Secondary neoplasms of the esophagus

A review of 62 cases of esophageal involvement by secondary neoplasms is reported. The common routes of esophageal involvement are by direct extension of the tumor from the contiguous or adjacent organs (45.2%), via mediastinal nodes (35.5%), and hematogenous spread from a distant primary (19.3%). In the first 2 modes of esophageal involvement, the diagnosis is usually obvious but hematogenous metastases to the esophagus usually pose a diagnostic challenge. Radiologically, hematogenous metastases show a spectrum of features consisting of a short segment of progressive stricture with normal to minimally irregular mucosa, a submucosal mass with or without ulceration, a polypoid mass or masses, and defects in esophageal motility including secondary achalasia. Since endoscopy and biopsy have limited diagnostic yield, radiologic diagnosis plays a key role in the diagnosis of secondary neoplasms of the esophagus irrespective of their mode of spread to the esophagus.     

A clinicopathological study of basaloid squamous carcinoma of the esophagus

We reviewed the clinicopathological characteristics of 14 patients who underwent resection of basaloid squamous carcinoma (BSC) of the esophagus. The mean age was 65.3 years, and all patients were male. Seven patients had superficial BSCs and 7 had advanced BSCs. BSCs were associated with high rates of lymph node metastases and venous invasion. With regard to immunohistochemistry, the rate of cyclin D1 expression was higher (13/14), and the preservation rate of E-cadherin expression was lower (4/14), than that seen in ordinary esophageal squamous cell carcinoma. Squamous cell carcinoma components were most often found at sites of lymph node metastases, whereas basaloid components predominated at sites of hematogenous metastases in 4 patients, including lung, brain, and liver. Seven of the 9 patients with stage I or II disease are alive without recurrence. All patients with stage III or IV tumors developed recurrent disease. Primary tumors responded well in 3 patients who received preoperative chemotherapy (5-fluorouracil plus cisplatin) and/or radiotherapy, but further studies are needed to clarify the role of chemoradiotherapy. We believe that control of the hematogenous spread of basaloid components may lead to improved outcomes in patients with esophageal BSC.     

The utility of EUS-guided FNA in the diagnosis of metastatic breast cancer to the esophagus and the mediastinum

BACKGROUND: Breast cancer can metastasize to the esophagus and the mediastinum. EUS-guided FNA (EUS-FNA) is being used increasingly as a less invasive alternative to mediastinoscopy for procuring a tissue diagnosis of mediastinal disease and may be useful for the diagnosis of breast cancer metastatic to the esophagus and the mediastinum. METHODS: Twelve women (age range 54-82 years) with a history of breast cancer presented with dysphagia or other symptoms between 1 and 15 years after initial diagnosis and treatment. CT and endoscopy with biopsies suggested a mediastinal mass or lymphadenopathy with extrinsic esophageal compression but failed to provide a tissue diagnosis. EUS-FNA was performed for diagnosis. RESULTS: Cytologic evaluation of specimens obtained by EUS-FNA confirmed breast cancer metastases in 11 of 12 patients (91%). Recurrent disease was found in intramural masses and periesophageal lymph nodes. No complication resulted from any EUS-FNA procedure. CONCLUSIONS: EUS-FNA is safe and effective for the diagnosis of breast cancer metastases to the esophagus and the mediastinum. EUS-FNA may be useful as a first-line method of evaluation when breast cancer metastasis to the esophagus and the mediastinum is suspected.     

The pattern of lymphatic metastases in superficial squamous cell carcinoma of the esophagus

BACKGROUND/AIMS: Lymphatic spread patterns in relation to the location of primary tumors of the superficial thoracic esophageal squamous cell carcinoma have not been well established. We therefore analyzed patterns of lymph node metastasis in these patients. METHODOLOGY: We reviewed medical records of 65 patients who underwent systematic three-field dissection for superficial squamous carcinoma of the thoracic esophagus from 1993 through 2000. RESULTS: Lymph node involvement was found in 0% (0/13) and 44% (23/52) of patients whose tumor invaded the muscularis mucosa and submucosal layer, respectively. The 5-year survival rate was 77% in the node-negative group and 59% in the node-positive group (P<0.05). None of the patients with upper thoracic esophageal cancer had metastasis to the mediastinal and abdominal nodes. Patients with lower thoracic esophageal tumors (Lt) had no metastasis to the cervical nodes. Patients with middle thoracic esophageal tumors (Mt) and Lt patients rarely had metastasis (2-5%) in the lower mediasinal nodes (Nos. 108-112). No patient with superficial thoracic esophageal cancer had metastasis to the subcarinal nodes in this study. CONCLUSIONS: In our series, no patient with intramucosal carcinoma had lymphatic metastases. Some patients with submucosal cancers metastasized beyond regional lymph nodes. However, this study suggests that subcarinal nodes might not need to be sampled or dissected in patients with superficial carcinoma of the thoracic esophagus. In Mt and Lt patients, metastases to the mediastinal nodes were infrequent (2-7%). Mediastinal nodes other than #107 can easily be sampled through cervical and abdominal incisions. Therefore, combined with lymph node sampling in cervical, mediasinal and abdominal stations through cervical and abdominal incisions, esophagectomy without thoracotomy might be acceptable in Mt and Lt patients with superficial squamous cell carcinoma of the esophagus.     

