- Email: [email protected]
Multiple Adenomatous Neoplasms Arising in Columnarlined (Barrett's) Esophagus
72:1317-1321,1977 Copyright © 1977 by the American Gastroenterological Association
Vol. 72, No.6
GASTROENTEROLOGY
Printed in U.S.A.
MULTIPLE ADENOMATOUS NEOPLASMS ARISING IN COLUMNARLINED (BARRETT'S) ESOPHAGUS GEORGE B. MCDONALD, M.D., DOUGLAS
L.
BRAND, M.D., AND DAVID
R.
THORNING,
M.D.
Departments of Medicine and Pathology, Seattle Veterans Administration Hospital and the University of Washington School of Medicine, Seattle, Washington
Multiple polypoid masses were found in the esophagus of a 62-year-old man. He underwent esophageal resection because exfoliative and brush cytological studies were positive for adenocarcinoma. The surgical specimen showed that the esophagus was lined by columnar epithelial cells which were focally hyperplastic, forming polypoid masses. In both the masses and the mucosa between them, there were atypical epithelial cell changes, ranging from dysplasia to focal carcinoma. These findings reinforce the concept that the Barrett's (columnar) epithelium is a premalignant lesion deserving periodical screening. Columnar-lined (Barrett's) esophagus is most often from the teeth to the gastroesophageal junction at 38 cm) had seen as a reparative response to gastroesophageal re- an erythematous, cobblestone appearance. In addition, from flux. l -6 The epithelium can vary from a specialized col- 28 to 38 cm there were numerous irregularly nodular masses umnar type to a gastric fundic type to a junctional type. 7 projecting into the lumen; these masses ranged in diameter Parietal and chief cells can be found, usually in the from 5 to 30 mm. The stomach and duodenum appeared norfundic type epithelium. 7, 8 Primary adenocarcinomas of mal. Endoscopic biopsies from the nodular masses were interthe esophagus have appeared in association with this preted as showing columnar mucosa with focal epithelial dyscolumnar epithelium, giving rise to the hypothesis that plasia and neutrophilic infiltration of both epithelium and the Barrett's epithelium is a premalignant lesion. !HI lamina propria. Dysplasia was considered compatible with We describe here a case with Barrett's epithelium in reaction to inflammation. Endoscopic brushings from the nodular lower esophageal which we found a spectrum of neoplastic changes ranging from adenomatous hyperplasia to adenocarcinoma segment (28 to 38 cm) and an exfoliative cytology specimen contained nests of cells that have increased nuclear-cytoplasin situ. Case Report A 62-year-old white male was admitted to the Veterans Administration Hospital, Seattle, Washington, in October 1975, because of hematemesis, anorexia, and weight loss of 45 Ib over the previous 4-month period. He denied heartburn, regurgitation, and dysphagia. However, review of his medical record for December 1971 revealed complaints of nausea and vomiting; a hiatal hernia was demonstrated radiographically. He had been treated with antacids with some relief. This medication was taken intermittently over the next year, and the patient then apparently did well until mid-1975. Physical examination on admission revealed only cachexia. Abnormal laboratory data included a hematocrit of 33% with normal indices, and blood urea nitrogen of 38 mg per 100 ml, with reversion to normal after volume repletion. Special studies. The barium upper gastrointestinal series demonstrated a dilated lower esophagus with multiple nodular masses extending into the distal lumen (fig. 1). The stomach appeared normal. Esophagogastroduodenoscopy performed with an Olympus GIF-D endoscope (Olympus Corporation of America, New Hyde Park, N. Y.) revealed that the entire esophagus (from 22 cm
mic ratios, hyperchromatic and pleomorphic nuclei, and irregularly clumped nuclear chromatin, i.e., features considered diagnostic of adenocarcinoma (fig. 2). Liver function tests, radioisotope scans of the liver, brain and bone, and an EEG showed no evidence of metastatic carcinoma. Course. A total esophagectomy and colonic interposition were performed. There is a close correspondence between the gross appearance of the surgical specimen (fig. 3) and the radiographic and endoscopic images. Postoperatively the patient did well until day 22 when he suffered a sudden cardiopulmonary arrest. He was resuscitated but remained comatose until day 45, when he expired. Postmortem examination revealed dehiscence of the esophagocolonic anastomosis with mediastinitis and bilateral bronchopneumonia. Microscopic studies. The surgical specimen (figs. 4 to 6) showed replacement of usual esophageal epithelium from the proximal margin of the specimen to the gastric cardia distally by columnar epithelial cells that are focally hyperplastic, forming polypoid masses. The polypoid masses have various combinations of adenomatous and villous growth patterns. Epithelial cells, both in polypoid lesions and in mucosa between these lesions, show multifocal atypical changes ranging through all degrees of dysplasia to focal carcinoma without invasion into the muscularis mucosa. Postmortem microscopy showed stratified squamous epithelium lining the proximal edge of the dehiscence defect and no evidence of local or metastatic esophageal adenocarcinoma.
