Varicoid Adenocarcinoma of the Esophagus: Case Report

Varicoid swellings resemble a varix, or an enlarged and convoluted vessel. Varicoid or superficial spreading carcinoma of the esophagus is a rare condition demonstrating an appearance similar to esophageal varices and as such can be misdiagnosed. In the majority of cases they tend to be squamous cell carcinomas. We present only the second reported case of a patient with varicoid adenocarcinoma of the esophagus. In the absence of chronic liver disease, we advocate that variceal lesions within the esophagus should be regarded with a high index of suspicion for possible varicoid esophageal cancer.     

Esophageal carcinoma in a patient with bleeding esophageal varices

More than 20 cases of esophageal carcinoma have been reported to develop after endoscopic injection sclerotherapy (EIS), and this technique is implicated in the pathogenesis of esophageal cancer. We report a case of esophageal carcinoma presenting as a superficial ulcer in a patient with esophageal varices with no prior EIS. Whether the development of esophageal carcinoma in patients with previous EIS is coincidental or consequential is controversial. Such carcinoma might have already existed before EIS in some reported cases. A causal relationship between EIS and esophageal carcinoma cannot be established without further clarification by a well-designed study.     

Endoscopic mucosal resection for early esophageal cancer with esophageal varices

Squamous cell carcinomas account for more than 80 % of esophageal malignancies in Germany. Alcohol and tobacco smoke are two of the most important risk factors. In superficial esophageal squamous cell carcinoma, endoscopic mucosal resection (EMR) is a very useful and effective treatment modality. However, in patients with submucosal esophageal cancer, radical esophageal resection is regarded as the gold standard for treatment at present. We report the case of a 71-year-old female patient with alcohol-induced liver cirrhosis with esophageal varices and a - therefore inoperable - early esophageal squamous cell carcinoma. Photodynamic therapy (PDT) using 5-aminolevulinic acid (5-ALA) seemed not to be an effective treatment modality due to its limited penetration depth (< 2 mm) and the liver toxicity of 5-ALA. PDT using Photofrin(R) with a higher penetration depth seemed to be associated with a high risk of bleeding due to the esophageal varices. Furthermore, this sensitizer is associated with a high rate of strictures and a long-lasting skin sensitivity. In contrast, arguments against an endoscopic mucosal resection (EMR) were endosonographically suspected submucosal tumor growth and a high risk of bleeding. Nevertheless, with respect to the lack alternatives we decided to perform an EMR after ligation of esophageal varices. The tumor could be resected in sano without major bleeding complication. Histology demonstrated a carcinoma in situ without submucosal invasion. After 3 months a second EMR was necessary due to recurrence. Meanwhile after a follow-up period of 18 months only low grade intraepithelial neoplasia without macroscopically suspicious lesions was observed.     

Successful endoscopic therapy of superficial esophageal cancer on varices in a patient with alcoholic liver cirrhosis

A case of successful endoscopic therapy of superficial esophageal cancer on varices in a patient with alcoholic liver cirrhosis is reported. A slightly depressed superficial cancer (type 0‐IIc) occupied half the inner surface of the middle esophagus. Endoscopic ultrasonography revealed esophageal varices and periesophageal collaterals, but no perforating veins connecting the varices and collaterals were observed where the cancer was located. The esophageal cancer could not be detected even with a 20 MHz microprobe. The tortuous esophageal varices in the lower esophagus were endoscopically ligated to reduce blood flow just below the cancer and 10 mL polidocanol solution was endoscopically injected to induce sclerosis of the varices. After these procedures, the mucosal cancer was endoscopically resected without any severe complications and residual cancer was eliminated by cauterization using a heater probe. Histopathological examination revealed that poorly differentiated squamous cell carcinoma invaded into the lamina propria mucosae but not into the vessels or the lymphatic system. Three years after treatment, the patient showed no signs of local recurrence of cancer. It is considered that the endoscopic techniques used in this patient constitute a valuable and minimally invasive treatment for superficial esophageal cancer on varices.     

