Gastrointestinal Pathology I Case Studies


CASE 2: Esophageal adenocarcinoma arising in Barrett mucosa


Clinical History:

This 55-year-old man had suffered from episodes of "heartburn" with sub-sternal chest pain from chronic reflux esophagitis for several decades (image 2.1). He then presented with dysphagia developing over the past month. On upper GI endoscopy a mass lesion was found in the lower esophagus, and biopsies were taken (image 2.2). Based upon the biopsy findings, a partial esophagectomy was performed. The mass lesion extended into the muscular wall and ulcerated the overlying surface mucosa (image 2.3). The predisposing lesion which developed from reflux is shown in image 2.4 and 2.5. The precursor lesion is seen in image 2.6, and the mass lesion in image 2.7.
  1. What is the diagnosis?

    2. This is a primary adenocarcinoma of the esophagus.

  2. Where is this lesion arising?

    3. About 5 to 10% of esophageal carcinomas are adenocarcinomas, but adenocarcinoma of the stomach that invades into the lower esophagus is probably more frequent.

  3. What is the major predisposing condition for lesions such as this that are known to arise within the esophagus?

    4. Of adenocarcinomas that arise in the esophagus, Barrett's mucosa is present in the majority. These patients often give a history of "heartburn" or burning substernal chest pain, especially after eating. Over 40% of adult Americans may experience regular GERD symptoms. The columnar metaplasia is seen in images 2.4 and 2.5 (it is gastric in image 2.4 but more intestinal with goblet cells in image 2.5--either can occur but intestinal type mucosa is the most typical for Barrett). After many years, a dysplasia can arise in Barrett's mucosa, as shown in image 2.6, and from this can arise an adenocarcinoma, as shown in image 2.7. There is about a 10% lifetime risk for adenocarcinoma in patients with Barrett esophagus. Endoscopic surveillance can detect some early, curable neoplasms in patients with Barrett's esophagus. Dysplasia in Barrett's esophagus is widely regarded as the precursor of invasive malignancy.