Received October 12, 1976. Accepted December 6, 1976. Address requests for reprints to: George B. McDonald, M.D., Seattle Veterans Administration Hospital, 4435 Beacon Avenue South, Seattle, Washington 98108. 1317
1318
CASE REPORTS
Discussion Barrett's columnar-lined esophagus is probably a common lesion which causes few symptoms. The diagnosis is usually made because of the development of strictures, ulcers, or bleeding. 5 , 9, 12, 13 A recent series of
FIG. 1. Barium contrast study demonstrating a dilated lower esophagus and multiple nodular masses.
Vol. 72, No.6
over 6000 esophagoscopies yielded 1225 cases of reflux esophagitis, 140 of which were associated with Barrett's epithelium. l l Of the 140 cases, 12 were discovered to have esophageal adenocarcinoma. II The findings in this case reinforce the concept that the Barrett's (columnar) epithelium is a premalignant lesion. They also suggest that benign epithelial neoplasms, i.e., adenomatous polyps, may develop before or synchronously with adenocarcinoma.
FIG. 3. Surgical specimen, opened longitudinally, showing multiple nodular masses (distal end on the right) .
FIG. 2. Esophageal cytology preparation showing a cluster of atypical cells with malignant characteristics (Papanicolaou stain, x 705).
June 1977
CASE REPORTS
1319
FIG. 4. Light micrograph of esophageal mucosa showing columnar lining and a papillary adenoma (H & E, x 74).
FIG. 5. Light micrograph of esophageal mucosa showing uniform columnar epithelium typical of Barrett's epithelium (H & E, x 282).
Both X-ray and esophagoscopy showed multiple polypoid tumors in an esophagus lined entirely by columnar epithelium. Histologically, the tumors are papillary adenomas; their epithelial cells manifest a range of atypical changes including dysplasia and adenocarcinoma in situ. Infiltrating and metastatic adenocarcinoma were not observed either in the resected esophagus or in tissue remaining at postmortem examination. We hypothesize that this man developed Barrett's epithelium
with subsequent development of multifocal hyperplasia, dysplasia, and adenocarcinoma. In addition to the 12 cases noted above, over 30 other cases of adenocarcinoma in Barrett's epithelium have been reported.!' 9, 10, 14-32 Additional cases can be found among series of patients with primary adenocarcinoma of the esophagus, an unusual tumor accounting for about 3% of all esophageal cancers. 3~36 Even more unusual are benign adenomatous polyps of the esopha-
1320
CASE REPORTS
Vol. 72, No . 6
FIG. 6. Light micrograph of esophageal mucosa showing atypical epithelial cells with malignant characteristics (H & E, x 282) .