Cyclin D1 Expression Is Useful as a Prognostic Indicator for Advanced Esophageal Carcinomas, but Not for Superficial Tumors

The purpose of the present study was to define the overexpression of cyclin D1 in superficial and advanced esophageal carcinomas and to investigate whether the expression of this molecule indicates a poor prognosis. This study included 41 patients with superficial esophageal carcinomas (Tis and T1) and 48 patients with advanced esophageal carcinomas (T2, T3, and T4). The expression of cyclin D1 in surgically resected specimens was evaluated immunohistochemically with a monoclonal antibody. Positive immunoreactivity was found in 31 of 89 cases (35%). Overexpression of cyclin D1 did not correlate with TNM classification or histologic type. Of the 48 patients with advanced esophageal carcinomas, 32 patients with cyclin D1-negative tumors survived longer than did 16 patients with cyclin D1-positive tumors (P = 0.0017). In contrast, we observed no survival difference between patients with cyclin D1-positive and -negative superficial esophageal carcinoma. These results suggest that cyclin D1 indicates a poor prognosis in cases of advanced esophageal carcinoma but not in cases of superficial esophageal carcinoma.     

Prediction of the invasion depth of superficial squamous cell carcinoma based on microvessel morphology: magnifying endoscopic classification of the Japan Esophageal Society

Predicting invasion depth of superficial esophageal squamous cell carcinoma is crucial in determining the precise indication for endoscopic resection because the rate of lymph node metastasis increases in proportion to the invasion depth of the carcinoma. Previous studies have shown a close relationship between microvascular patterns observed by Narrow Band Imaging magnifying endoscopy and invasion depth of the superficial carcinoma. Thus, the Japan Esophageal Society (JES) developed a simplified magnifying endoscopic classification for estimating invasion depth of superficial esophageal squamous cell carcinomas. We conducted a prospective study to evaluate the diagnostic values of type B vessels in the pretreatment estimation of invasion depth of superficial esophageal squamous cell carcinomas utilizing JES classification, the criteria of which are based on the degree of irregularity in the microvascular morphology. Type A microvessels corresponded to noncancerous lesions and lack severe irregularity; type B, to cancerous lesions, and exhibit severe irregularity. Type B vessels were subclassified into B1, B2, and B3, diagnostic criteria for T1a-EP or T1a-LPM, T1a-MM or T1b-SM1, and T1b-SM2 tumors, respectively. We enrolled 211 patients with superficial esophageal squamous cell carcinoma. The overall accuracy of type B microvessels in estimating tumor invasion depth was 90.5 %. We propose that the newly developed JES magnifying endoscopic classification is useful in estimating the invasion depth of superficial esophageal squamous cell carcinoma.     

Downhill esophageal varices due to superior vena cava syndrome

This study examined the incidence of downhill esophageal varices due to SVC syndrome. The presence of downhill esophageal varices was examined by esophagoscopy or autopsy. Downhill esophageal varices were detected in two of nine (22%) patients with SVC syndrome. One case was a 66-year-old male case who and underwent upper lobectomy for lung cancer in September 1985. He developed SVC syndrome due to recurrence in 1986 and died in 1987. Downhill esophageal varices wer in the upper esophagus by esophagoscopy and confirmed by autopsy. The another case was a 61-year-old female who developed carcinoma of the tongue in 1986 and lymph node metastasis to the mediastinum in 1987. Autopsy revealed downhill esophageal varices in the upper and middle esophagus. Eleven cases of downhill esophageal varices due to SVC syndrome reported in Japan were reviewed and discussed.     

Endoscopic injection sclerotherapy for esophageal varices prolonged survival of patients with hepatocellular carcinoma complicating liver cirrhosis