Esophageal duplication cysts: endosonographic findings in asymptomatic patients

Esophageal duplication cysts are rare inherited lesions usually diagnosed in early childhood. Most of them are found in the mediastinum and manifest themselves as separate masses along or in continuity with the native esophagus. Their prevalence remains unknown and they are treated either surgically or endoscopically. In this report we describe a series of four adult patients in whom esophageal duplication cysts were localised intramurally as masses pressing on the esophageal lumen and who were diagnosed with endoscopic ultrasonography. All patients were initially referred to other centres for upper gastroduodenoscopy due to non-specific dyspeptic symptoms. After finding suspicious lesions in the esophagus their endoscopists referred them for endoscopic ultrasound examination at our centre. In two of the cases lesions mimicked esophageal varices and the other two submucosal tumours. In all four patients endoscopic ultrasonography has shown esophageal duplication cysts. Patients had no symptoms suggesting disease of the esophagus and required no treatment. As the true prevalence of esophageal cysts is unknown, it is very likely that in many patients, like in these four described by us, they may cause no symptoms, remain undetected and require no intervention. Increasing availability of new diagnostic modalities such as endoscopic ultrasonography may change the current view regarding the prevalence of esophageal duplication cysts and prove that they may, in fact, not be such rare findings.     

Thoracoscopic enucleation for small-sized gastrointestinal stromal tumor of the esophagus: report of two cases

Gastrointestinal stromal tumors (GISTs) rarely occur in the esophagus. Surgical approaches for such tumors have not been established, since the standard wedge or segmental resection that is used for intra-abdominal GIST is not possible in the esophagus. We report two cases of small esophageal GIST in which thoracoscopic enucleation was performed. Both patients underwent the thoracoscopic surgery using four trocars. The tumor size was 43 and 32 mm in patients 1 and 2, respectively. The operating time was 240 and 238 min. The final diagnosis was as low-risk GIST in both patients. Postoperative course was uneventful and both patients have been disease-free at a follow-up of 40 and 32 months. Considering the special case of the esophagus and the very good prognosis of low-risk tumors, enucleation under the thoracoscopic technique may be feasible for small-sized esophageal GIST as a minimally invasive surgery. We also review the literature in this report.     

Down syndrome and esophageal cancer

We present two cases of Down syndrome with inoperable esophageal cancer at a relatively young age. The first patient had a locally advanced squamous cell carcinoma of the distal esophagus. The second had a short circular adenocarcinoma of the distal esophagus with peritoneal and liver metastases. The cases are discussed with regard to the current literature on Down syndrome and esophageal cancer.     

Primary malignant melanoma of the esophagus

is a rare disease, with only 200 cases being reported since this condition became an established clinical entity in 1963. This tumor, which accounts for only 0.1-0.2% of all esophageal neoplasms, is typically aggressive and disseminates early via the bloodstream and lymphatics, with only some 30% of patients surviving > 1 year after diagnosis. Management of patients with esophageal melanomata is unsatisfactory, as most tumors are advanced at diagnosis, and therapeutic options are limited by inaccessibility and early dissemination of the neoplasms. Poor survival rates reflect the inoperability of many tumors and the ineffectiveness of radiation and chemotherapy in eradicating advanced tumors and metastases. We present two patients with primary melanoma of the esophagus and discuss the treatment options currently available.     

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.     

Alpha-fetoprotein-producing esophageal adenocarcinoma: a mimicker of hepatocellular carcinoma

Alpha-fetoprotein (AFP)-producing esophageal adenocarcinoma (EAC) is a rare occurrence. Elevation of serum AFP is commonly associated with hepatocellular carcinoma and yolk sac tumors, but rarely with esophageal carcinoma. Here, we report a rare case of AFP-producing EAC. A 51-year-old man presented with two weeks of acid reflux and a 35-lb weight loss. Laboratory data were notable for transaminitis and AFP was 2524 ng/mL. Computed tomography of the abdomen revealed abnormal thickening of the esophagus and multiple metastatic masses throughout the liver. Biopsy of one of the masses revealed adenocarcinoma of gastrointestinal origin. Subsequent upper endoscopy revealed an esophageal mass with biopsy notable for ulcerated dysplastic glandular mucosa with likely underlying malignancy. The patient underwent palliative esophageal stent placement but died two months later. Elevated AFP levels are an unusual occurrence in EAC. Prognosis is poor given its advanced presenting stage and high metastatic potential. Most cases are unsuccessfully treated with surgery and chemotherapy. Serial measurement of serum AFP may be useful for monitoring clinical status and treatment response. Clinicians should consider AFP-producing EAC in their differential diagnosis in the work-up of a liver mass in the setting of elevated AFP or liver function impairment, especially in the absence of chronic liver disease.     