gus. 37, 38 Thus, the simultaneous appearance of adenom- antireflux surgery.6, 8 These studies can be faulted only atous polyps and adenocarcinoma in our case seems to for the lack of proof that surgery did indeed eliminate be related to the underlying columnar epithelium and reflux. Thus, the possibility that effective antireflux not to chance occurrence. surgery may prevent cancer remains unproved. There are 3 reported cases which suggest polypoid REFERENCES epithelial hyperplasia (or adenomatous polyp) as a pre1. Allison PR, Johnstone AS: The oesophagus lined with gastric cursor for adenocarcinoma. Marked dysplastic changes mucous membrane. Thorax 8:87-101 , 1953 were found in the proximal columnar epithelium of 1 of 2. Goldman MC, Beckman RC: Barrett syndrome: case report with 7 11 well studied patients with Barrett's epithelium. Andiscussion about concepts of pathogenesis. Gastroenterology other patient developed an esophageal "papillomatous 39:104-110, 1960 tumor with markedly atypical cells" after 8 years of 3. Mossberg SM: The columnar-lined esophagus (Barrett synobservation for her Barrett's esophagus.39 A similar drome): an acquired condition? Gastroenterology 50:671-676, large multicentric polypoid mass was removed from the 1965 Barrett's esophagus of still another patient; histology 4. Heitman P, Strauszer T, Sapunar J, et al: Lower esophagus lined with columnar epithelium: morphological and physiological corshowed both adenoma and well differentiated superfirelation. Gastroenterology 53:611-624, 1967 cial adenocarcinoma without invasion of the muscle 5. Burgess IN, Payne WS, Andersen HA, et al: Barrett esophagus: layer.40 the columnar-epithelial-lined lower esophagus. Mayo Clin Proc Careful periodic screening of patients with Barrett's 46:728-734, 1971 epithelium should be done to find either dysplastic 6. Endo M, Kobayashi S, Kozu T, et al: A case of Barrett epithelizachanges, benign adenomas, or curable intraepithelial tion followed up for five years. Endoscopy 6:48-51, 1974 adenocarcinoma. Esophagoscopy with directed biopsy 7. Paull AP, TrierJS, Dalton MD, et al: The histologic spectrum of 30 and cytology is the best screening procedure. , 41 SurgiBarrett's esophagus. N Engl J Med 295:476-480, 1976 cal removal seems to be the treatment of choice for 8. Mangla JC, Schenk EA, Desbaillets L, et al: Pepsin secretion, adenocarcinoma of the esophagus. There is no great pepsinogen, and gastrin in "Barrett's esophagus." Clinical and expectation of cure of symptomatic adenocarcinoma,33, 35 morphological characteristics. Gastroenterology 70:669-676, 1976 but it is possible that early detection will improve sur9. Adler RH: The lower esophagus lined by columnar epithelium: vival. its association with hiatal hernia, ulcer, strictures, and tumor. J Can Barrett's epithelium disappear once it has lined Thorac Cardiovasc Surg 45:13-34, 1963 the esophagus? The epithelial change appears to be an 10. Hawe A, Payne WS, Weiland LH, et al: Adenocarcinoma in the adaptation to chronic reflux of gastric contents; therecolumnar-epithelial lined lower (Barrett) oesophagus. Thorax fore, a successful antireflux operation may be expected 28:511-514, 1973 to result in return of normal squamous epithelium. 11. Naef AP, Savary M, Ozzello L: Columnar-lined lower esophagus: Such surgery is effective in treating Barrett's ulcers and an acquired lesion with malignant predisposition. J Thorac Carstrictures,42-44 but there are several cases in which coldiovasc Surg 70:826-835, 1975 umnar epithelium persisted despite clinically successful 12. Heitmann P: Lower esophagus lined with columnar epithelium.
June 1977
13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25 . 26. 27.
28.
