    • Staining variation.
  • +/-Mitoses (common).

DDx:

• High-grade columnar dysplasia of the esophagus - see table in esophagus article
• Squamous cell carcinoma of the esophagus.
• Gastric adenocarcinoma.

Images

• 

  Esophageal adenocarcinoma - very low mag. (WC)

• 

  Esophageal adenocarcinoma - low mag. (WC)

• 

  Esophageal adenocarcinoma - intermed. mag. (WC)

• 

  Esophageal adenocarcinoma - high mag. (WC)

Grading

Graded like other adenocarcinoma:

• >95 % of tumour in glandular arrangement = well-differentiated.
• 95-50% of tumour in glandular arrangement= moderately-differentiated.
• <50% of tumour in glandular arrangment = poorly-differentiated.

Staging

Early esophageal adenocarcinoma has its own staging system:

• M1 = lamina propria.
• M2 = superficial muscularis mucosae.
• M3 = submucosa.
• M4 = muscularis propria.

IHC

• CK7 +ve.
• CK20 +ve.

To rule-out SCC:

• p63 -ve.
• HWMK -ve.

Others:

• p53 +ve.
• COX-2 +ve.
• p16 +ve - but not that useful as it's frequently positive in the precursors.

Staging

• The number of lymph nodes is important for staging, as a small number may lead to stage migration (Will Rogers phenomenon).
• There is no established standard for esophageal cancer (as per UICC/AJCC staging - based on Li et al.), several studies give different numbers (18 lymph nodes Greenstein et al., 23 lymph nodes Peyre et al.).

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GASTROESOPHAGEAL JUNCTION, RESECTION:
- INTRAMUCOSAL ADENOCARCINOMA, pT1a, pNx, SEE TUMOUR SUMMARY.
-- MUCOSAL MARGIN HAS CAUTERIZED DYSPLASTIC EPITHELIUM, SEE COMMENT.
-- DEEP MARGIN NEGATIVE FOR MALIGNANCY.

COMMENT:
The cauterized dysplastic epithelium cannot be further interpreted. 
Malignant-appearing glands are within 1 mm of the cauterized epithelium. 
Close follow-up and re-biopsy (or endoscopic re-resection if clinically 
indicated) is recommended.

This case was partially reviewed internally. There is agreement on the presence of
intramucosal adenocarcinoma and dysplastic epithelium at the mucosal margin.

See also

• Esophagus.
• Esophageal cancer.
• Adenocarcinoma.
• Siewert classification.