BACKGROUND: A prospective controlled study was performed between 1982 and 1991 to evaluate the efficacy of endoscopic injection sclerotherapy (EIS) in patients with esophageal varices complicated by hepatocellular carcinoma and liver cirrhosis. METHODS: The study included 83 patients with esophageal varices, hepatocellular carcinoma, and liver cirrhosis. Forty-three patients (group 1) underwent prophylactic EIS or emergent EIS for bleeding varices. EIS was performed weekly 4 to 6 times until the varices disappeared. The remaining 40 patients (group 2) underwent conservative therapy and did not undergo EIS. Survival rates were compared between the 2 groups. RESULTS: During the 5-year observational period, all patients who did not undergo EIS died. Sixteen in group 2 (40.0%) died of gastrointestinal bleeding including ruptured esophageal varices. In contrast, patients treated with EIS survived significantly longer (p<0.001). Nine patients (20.9%) treated with EIS experienced gastrointestinal bleeding as a result of which 5 (11.6%) died. EIS prolonged survival in patients classified as Child's A or B but did not affect survival in patients with Child's C hepatic function. EIS was effective in prolonging survival in patients with hepatocellular carcinomas smaller than 5 cm. However, EIS had no effect in patients with hepatocellular carcinomas that were larger than 5 cm. EIS prolonged survival only for patients with nodular hepatocellular carcinoma and had no effect in patients with massive and diffuse hepatocellular carcinoma. Further, EIS prolonged survival only for patients who did not have portal vein thrombosis. CONCLUSION: Based on this prospective study, we concluded that EIS was effective in prolonging the survival period of a select subset of patients with hepatocellular carcinoma.     

Considerable multiple esophageal carcinoma. Implications of a new clinical entity

BACKGROUND/AIMS: The multiple occurrence of primary squamous cell carcinoma of the esophagus is often observed, and most such occurrences are double cancers. There have also been some cases with three or more intra-esophageal cancers, however, no detailed clinicopathologic study has yet been performed in the literature. METHODOLOGY: Two hundred and fifty patients of primary esophageal squamous cell carcinoma without preoperative treatment that underwent esophageal resection were re-evaluated by serial histopathologic investigations and we analyzed the data of ten patients with three or more intraesophageal cancers. RESULTS: The clinical and histopathologic characteristics were as follows; 1) all but one of the cases were male, 2) all patients had a history of both heavy smoking and drinking but only one case had a family history of esophageal cancers among their siblings, 3) the depth of invasion in the carcinomas was restricted to within the submucosal layer of the esophageal wall, which was defined as superficial esophageal carcinoma, almost all (90%) of the cases accompanied esophageal squamous epithelial dysplasia. CONCLUSIONS: Based on these prominent characteristics of considerable multiple intra-esophageal cancers, a new clinical entity of "esophageal field cancers" could thus be suggested.     

Squamous Cell Carcinoma after Endoscopic Injection Sclerotherapy for Esophageal Varices

We report two cases of squamous cell carcinoma of the esophagus following endoscopic injection sclerotherapy for esophageal varices. The interval between sclerotherapy and the development of carcinoma was 24 months in case 1 and 21 months in case 2. The sclerosant was 5% sodium morrhuate in case 1 (total dose, 10 ml) and 5% ethanolamine oleate in case 2 (45.5 ml). Although no recurrent variceal bleeding occurred after sclerotherapy, we could not perform any curative surgical treatment for esophageal cancer because of the advanced stage of the cancer and the severity of the accompanying liver dysfunction. It is difficult to determine the relationship between sclerotherapy and carcinoma; however, long-term surveillance is essential to avoid overlooking a neoplasm in the esophagus after endoscopic injection sclerotherapy.     

Varicoid Carcinoma of the Esophagus

A patient with varicoid carcinoma of the esophagus is reported. These tumors differ from classical esophageal carcinoma and have some resemblance to esophageal varices in their radiological and endoscopic appearances. Dysphagia is generally not the presenting symptom. The histological picture in our patient was that of a poorly differentiated adenocarcinoma with areas of signet-cell carcinoma. This is an exceptional finding since all previously reported cases of varicoid carcinoma of the esophagus have been squamous cell carcinomas.     

Esophageal cancer and endoscopic sclerosis of esophageal varices: a fortuitous association?

We report the case of 4 male patients, smokers, with alcoholic cirrhosis, mean age 54.7 +/- 6 years, treated by sclerotherapy for bleeding esophageal varices. Variceal eradication was obtained following juxtacardial intravariceal injection of 1.5 p. 100 polidocanol in one case (100 ml), and 0.5 p. 100 polidocanol in 3 cases (90, 240 and 310 ml). Local complications were observed in all patients (ulcers: 3; stenosis: 1). Carcinoma of the lower third of the esophagus was detected 12, 20, 22 and 30 months after esophageal sclerosis. Carcinoma was circular (one case), semicircular (2 cases), and nodular superimposed on Barrett's esophagus (one case). Histologic features included squamous cell carcinoma in 3 cases and adenocarcinoma in one case. Sclerotherapy could lead to the development of carcinoma because of mucosal alterations. However, other high risk factors (age, alcohol-tobacco intoxication, Barrett's esophagus) and different histologic features suggest a causal association. Endoscopic follow-up of patients after esophageal sclerosis could confirm this hypothesis.     