CASE REPORTS
In Diseases of the Esophagus Edited by G Vantrappen, J HelJemans. New York, Berlin, Heidelberg, Springer-Verlag, 1974, p 525-538 Johnston JH: Gastric lined esophagus associated with rings and stenoses. Ann Surg 173:641-648, 1971 Carrie A: Adenocarcinoma of the oesophagus arising from ectopic gastric epithelium. Br J Surg 37:474, 1950 Morson BC, Belcher JR: Adenocarcinoma of the oesophagus and ectopic gastric mucosa. Br J Cancer 6:127-130, 1952 Thomas JV, Hay LJ: Adenocarcinoma of the esophagus. Report of a case of glandular metaplasia of the esophageal mucosa. Surgery 35:635-639, 1954 McCorkle RG, Blades B: Adenocarcinoma of the esophagus arising in aberrant gastric mucosa. Am Surg 21:781-785, 1955 Smithers DW: Adenocarcinoma of the esophagus. Thorax 11:257267, 1956 Armstrong RA, Blalock JB, Carrera GM: Adenocarcinoma of the middle third of the esophagus arising from ectopic gastric mucosa. J Thorac Cardiovasc Surg 37:398-403, 1959 Dodge OG: Intraoesophageal adenocarcinoma. Gut 1:351-356, 1960 Stemmer EA, Adams WE: The incidence of carcinoma of the esophago-gastricjunction in short esophagus. Arch Surg 81:771780,1960 Azzopardi JG, Menzies T: Primary oesophageal adenocarcinoma-confirmation of its existence by the finding of mucous gland tumors. Br J Surg 49:497-506, 1962 Dawson JL: Adenocarcinoma of the middle oesophagus arising in an oesophagus lined by gastric (parietal) epithelium. Br J Surg 51:940-942, 1964 Wright JT: Allison and Johnstone's anomaly. Am J Roentgenol Radium Ther Nucl Med 94:308-320, 1965 Hershfield NB, Lind JF, Hildes JA, et al: Secretory function ofBarrett's epithelium. Gut 6:535-539, 1965 Burns WA, Flores PA, Moshyedi A, et al: Clinical conditions associated with columnar lined epithelium. Am J Dig Dis 15:607-615, 1970 Jernstrom P, Brewer LA: Primary adenocarcinoma of the midesophagus arising in ectopic gastric mucosa with associated hiatal hernia and reflux esophagitis (Dawson's syndrome) . Cancer 26:1343-1348, 1970 Shafer RB: Adenocarcinoma in Barrett's columnar-lined esopha-
1321
gus. Arch Surg 103:411-413, 1971 29. Maas LC, Katz LA, Pascale JF: Adenocarcinoma of the esophagus arising in metaplastic (Barrett's) epithelium. Gastrointest Endosc 21:73-74, 1974 30. BelJadonna JA, Hajdu SJ, Bains MS, et al: Adenocarcinoma in situ of Barrett's esophagus diagnosed by endoscopic cytology. N Engl J Med 291:895-896, 1974 31. Cho KJ, Hunter TB, Whitehouse WM: The columnar-epitheliallined lower esophagus and its association with adenocarcinoma of the esophagus. Radiology 115:563-568, 1975 32. Farnsworth AE: Adenocarcinoma in a Barrett oesophagus. Med J Aust 1:470-472, 1975 33. Raphael HA, Ellis FH, Dockerty MB: Primary adenocarcinoma of the esophagus: 18-year review and review of literature. Ann Surg 164:785-796, 1966 34. Lortat-Jacob JL, Maillard IN, Richard CA, et a1: Primary esophageal adenocarcinoma: report of 16 cases. Surgery 64:535-543, 1968 35. Turnbull ADM, Goodner JT: Primary adenocarcinoma of the esophagus. Cancer 22:915-918, 1968 36. Hankins JR, Cole FN, Attar S, et al: Adenocarcinoma involving the esophagus. J Thorac Cardiovasc Surg 68:148-158, 1974 37. Plachta A: Benign tumors of the esophagus. Review of literature and report of 99 cases. Am J Gastroenterol 38:639-652, 1962 38. Spin FP, Adenomas of the esophagus: a case report and review of the literature. Gastrointest Endosc 20:26-27, 1973 39. Kalsbeek HL, Vanderwouden A: Barrett-oesophagus with papillomatous tumour. Arch Chir Neerl 23-24:287-296, 1971 40. Stillman AE, Selwyn JI: Primary adenocarcinoma of the esophagus arising in a columnar-lined esophagus. Am J Dig Dis 20:577582, 1975 41. Winawer S, Posner G, BelJadonna J, et al: Application of panendoscopic directed brush cytology to the diagnosis of esophageal cancer (abstr). Gastrointest Endose 20:188, 1974 42 . Naef AP, Savary M: Conservative operations for peptic esophagitis with stenosis in columnar-lined lower esophagus. Ann Thorac Surg 13:543-551, 1972 43. Hill LD, Gelfand M, Bauermeister D: Simplified management of reflux esophagitis with stricture. Ann Surg 172:638-651, 1970 44. Csendes A, Larrain A: Effect of posterior gastropexy on gastroesophageal sphincter pressure and symptomatic reflux in patients with hiatal hernia. Gastroenterology 63:19-24, 1972
Vol. 72, No.6
GASTROENTEROLOGY
Printed in U.S.A.