Metastases of esophageal carcinoma to skeletal muscle: Single center experience

Metastases of esophageal carcinoma to the skeletal muscle are rare, but the incidence may be increasing because of better diagnosis resulting from widespread use of positron emission tomography/computed tomography (PET/CT). A cohort of 205 patients with esophageal carcinoma treated at our center who had PET/CT between 2006 and 2010 was retrospectively evaluated for the presence of skeletal muscle metastases. Four patients had skeletal muscle metastases of esophageal carcinoma, including two patients with squamous cell carcinoma. In another patient with squamous cell carcinoma of the esophagus and synchronous skeletal muscle metastases, muscle metastases were subsequently shown to be related to second primary pancreatic adenocarcinoma. In all cases, skeletal muscle metastases were the first manifestation of systemic disease. In three patients palliation was obtained with the combination of external beam radiation therapy, systemic chemotherapy or surgical resection. Skeletal muscle metastases are a rare complication of esophageal carcinoma.     

A Case of Esophageal Cyst Excised Successfully Using Laparoscopy

Laparoscopic excision of an esophageal cyst was successfully performed on a 29-year-old male. The patient, complaining of back pain, was admitted to our hospital for further evaluation of a submucosal esophageal tumor. Close examination revealed a cystic tumor originating from the proper muscular layer at the distal esophagus, measuring 3 cm in diameter. Under general anesthesia, the tumor was excised laparoscopi-cally without esophageal mucosal injury, with monitering by esophagoscopy. Postoperative esophagography showed no stagnation or stenosis. He was discharged on the 11th postoperative day. The cyst was diagnosed pathologically as an inclusion cyst of the esophagus. Laparoscopic or thoracoscopic surgery is a useful treatment for benign esophageal tumors, because it is less invasive giving more rapid recovery. Concomitant esophagoscopic monitering is beneficial to avoid injury of the esophageal mucosa, especially in such benign tumors that are firmly adherent to the esophageal muscle and mucosal layer.     

ENDOSCOPICALLY RESECTED LIPOMA OF THE ESOPHAGUS: REPORT OF A CASE

Lipoma of the esophagus is rare. There are few reports of the endoscopic resection of esophageal lipoma. We present a 73‐year‐old woman with lipoma of the esophagus which was successfully extirpated using the technique of endoscopic mucosal resection. To determine the depth of tumor invasion, endoscopic ultrasonography was used. A total of 31 cases of esophageal lipoma have been reported in Japan. Of these, seven were successfully resected using endoscopic techniques. Lipomas of the esophagus can grow to become large pedunculated tumors which can obstruct the airway. The majority of these tumors occur in the cervical portion of the esophagus. Most patients have no symptoms. These tumors can be resected using minimally invasive surgery when they are small.     

Direct esophageal metastasis from a distant primary tumor is a submucosal process: a review of six cases

Malignant esophageal stricture secondary to invasion from a tumor arising in a contiguous organ is a relatively rare finding; even more uncommon is a direct metastasis to the esophagus from a distant primary carcinoma. We present six cases, the largest current series, of esophageal strictures secondary to metastases from a separate primary cancer. We reviewed the records of 20 patients treated at Virginia Mason Medical Center between 1972 and 2000 with a diagnosis of malignant esophageal stricture secondary to an extraesophageal primary carcinoma. Patients whose stricture appeared to be secondary to esophageal invasion or compression from a contiguous tumor or lymph nodes were excluded. The remaining six patients who had metastases to the esophagus itself were reviewed with respect to the nature of the primary tumor, presentation, radiologic and endoscopic findings, and treatment. Among the 20 patients reviewed, 14 were excluded owing to either contiguous involvement from a nearby primary malignancy, regional nodal involvement, or complications of external beam radiation treatment. Six patients were considered to have direct metastasis to the esophagus from distant primary malignancies. The mean age of these patients was 72 years (range 68-74). Two of the primary lesions were lung carcinoma, while four primaries were breast cancers. The average time interval from the diagnosis of a primary tumor to esophageal involvement was 7 years in patients with breast cancer and 5 months in patients with lung cancer. Three patients were palliated with endoscopic dilation and stent placement. The other three patients have died secondary to upper gastrointestinal bleeding. Metastatic cancer to the esophagus is a rare occurrence. The process is usually submucosal and can be difficult to diagnose. The diagnosis should be considered when a patient presents with malignant dysphagia and has a background of distant carcinoma.     

