Esophagus
Carcinoma
Adenocarcinoma

Author: Elliot Weisenberg, M.D. (see Authors page)

Revised: 22 January 2018, last major update June 2013

Copyright: (c) 2003-2018, PathologyOutlines.com, Inc.

PubMed Search: Adenocarcinoma[TI] esophagus[TI] pathology free full text[sb]

See also: Arising in ectopic gastric mucosa, Gastroesophageal junction, Intramucosal carcinoma
Cite this page: Weisenberg, E. Adenocarcinoma. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/esophagusadenocarcinoma.html. Accessed July 22nd, 2018.
Definition / general
  • Malignant gland forming tumor of esophagus
Epidemiology
  • In developed world, incidence has increased, while incidence of squamous cell carcinoma has remained constant (Ann Oncol 2012;23:3155, J Natl Compr Canc Netw 2011;9:830)
  • 50 - 70% of esophageal carcinomas are adenocarcinoma
  • In 2013, American Cancer Society estimates 17,990 new cases of esophageal carcinoma in US with 15,210 deaths
  • Mean age is ~60 years old; cases before age 50 are uncommon
  • ~80% men
  • While the most substantial increase has been among white men, incidence is increasing in women and men of other ethnicities
  • Obesity and high BMI are strong risk factors, likely related to increased GERD and Barrett esophagus
  • Barrett esophagus is most important risk factor
  • Tobacco is moderate risk factor
  • Infection with cagA+ Helicobacter pylori appears to be protective against reflux esophagitis, the initial step in development of adenocarcinoma (pathway is reflux to Barrett esophagus to dysplasia to adenocarcinoma); increase in adenocarcinoma may be due, in part, to decline in prevalence of Helicobacter pylori (Cancer Res 1998;58:588, Cancer Prev Res (Phila) 2008;1:329)
  • H. pylori infection may cause atrophic gastritis, decreasing acid production and thus decreasing reflux disease
Sites
  • Generally in distal esophagus
  • Rarely may arise in submucosal glands or ectopic gastric mucosa
Pathophysiology
  • Dysplasia - carcinoma sequence in Barrett mucosa with stepwise accumulation of genetic mutations, especially p53 gene; additional changes involve HER2 / c-ERBB2, cyclin D1, cyclin E genes, RB, p16 genes
Clinical features
  • Insidious onset, dysphagia to solids, followed by dysphagia to all food
  • Extreme weight loss due to loss of nutrition and the tumor itself
  • Metastasis generally occurs early even in superficial tumors, due to extensive lymphatic network in esophagus that allows horizontal and longitudinal spread
  • Adenocarcinoma occurs in lower esophagus and lymph node metastases involve gastric and celiac lymph nodes
  • Visceral metastases to liver, lungs, pleura
  • Recurrences are common
Diagnosis
  • Overwhelming majority diagnosed by endoscopic biopsy
Radiology description
  • Imaging reveals mass in distal esophagus
Prognostic factors
  • Lymph node metastases, extracapsular lymph node involvement (Am J Surg Pathol 2006;30:171), depth of invasion (but see J Clin Oncol 2007;25:507), status of resection margins; possibly endoglin / CD105 (Hum Pathol 2005;36:955)
  • Postchemoradiation therapy prognostic factors in resection specimens:
    1. Extent of residual carcinoma predicts survival based on 3 groups:
    2. Prominent mucin pools in patients with Barrett associated adenocarcinoma are associated with mucinous tumors but acellular mucin pools are NOT associated with poor survival, even if at radial margin (Am J Surg Pathol 2006;30:28)
Case reports
Treatment
  • 5 year survival for nonresectable tumors is rare
  • Resection if primary treatment modality (if possible); may be preceded by neoadjuvant therapy - report Barrett metaplasia on proximal margin, if present
  • Adjuvant chemoradiation often given
Gross description
  • Usually distal esophageal tumor with invasion of gastric cardia; appears as flat patches to nodular masses; may have adjacent Barrett mucosa
Gross images

Images hosted on PathOut server:

Adenocarcinoma in Barrett esophagus



Images contributed by Dr. Mark R. Wick:

In Barrett metaplasia



Images hosted on other servers:

Polypoid tumor



Images contributed by Dr. Elliot Weisenberg:
Microscopic (histologic) description
  • Usually moderate or well differentiated, usually mucin producing (intestinal type mucosa), may have foci of squamous or endocrine differentiation
  • Usually has adjacent Barrett mucosa with high grade dysplasia (may be displaced by adenocarcinoma)
  • Rarely signet ring cells, papillary structures, Paneth cells, endocrine cells, pagetoid spread of tumor cells
Microscopic (histologic) images

Images hosted on PathOut server:

Arising from Barrett epithelium:

Various images



Images contributed by Dr. Mark R. Wick:

Metaplasia



Images hosted on other servers:

Arising from
Barrett epithelium:
moderately
differentiated

Adenocarcinoma / neuroendocrine carcinoma collision tumor



Images contributed by Dr. Elliot Weisenberg:

In lymphatics

Positive stains
Negative stains
Electron microscopy images

Images hosted on other servers:

Adenocarcinoma (site unspecified)

Differential diagnosis