MULTIPLE ADENOMATOUS NEOPLASMS ARISING IN COLUMNARLINED (BARRETT'S) ESOPHAGUS GEORGE B. MCDONALD, M.D., DOUGLAS
L.
BRAND, M.D., AND DAVID
R.
THORNING,
M.D.
Departments of Medicine and Pathology, Seattle Veterans Administration Hospital and the University of Washington School of Medicine, Seattle, Washington
Multiple polypoid masses were found in the esophagus of a 62-year-old man. He underwent esophageal resection because exfoliative and brush cytological studies were positive for adenocarcinoma. The surgical specimen showed that the esophagus was lined by columnar epithelial cells which were focally hyperplastic, forming polypoid masses. In both the masses and the mucosa between them, there were atypical epithelial cell changes, ranging from dysplasia to focal carcinoma. These findings reinforce the concept that the Barrett's (columnar) epithelium is a premalignant lesion deserving periodical screening. Columnar-lined (Barrett's) esophagus is most often from the teeth to the gastroesophageal junction at 38 cm) had seen as a reparative response to gastroesophageal re- an erythematous, cobblestone appearance. In addition, from flux. l -6 The epithelium can vary from a specialized col- 28 to 38 cm there were numerous irregularly nodular masses umnar type to a gastric fundic type to a junctional type. 7 projecting into the lumen; these masses ranged in diameter Parietal and chief cells can be found, usually in the from 5 to 30 mm. The stomach and duodenum appeared norfundic type epithelium. 7, 8 Primary adenocarcinomas of mal. Endoscopic biopsies from the nodular masses were interthe esophagus have appeared in association with this preted as showing columnar mucosa with focal epithelial dyscolumnar epithelium, giving rise to the hypothesis that plasia and neutrophilic infiltration of both epithelium and the Barrett's epithelium is a premalignant lesion. !HI lamina propria. Dysplasia was considered compatible with We describe here a case with Barrett's epithelium in reaction to inflammation. Endoscopic brushings from the nodular lower esophageal which we found a spectrum of neoplastic changes ranging from adenomatous hyperplasia to adenocarcinoma segment (28 to 38 cm) and an exfoliative cytology specimen contained nests of cells that have increased nuclear-cytoplasin situ. Case Report A 62-year-old white male was admitted to the Veterans Administration Hospital, Seattle, Washington, in October 1975, because of hematemesis, anorexia, and weight loss of 45 Ib over the previous 4-month period. He denied heartburn, regurgitation, and dysphagia. However, review of his medical record for December 1971 revealed complaints of nausea and vomiting; a hiatal hernia was demonstrated radiographically. He had been treated with antacids with some relief. This medication was taken intermittently over the next year, and the patient then apparently did well until mid-1975. Physical examination on admission revealed only cachexia. Abnormal laboratory data included a hematocrit of 33% with normal indices, and blood urea nitrogen of 38 mg per 100 ml, with reversion to normal after volume repletion. Special studies. The barium upper gastrointestinal series demonstrated a dilated lower esophagus with multiple nodular masses extending into the distal lumen (fig. 1). The stomach appeared normal. Esophagogastroduodenoscopy performed with an Olympus GIF-D endoscope (Olympus Corporation of America, New Hyde Park, N. Y.) revealed that the entire esophagus (from 22 cm
mic ratios, hyperchromatic and pleomorphic nuclei, and irregularly clumped nuclear chromatin, i.e., features considered diagnostic of adenocarcinoma (fig. 2). Liver function tests, radioisotope scans of the liver, brain and bone, and an EEG showed no evidence of metastatic carcinoma. Course. A total esophagectomy and colonic interposition were performed. There is a close correspondence between the gross appearance of the surgical specimen (fig. 3) and the radiographic and endoscopic images. Postoperatively the patient did well until day 22 when he suffered a sudden cardiopulmonary arrest. He was resuscitated but remained comatose until day 45, when he expired. Postmortem examination revealed dehiscence of the esophagocolonic anastomosis with mediastinitis and bilateral bronchopneumonia. Microscopic studies. The surgical specimen (figs. 4 to 6) showed replacement of usual esophageal epithelium from the proximal margin of the specimen to the gastric cardia distally by columnar epithelial cells that are focally hyperplastic, forming polypoid masses. The polypoid masses have various combinations of adenomatous and villous growth patterns. Epithelial cells, both in polypoid lesions and in mucosa between these lesions, show multifocal atypical changes ranging through all degrees of dysplasia to focal carcinoma without invasion into the muscularis mucosa. Postmortem microscopy showed stratified squamous epithelium lining the proximal edge of the dehiscence defect and no evidence of local or metastatic esophageal adenocarcinoma.