Clinical evaluation of endoscopic injection sclerotherapy for bleeding esophageal varices in liver cirrhosis with hepatocellular carcinoma

Endoscopic injection sclerotherapy (EIS) for rupture of esophageal varices was carried out in 13 patients of liver cirrhosis with hepatocellular carcinoma (HCC). Sclerotherapy was performed by intravariceal injections of 5% ethanolamine oleate. According to the manual for the staging of cancer, these HCCs were classified as Stage I in 1 case, II in 1 case, III in 2 cases, and IV in 9 cases. There was no difference between post EIS prognosis and stage. Child’s classification of these patients were class A in 1 case, B in 5 cases, and C in the remaining 7 cases. Only in 1 case of Child’s A and 1 case of Child’s B who were less advanced clinically and were free from icterus and ascites did EIS produce favorable results, it arresting esophageal variceal hemorrhage and led to a relatively good outcome. We suggest that emergency EIS for rupture of esophageal varices should be performed in patients with relatively good general conditions, irrespective of the stage of HCC.     

Coexistence of esophageal superficial carcinoma and multiple leiomyomas： A case report

Leiomyomas are the most common benign tumors of the esophagus. They usually occur as a single lesion or as two or three nodules. Only two cases of esophageal multiple leiomyomas comprising more than 10 nodules have been reported previously. Moreover, there have been few reports of esophageal squamous cell carcinoma overlying submucosal tumors. We describe a 71-year-old man who was diagnosed as having a superficial esophageal cancer coexisting with two or three leiomyoma nodules. During surgery, 10 or more nodules that had not been evident preoperatively were palpable in the submucosal and muscular layers throughout the esophagus. As intramural metastasis of the esophageal cancer was suspected, we considered additional lymphadenectomy, but had to rule out this option because of the patient's severe anoxemia. Microscopic examination revealed that all the nodules were leiomyomas (20 lesions, up to 3 cm in diameter), and that invasion of the carcinoma cells was limited to the submucosal layer overlying a relatively large leiomyoma. This is the first report of superficial esophageal cancer coexisting with numerous solitary leiomyomas. Multiple minute leiomyomas are often misdiagnosed as intramural metastasis, and a leiomyoma at the base of a carcinoma lesion can also be misdiagnosed as tumor invasion. The present case shows that accurate diagnosis is required for the management of patients with coexisting superficial esophageal cancer and multiple leiomyomas.     

Cruveilhier-Baumgarten syndrome without esophageal varices: ultrasonographic diagnosis and echo-Doppler study

Two cases of Cruveilhier-Baumgarten syndrome not clinically evident and without esophageal varices in patients with liver cirrhosis and portal hypertension are presented. The diagnosis was made by real-time ultrasonography, which showed echographic caput medusae with large afferent umbilical veins and efferent inferior superficial epigastric veins. Doppler flowmetry documented high blood flow rates in these collateral portal-systemic circulations, and this explained the absence of large varices at endoscopy. The role of massive spontaneous portal-systemic shunts in preventing the formation of other shunts and particularly esophageal variceal bleeding is discussed.     

Association of esophageal cancer and esophageal varices

Of the 312 cases of esophageal cancer seen over 2 years, four patients had associated varices. Three patients gave history of alcohol abuse. All had malnutrition and splenomegaly. Endoscopic biopsies were safe in the presence of varices. External radiation did not have any untoward effect on the varices. Prophylactic sclerotherapy was not required in these patients. The association between esophageal carcinoma and varices could be secondary to alcohol consumption or merely coincidental.     

Concurrent superficial squamous cell carcinoma of the esophagus and early gastric adenocarcinoma. Report of a case.

