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Ann Thorac Surg 1985;40:330-336
© 1985 The Society of Thoracic Surgeons

Articles

Management of Adenocarcinoma in a Columnar-Lined Esophagus

I.A. Harle, M.D.*, R.J. Finley, M.D., F.R.C.S.(C)*, M. Belsheim, M.D., F.R.C.P.(C), D.C. Bondy, M.D., F.R.C.P.(C), M. Booth, M.D., F.R.C.P.(C), D. Lloyd, M.D., F.R.C.P.(C), J.W.D. McDonald, F.R.C.P.(C), S. Sullivan, M.D., F.R.C.P.(C), L.S. Valberg, M.D., F.R.C.P.(C), W.C. Watson, M.D., F.R.C.P.(C), J.V. Frei, M.D., F.R.C.P.(C), R. Slinger, M.D., F.R.C.P.(C), M. Troster, M.D., F.R.C.P.(C), G.E. Meads, M.D., F.R.C.S.(C), J.H. Duff, M.D., F.R.C.S.(C)

From the Departments of Surgery, Medicine, and Pathology, University of Western Ontario and St. Joseph's University, and Victoria Hospitals, London, Ont, Canada

* Address reprint requests to Dr. Harle, c/o R. J. Finley, M. D., Department of Surgery, Victoria Hospital, 375 South St, London, Ont, Canada N6E 2H3

Of 89 patients diagnosed between 1973 and 1983 as having at least 3 cm of columnar-lined esophagus, 22 were found to have adenocarcinoma. There was no difference in sex ratio, smoking, or the use of alcohol between the benign and adenocarcinoma groups. The patients with adenocarcinoma were older (63 years versus 57 years) and had a higher frequency of dysphagia (64% versus 46%), gastrointestinal bleeding (36% versus 24%), extended columnar-lined esophagus (94% versus 28%), and epithelial dysplasia (68% versus 10%). Heartburn was less frequent in the adenocarcinoma group (59% versus 79%), but when it occurred, it was of longer duration (mean, 18.8 years versus 10.9 years). In 2 patients, progression from benign columnar-lined esophagus to early adenocarcinoma was observed.

Of the patients with adenocarcinoma, 2 received palliative treatment without resection and died four and nine months later. Six underwent partial esophagogastrectomy with 1 postoperative death. Four had residual columnar-lined esophagus at the resection margins. In one of them, stricture developed and in one, anastomotic recurrence of adenocarcinoma; 1-year survival was 50%. Fourteen patients underwent total thoracic esophagectomy with no operative deaths, strictures, or anastomotic recurrences; 1-year survival was 5 of 6. Surgical staging revealed that 63% had transmural spread and 55%, lymph node involvement.

Patients with columnar-lined esophagus, particularly with epithelial dysplasia, extended columnar-lined esophagus, and a long duration of heartburn, are at risk of developing adenocarcinoma. Adenocarcinoma may be diagnosed at an early stage if patients with epithelial dysplasia are followed with regular endoscopy. Total versus partial removal of the esophagus for adenocarcinoma in columnar-lined esophagus decreases the risk of complications from residual columnar-lined esophagus.




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