Received October 12, 1976. Accepted December 6, 1976. Address requests for reprints to: George B. McDonald, M.D., Seattle Veterans Administration Hospital, 4435 Beacon Avenue South, Seattle, Washington 98108. 1317
1318
CASE REPORTS
Discussion Barrett's columnar-lined esophagus is probably a common lesion which causes few symptoms. The diagnosis is usually made because of the development of strictures, ulcers, or bleeding. 5 , 9, 12, 13 A recent series of
FIG. 1. Barium contrast study demonstrating a dilated lower esophagus and multiple nodular masses.
Vol. 72, No.6
over 6000 esophagoscopies yielded 1225 cases of reflux esophagitis, 140 of which were associated with Barrett's epithelium. l l Of the 140 cases, 12 were discovered to have esophageal adenocarcinoma. II The findings in this case reinforce the concept that the Barrett's (columnar) epithelium is a premalignant lesion. They also suggest that benign epithelial neoplasms, i.e., adenomatous polyps, may develop before or synchronously with adenocarcinoma.
FIG. 3. Surgical specimen, opened longitudinally, showing multiple nodular masses (distal end on the right) .
FIG. 2. Esophageal cytology preparation showing a cluster of atypical cells with malignant characteristics (Papanicolaou stain, x 705).
June 1977
CASE REPORTS
1319
FIG. 4. Light micrograph of esophageal mucosa showing columnar lining and a papillary adenoma (H & E, x 74).
FIG. 5. Light micrograph of esophageal mucosa showing uniform columnar epithelium typical of Barrett's epithelium (H & E, x 282).
Both X-ray and esophagoscopy showed multiple polypoid tumors in an esophagus lined entirely by columnar epithelium. Histologically, the tumors are papillary adenomas; their epithelial cells manifest a range of atypical changes including dysplasia and adenocarcinoma in situ. Infiltrating and metastatic adenocarcinoma were not observed either in the resected esophagus or in tissue remaining at postmortem examination. We hypothesize that this man developed Barrett's epithelium
with subsequent development of multifocal hyperplasia, dysplasia, and adenocarcinoma. In addition to the 12 cases noted above, over 30 other cases of adenocarcinoma in Barrett's epithelium have been reported.!' 9, 10, 14-32 Additional cases can be found among series of patients with primary adenocarcinoma of the esophagus, an unusual tumor accounting for about 3% of all esophageal cancers. 3~36 Even more unusual are benign adenomatous polyps of the esopha-
1320
CASE REPORTS
Vol. 72, No . 6
FIG. 6. Light micrograph of esophageal mucosa showing atypical epithelial cells with malignant characteristics (H & E, x 282) .