Resection of skeletal muscle metastases from squamous cell carcinoma of the esophagus: case report and literature review

Skeletal muscle metastasis from esophageal squamous cell carcinoma is an unusual entity. A 72-year-old man underwent a subtotal esophagectomy for advanced esophageal squamous cell carcinoma. Mediastinal lymph node metastases developed 36 months after operation, and the patient received chemoradiotherapy. He complained about two painful, subcutaneous masses in the upper part of the left arm at 3 months after the end of chemoradiotherapy. Histopathological examination of tissue specimens obtained by explorative surgery showed skeletal muscle metastases from poorly differentiated squamous cell carcinoma. The patient died of multiple metastases 7 months after chemoradiotherapy. This is considered a very rare case of metastasis from squamous cell carcinoma of the esophagus to the triceps muscle of the left arm.     

Salvage endoscopic submucosal dissection for recurrent esophageal squamous-cell carcinoma after definitive chemoradiotherapy

Although concurrent definitive chemoradiotherapy (CRT) is considered a standard treatment for unresectable esophageal carcinoma, CRT is associated with local failure (40–50%), and further interventions are needed in these cases. However, morbidity and mortality rates remain high among patients undergoing salvage esophagectomy for recurrent tumors. Here, we report a rare experience of salvage endoscopic submucosal dissection (ESD) for recurrent esophageal squamous-cell carcinoma (SCC) after definitive CRT. A 55-year-old male was diagnosed with unresectable advanced mid-thoracic esophageal SCC with lymph node metastases involving the trachea. After definitive CRT with cis-diamminedichloroplatinum (CDDP)/5-fluorouracil (5-FU) and 60 Gy irradiation was performed, complete response was obtained. However, a recurrent esophageal SCC was detected in the mid-thoracic esophagus on endoscopy performed 6 months after CRT. The tumor was resected en bloc using ESD without any complications. There was no recurrence for 4 months after ESD. Salvage ESD may be a safe and effective treatment for recurrent esophageal SCC after CRT.     

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.     

Recurrent giant fibrovascular polyp of the esophagus

Giant fibrovascular polyps of the esophagus and hypopharynx are rare benign esophageal tumors. They arise most commonly in the upper esophagus and may, rarely, originate in the hypopharynx. They can vary significantly in size. Even though they are benign, they may be lethal due to either bleeding or, rarely, asphyxiation if a large polyp is regurgitated. Patients commonly present with dysphagia or hematemesis. The polyps may not be well visualized on endoscopy and imaging plays a vital role in aiding diagnosis as well as providing important information for preoperative planning, such as the location of the pedicle, the vascularity of the polyp and the tissue elements of the mass. They can also be recurrent in rare cases, especially if the resection margins of the base are involved. We review the recent literature and report a case of a 61-year-old man with a recurrent giant esophageal fibrovascular polyp with illustrative contrast barium swallow, CT and intra-operative images, who required several surgeries via a combination of endoscopic, trans-oral, trans-cervical, trans-thoracic and trans-abdominal approaches.     

Endotracheal metastasis from basaloid squamous carcinoma of the esophagus

Endobronchial metastases from extrapulmonary neoplasms are rare events, and there is no report in the literature of metastasis originating from esophageal cancer. Basaloid squamous carcinoma of the esophagus is a rare histologic type that is known to be a biologically aggressive phenotype. We describe a rare case of metachronous endotracheal metastasis originating from esophageal basaloid squamous carcinoma. A 72-year-old Japanese man underwent esophagectomy for stage I esophageal cancer. Pathological diagnosis of the resected specimen was basaloid squamous carcinoma. One year later, a follow-up computed tomography scan displayed a tumor shadow in the tracheal wall. Bronchoscopy revealed a protruding tumor in the tracheal wall, and the pathologic diagnosis of the biopsy specimen was also basaloid squamous carcinoma. According to the diagnosis of metachronous endobronchial metastasis from esophageal basaloid squamous carcinoma, we treated the patient with chemotherapy comprising docetaxel, cisplatin, and 5-fluorouracil followed by chemoradiotherapy, and complete response was achieved. The patient has not suffered a recurrence of the disease for 23 months since the diagnosis of the endobronchial tumor. Careful follow-up is needed to ensure that rare types of metastasis are not missed in cases with biologically aggressive tumors.     

Carcinoma of the Esophagus and Hypercalcemia

Hypercalcemia was found in 19 (28%) of 67 patients with cancer of the esophagus. There was no evidence of bone metastases in 14 (20%) of the patients with hypercalcemia. The location of the lesion (upper, middle or lower esophagus) appears to have no bearing on the clinical features in this condition and the association of hypercalcemia with esophageal malignancy, even in the absence of bone metastases, should be recognized.