Ann Thorac Surg 1996;61:216-218
© 1996 The Society of Thoracic Surgeons
Case Report
Multiple Polyposis and Adenocarcinoma Arising in Barrett's Esophagus
Rose S. Wong, MD,
R. Thomas Temes, MD,
Fabrizio M. Follis, MD,
Randolph M. Kessler, MD,
Stuart B. Pett, Jr, MD,
Jorge A. Wernly, MD
Division of Thoracic and Cardiovascular Surgery, University of New Mexico, Albuquerque, New Mexico
Accepted for publication July 11, 1995.
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Abstract
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Adenomatous polyps of the esophagus are rare in comparison with those of the lower gastrointestinal tract. Like adenomatous colon polyps, they have been associated with malignancy. We describe a case of early adenocarcinoma and multiple polyposis of the esophagus arising in a Barrett's epithelium, treated with surgical resection.
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Introduction
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The majority of esophageal polyps are benign. They include fibrovascular polyps, papillomas and adenomas, the last accounting for less than 1% [1]. In this article, we report a case of adenocarcinoma arising from a Barrett's esophagus containing multiple adenomatous polypoid lesions.
The patient was a 67-year-old man who presented with upper gastrointestinal bleeding. His past medical history was significant for severe chronic obstructive lung disease, right below-knee amputation for trauma, and left nephrectomy for trauma. Polypoid esophageal lesions extending from 27 to 41 cm were identified on upper endoscopy. Biopsies revealed metaplastic mucosa consistent with Barrett's esophagus.
He was treated with H2 blockers. Eight months later surveillance endoscopy confirmed diffuse polyposis of the distal two thirds of the esophagus. Biopsy at this time revealed high-grade dysplasia and possible invasive adenocarcinoma. Preoperative computed tomographic scan confirmed esophageal polyposis extending from above the carina to the gastroesophageal junction. There was no evidence of metastatic disease or mediastinal or celiac adenopathy.
On physical examination, he had stigmata of severe chronic obstructive pulmonary disease. There was no cervical or supraclavicular adenopathy and no abdominal masses. Pulmonary function testing demonstrated a forced expiratory volume in 1 second of 1.06 L (37% predicted) without response to bronchodilators. Room air arterial oxygen saturation ranged from 86% to 91%.
Intraoperative exploration of the abdomen was normal. There was no celiac adenopathy or palpable metastatic disease to the liver. The patient underwent transhiatal esophagectomy with cervical esophagogastric anastomosis, pyloromyotomy, and feeding jejunostomy. Gross examination of the resected specimen showed extensive polypoid lesions occupying two thirds of the length of the esophagus (Fig 1
).
His postoperative course was complicated by respiratory failure and pneumonia. Tracheostomy was performed after several failed attempts at extubation. After a period of rehabilitation, he was discharged without symptoms of dysphagia.
Final pathologic examination showed extensive mucosal polyposis, with polyps ranging from 0.3 to 2.5 cm in diameter. The majority of the specimen contained Barrett's epithelium, with changes ranging from glandular metaplasia to multiple foci of invasive adenocarcinoma. The polypoid lesions consisted primarily of severe dysplasia; areas of invasive carcinoma were small and did not correlate precisely with polyps.
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Comment
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Adenocarcinoma is becoming a common form of esophageal carcinoma. The incidence of adenocarcinoma in Barrett's esophagus is reported to be 8% [2]. The endoscopic appearance is usually one of ulceration or mass.
The presence of adenomatous polyps in areas usually occupied by squamous epithelium is infrequent. Most are solitary lesions. Benign adenomas are rarely found near heterotopic islands of gastric mucosa or within Barrett's mucosa. Solitary benign polyps arising within Barrett's mucosa have been removed and followed up [1].
An early report of an adenomatous polyp with carcinoma postulated malignant degeneration of a benign polyp as cause. The patient was lost to follow-up [3]. The first patient surgically treated with adenocarcinoma arising within a polyp had ectopic gastric mucosa adjacent to the tumor [4]. Another early adenocarcinoma arising within a polyp surrounded by Barrett's mucosa was reported in 1988 [5]. These reports of adenocarcinoma arising within adenomas were of solitary lesions.
There are only 2 reported cases of surgically treated multiple adenomatous polyps of the esophagus in the English-language literature [6, 7]. One case of carcinoma in situ resulted in the death of the patient after anastomotic dehiscence. The other report described a patient with stage II disease but provided no follow-up. Our patient with adenocarcinoma arising from polyposis of Barrett's esophagus was treated with transhiatal esophagectomy for a stage I tumor. The patient was free of recurrence 1 year later.
Adenomas of the distal esophagus, like those in the lower gastrointestinal tract, should be considered precursors to carcinoma [6, 8]. They should receive careful endoscopic surveillance to allow resection for cure at an early stage.
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Footnotes
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Address reprint requests to Dr Temes, Division of Thoracic and Cardiovascular Surgery, University of New Mexico, 2211 Lomas Blvd NE, Albuquerque, NM 87131.
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References
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- Keeffe EB, Hisken EC, Schubert F. Adenomatous polyp arising in Barrett's esophagus. J Clin Gastroenterol 1986;8:271–4.[Medline]
- Reid BJ. Barrett's esophagus and esophageal adenocarcinoma. Gastroenterol Clin North Am 1991;20:817–35.[Medline]
- Feldman M. Adenocarcinomatous pedunculated polyp of the esophagus. Am J Digest Dis 1939;6:453–4.
- Davis WM, Goodwin MN Jr, Black HC, Hawk JC. Polypoid adenocarcinoma of the cervical esophagus. Arch Pathol 1969;88:367–70.[Medline]
- Singal AK, Chaudhary A, Malik R, Anand BS. Adenocarcinoma in Barrett's oesophagus presenting as a polyp. J Assoc Phys India 1988;36:567–8.
- Paraf F, Flejou JF, Potet F, Molas G, Fekete F. Adenomas arising in Barrett's esophagus with adenocarcinoma. Pathol Res Pract 1992;188:1028–32.[Medline]
- McDonald GB, Brand DL, Thorning DR. Multiple adenomatous neoplasms arising in columnar-lined (Barrett's) esophagus. Gastroenterology 1977;72:1317–21.[Medline]
- Lee RG. Adenomas arising in Barrett's esophagus. Am J Clin Pathol 1986;85:629–32.[Medline]
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Abstract
Introduction