gus. 37, 38 Thus, the simultaneous appearance of adenom- antireflux surgery.6, 8 These studies can be faulted only atous polyps and adenocarcinoma in our case seems to for the lack of proof that surgery did indeed eliminate be related to the underlying columnar epithelium and reflux. Thus, the possibility that effective antireflux not to chance occurrence. surgery may prevent cancer remains unproved. There are 3 reported cases which suggest polypoid REFERENCES epithelial hyperplasia (or adenomatous polyp) as a pre1. Allison PR, Johnstone AS: The oesophagus lined with gastric cursor for adenocarcinoma. Marked dysplastic changes mucous membrane. Thorax 8:87-101 , 1953 were found in the proximal columnar epithelium of 1 of 2. Goldman MC, Beckman RC: Barrett syndrome: case report with 7 11 well studied patients with Barrett's epithelium. Andiscussion about concepts of pathogenesis. Gastroenterology other patient developed an esophageal "papillomatous 39:104-110, 1960 tumor with markedly atypical cells" after 8 years of 3. Mossberg SM: The columnar-lined esophagus (Barrett synobservation for her Barrett's esophagus.39 A similar drome): an acquired condition? Gastroenterology 50:671-676, large multicentric polypoid mass was removed from the 1965 Barrett's esophagus of still another patient; histology 4. Heitman P, Strauszer T, Sapunar J, et al: Lower esophagus lined with columnar epithelium: morphological and physiological corshowed both adenoma and well differentiated superfirelation. Gastroenterology 53:611-624, 1967 cial adenocarcinoma without invasion of the muscle 5. Burgess IN, Payne WS, Andersen HA, et al: Barrett esophagus: layer.40 the columnar-epithelial-lined lower esophagus. Mayo Clin Proc Careful periodic screening of patients with Barrett's 46:728-734, 1971 epithelium should be done to find either dysplastic 6. Endo M, Kobayashi S, Kozu T, et al: A case of Barrett epithelizachanges, benign adenomas, or curable intraepithelial tion followed up for five years. Endoscopy 6:48-51, 1974 adenocarcinoma. Esophagoscopy with directed biopsy 7. Paull AP, TrierJS, Dalton MD, et al: The histologic spectrum of 30 and cytology is the best screening procedure. , 41 SurgiBarrett's esophagus. N Engl J Med 295:476-480, 1976 cal removal seems to be the treatment of choice for 8. Mangla JC, Schenk EA, Desbaillets L, et al: Pepsin secretion, adenocarcinoma of the esophagus. There is no great pepsinogen, and gastrin in "Barrett's esophagus." Clinical and expectation of cure of symptomatic adenocarcinoma,33, 35 morphological characteristics. Gastroenterology 70:669-676, 1976 but it is possible that early detection will improve sur9. Adler RH: The lower esophagus lined by columnar epithelium: vival. its association with hiatal hernia, ulcer, strictures, and tumor. J Can Barrett's epithelium disappear once it has lined Thorac Cardiovasc Surg 45:13-34, 1963 the esophagus? The epithelial change appears to be an 10. Hawe A, Payne WS, Weiland LH, et al: Adenocarcinoma in the adaptation to chronic reflux of gastric contents; therecolumnar-epithelial lined lower (Barrett) oesophagus. Thorax fore, a successful antireflux operation may be expected 28:511-514, 1973 to result in return of normal squamous epithelium. 11. Naef AP, Savary M, Ozzello L: Columnar-lined lower esophagus: Such surgery is effective in treating Barrett's ulcers and an acquired lesion with malignant predisposition. J Thorac Carstrictures,42-44 but there are several cases in which coldiovasc Surg 70:826-835, 1975 umnar epithelium persisted despite clinically successful 12. Heitmann P: Lower esophagus lined with columnar epithelium.
June 1977
13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25 . 26. 27.
28.
