Ann Thorac Surg 2000;69:288-289
© 2000 The Society of Thoracic Surgeons
Case Reports
Adenocarcinoma in a mid-esophageal diverticulum
Eli Avisar, MDa,
James D. Luketich, MDa
a Section of Thoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
Address reprint requests to Dr Luketich, Section of Thoracic Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, C800, Pittsburgh, PA 15213-3221
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Abstract
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The incidence of esophageal adenocarcinoma has been increasing compared with squamous cell carcinoma. The most common location of adenocarcinoma of the esophagus is the distal one third. Cancer developing in an esophageal diverticulum is uncommon, but tumors of squamous cell origin in esophageal diverticula have been reported previously. We describe an adenocarcinoma in a midesophageal diverticulum and review malignancies occurring in esophageal diverticula.
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Introduction
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Esophageal cancer accounts for 2% of new cancer cases in the United States per year. The main symptoms are weight loss and dysphagia, which are caused by narrowing of the esophageal lumen by the tumor. Early diagnosis is essential in this aggressive disease, which carries a 5-year survival rate of only 5% to 10%. The rare occurrence of a malignancy in a diverticulum makes it even more difficult to diagnose early, because many of these patients already suffer from varying degrees of dysphagia because of underlying motility disorders and because the lesion is located outside of the main food channel. Previous reports of esophageal carcinoma developing in diverticula have all been of the squamous cell type. Herein we describe a case of adenocarcinoma in a midesophageal diverticulum.
A 60-year-old man with severe emphysema presented to the thoracic surgery clinic complaining of a 3-month history of increasing dysphagia to solids accompanied by a weight loss of 20 pounds. He reported a heavy smoking history and prior ethanol abuse.
Barium swallow and upper endoscopy revealed a diverticulum 28 cm from the incisors containing a large ulcerated tumor (Figs 1, 2). Biopsies revealed a poorly differentiated adenocarcinoma. Computed tomography of the chest demonstrated enlarged mediastinal lymph nodes and endoscopic ultrasound staging was T3N1. A mediastinoscopy and laparoscopic staging were performed as part of a neoadjuvant chemotherapeutic protocol for locally advanced tumors. The right paratracheal, subcarinal, and hilar nodes were found to contain metastases. After two cycles of chemotherapy with paclitaxel and carboplatinum, an attempt of resection was performed through a right thoracotomy, but the procedure was aborted after evidence of extension into the lung hilum was found.
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Comment
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Adenocarcinoma of the lower third of the esophagus has become more common in the last 20 years, but the only consistent risk factor described is chronic gastroesophageal reflux, often in the setting of Barrett’s esophagus. This increase in the incidence of esophageal adenocarcinoma is progressing at an alarming pace from rates of less than 8% of all primary neoplasms of the esophagus in 1984 [1] to a recently reported rate of 43% [2]. It is especially predominant in white males, in whom it can account for more than 90% of cancers in the esophagus [3].
Esophageal diverticula are commonly divided by their anatomic location and their etiology. Motility problems causing bulging of the mucosa through the muscular fibers account for the formation of pharyngoesophageal (Zenker’s) and epiphrenic diverticula, which are called pulsion diverticula. External inflammatory processes, however, are responsible for the formation of mid-esophageal diverticula by traction on the esophageal wall, which are accordingly named traction diverticula.
The first two reports of a carcinoma arising in a pharyngoesophageal diverticulum were by Vinson [4] in 1927 and by Sparks [5] in 1933. Since that time, approximately 30 patients with squamous cell carcinoma developing in a Zenker’s diverticulum have been reported.
Shin [6] in 1971 and Giuli and colleagues [7] in 1974 each described a case of squamous cell carcinoma located in an epiphrenic diverticulum. In 1996 Schultz and associates [8] reviewed 14 additional cases from the English literature. One case of a benign leiomyoma [9] and a case of metastatic neuroma [10] arising in an epiphrenic diverticulum were also reported.
Midesophageal diverticula are less common than pharyngoesophageal and epiphrenic diverticula. Two cases of squamous cell carcinoma in a midesophageal diverticulum were described in Japan [11, 12]. Another two cases were reported from France and Argentina [13, 14]. Interestingly, none of the cases of malignancies in esophageal diverticula was an adenocarcinoma.
In summary, adenocarcinoma of the esophagus is a disease on the rise that can be found also in a diverticulum. If mucosal changes are seen in esophageal diverticula they should be biopsied, and if malignant, treated as other esophageal cancers.
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References
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Accepted for publication June 9, 1999.
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Abstract
Introduction