We report a patient with concurrent superficial carcinomas of the esophagus and stomach. The tumors occurred in a 68-year-old woman. The esophageal tumor was an intramucosal squamous cell carcinoma, and the gastric tumor an intramucosal adenocarcinoma, type III in the Japanese classification of early gastric cancer. This is the first reported case of associated superficial esophageal and gastric cancers originating from a Western country. Such an association may be more frequent than realized, and therefore it is important to examine both the stomach and esophagus if a patient has one of these tumors.     

Percutaneous transsplenic embolization of esophageal and gastrio-fundal varices in 18 patients

AIM:Clinical application and potential complication ofpercutaneous transsplenic varices embolization(PTSVE)ofesophageal or gastrio-fundal varices in patients withhepetooellular carcinoma(HCC)complicated with portalvein cancerous thrombosis(PVCT).METHODS:18 patients with HCC complicated with PVCT andesophageal or gastrio-fundal varices who underwent PTSVEwore collected.The rate of success,complication,mortalityof the procedure and postoperative complication wererecorded and analyzed.RESULTS:PTSVE were successfully performed in 16 of 18cases,and the rate of success was 89%.After therapyerythrocyte counts decreased in all of the natunts.5 ofpatients needed blood transfusion,2 patientsrequiredsurgical intervention because of and 11 patients withascites were alleviated by diuresis.Among these 18patients,the procedure-related mortality was 11%(2/18),one died of acute hepatic failure on the forth day afterprocedure,another died of acute renal failure on the fifthday.The patients were follow up for 112 mon exceptone.13of them died of their tumors but none of them experiencedvariceel bleeding.CONCLUSION:PTSVE Is a relatively safe and effectivemethod to treat esophageal or gastrio-fundal varices in HCCpatients with PVCT when percutaneous transhepatic varicesembolization(PTHVE)of varices is impossible.     

Effect of food characteristics on rate of hemorrhagic complications and early results of endoscopic sclerosing treatment of esophageal varices

To evaluate the possible influence of the trauma of swallowing solids on the outcome and complication rate of endoscopic injection sclerotherapy we carried out a prospective randomized trial in 46 cirrhotics undergoing sclerotherapy because of recent or acute variceal bleeding. The patients were randomly assigned to mashed food (24 = group A) or normal solid food (22 = group B). Both groups were comparable according to age, sex, Child classes, size of the varices and patients undergoing emergency sclerotherapy (8 in each group). Duration of hospital care (A 26.6, B 27.3 days) (means), number of endoscopic studies (A 4.7, B 4.6), number of sclerotherapy sessions (A 2.4, B 2.5) and required amount of Polidicanol in each patient (A 62.7, B 56.4 ml) were not different. Variceal eradication was achieved in 13 cases in A, in 14 in B. III degrees varices remained in 6 patients in A (3 quit against advice before completing ST) and in 1 case in group B. Staple-gun transection and devascularization because of recurrent bleeding were necessary in 2 cases in A and in 1 case in B. Death occurred in 2 cases in A (liver failure), in 4 cases in B (3 cases of liver failure and in 1 case with recurrent bleeding, without operation because of hepatocellular carcinoma). Episodes of acute massive bleeding from varices or esophageal ulcers occurred 9 times in group A and 10 times in group B. Minor bleedings occurred 10 times in A and 9 times in B. Transfusion requirement was 110 units of packed red cells in A and 106 in B.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical repair of esophagobronchial fistula caused by radiation injury

We present an unusual case of a benign esophagobronchial fistula caused by radiotherapy to treat esophageal carcinoma which was closed successfully. A 62-year-old man with superficial squamous cell carcinoma of the esophagus underwent radiotherapy, including 60 Gy externally and 10 Gy intraluminally from January to March 1995. Esophagography revealed a fistula between the esophagus and left main stem bronchus on January 14, 1996. No residual cancer existed. Neither stenting with a silicone tube nor with a covered flexible metallic stent occluded the fistula. Thoracic esophagectomy, closure of the esophagobronchial fistula using a 2-cm nubbin of esophageal wall, surrounding the orifice of the fistula and antesternal gastric pull-through reconstruction with mediastinal lymphadenectomy were performed. The postoperative course was uneventful and there is no evidence of recurrence of the fistula or the cancer 5 years postoperatively. Radiotherapy may cause esophagobronchial fistula even in cases of superficial esophageal cancer. Bypass surgery should be considered because stenting is not effective for benign fistula without stricture.