CASE REPORTS
In Diseases of the Esophagus Edited by G Vantrappen, J HelJemans. New York, Berlin, Heidelberg, Springer-Verlag, 1974, p 525-538 Johnston JH: Gastric lined esophagus associated with rings and stenoses. Ann Surg 173:641-648, 1971 Carrie A: Adenocarcinoma of the oesophagus arising from ectopic gastric epithelium. Br J Surg 37:474, 1950 Morson BC, Belcher JR: Adenocarcinoma of the oesophagus and ectopic gastric mucosa. Br J Cancer 6:127-130, 1952 Thomas JV, Hay LJ: Adenocarcinoma of the esophagus. Report of a case of glandular metaplasia of the esophageal mucosa. Surgery 35:635-639, 1954 McCorkle RG, Blades B: Adenocarcinoma of the esophagus arising in aberrant gastric mucosa. Am Surg 21:781-785, 1955 Smithers DW: Adenocarcinoma of the esophagus. Thorax 11:257267, 1956 Armstrong RA, Blalock JB, Carrera GM: Adenocarcinoma of the middle third of the esophagus arising from ectopic gastric mucosa. J Thorac Cardiovasc Surg 37:398-403, 1959 Dodge OG: Intraoesophageal adenocarcinoma. Gut 1:351-356, 1960 Stemmer EA, Adams WE: The incidence of carcinoma of the esophago-gastricjunction in short esophagus. Arch Surg 81:771780,1960 Azzopardi JG, Menzies T: Primary oesophageal adenocarcinoma-confirmation of its existence by the finding of mucous gland tumors. Br J Surg 49:497-506, 1962 Dawson JL: Adenocarcinoma of the middle oesophagus arising in an oesophagus lined by gastric (parietal) epithelium. Br J Surg 51:940-942, 1964 Wright JT: Allison and Johnstone's anomaly. Am J Roentgenol Radium Ther Nucl Med 94:308-320, 1965 Hershfield NB, Lind JF, Hildes JA, et al: Secretory function ofBarrett's epithelium. Gut 6:535-539, 1965 Burns WA, Flores PA, Moshyedi A, et al: Clinical conditions associated with columnar lined epithelium. Am J Dig Dis 15:607-615, 1970 Jernstrom P, Brewer LA: Primary adenocarcinoma of the midesophagus arising in ectopic gastric mucosa with associated hiatal hernia and reflux esophagitis (Dawson's syndrome) . Cancer 26:1343-1348, 1970 Shafer RB: Adenocarcinoma in Barrett's columnar-lined esopha-
1321
gus. Arch Surg 103:411-413, 1971 29. Maas LC, Katz LA, Pascale JF: Adenocarcinoma of the esophagus arising in metaplastic (Barrett's) epithelium. Gastrointest Endosc 21:73-74, 1974 30. BelJadonna JA, Hajdu SJ, Bains MS, et al: Adenocarcinoma in situ of Barrett's esophagus diagnosed by endoscopic cytology. N Engl J Med 291:895-896, 1974 31. Cho KJ, Hunter TB, Whitehouse WM: The columnar-epitheliallined lower esophagus and its association with adenocarcinoma of the esophagus. Radiology 115:563-568, 1975 32. Farnsworth AE: Adenocarcinoma in a Barrett oesophagus. Med J Aust 1:470-472, 1975 33. Raphael HA, Ellis FH, Dockerty MB: Primary adenocarcinoma of the esophagus: 18-year review and review of literature. Ann Surg 164:785-796, 1966 34. Lortat-Jacob JL, Maillard IN, Richard CA, et a1: Primary esophageal adenocarcinoma: report of 16 cases. Surgery 64:535-543, 1968 35. Turnbull ADM, Goodner JT: Primary adenocarcinoma of the esophagus. Cancer 22:915-918, 1968 36. Hankins JR, Cole FN, Attar S, et al: Adenocarcinoma involving the esophagus. J Thorac Cardiovasc Surg 68:148-158, 1974 37. Plachta A: Benign tumors of the esophagus. Review of literature and report of 99 cases. Am J Gastroenterol 38:639-652, 1962 38. Spin FP, Adenomas of the esophagus: a case report and review of the literature. Gastrointest Endosc 20:26-27, 1973 39. Kalsbeek HL, Vanderwouden A: Barrett-oesophagus with papillomatous tumour. Arch Chir Neerl 23-24:287-296, 1971 40. Stillman AE, Selwyn JI: Primary adenocarcinoma of the esophagus arising in a columnar-lined esophagus. Am J Dig Dis 20:577582, 1975 41. Winawer S, Posner G, BelJadonna J, et al: Application of panendoscopic directed brush cytology to the diagnosis of esophageal cancer (abstr). Gastrointest Endose 20:188, 1974 42 . Naef AP, Savary M: Conservative operations for peptic esophagitis with stenosis in columnar-lined lower esophagus. Ann Thorac Surg 13:543-551, 1972 43. Hill LD, Gelfand M, Bauermeister D: Simplified management of reflux esophagitis with stricture. Ann Surg 172:638-651, 1970 44. Csendes A, Larrain A: Effect of posterior gastropexy on gastroesophageal sphincter pressure and symptomatic reflux in patients with hiatal hernia. Gastroenterology 63:19-24, 1972