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Table of Contents
Definition / general | Epidemiology | Sites | Pathophysiology | Clinical features | Diagnosis | Radiology description | Prognostic factors | Case reports | Treatment | Gross description | Gross images | Microscopic (histologic) description | Microscopic (histologic) images | Positive stains | Negative stains | Electron microscopy images | Differential diagnosis | Additional referencesCite this page: Weisenberg E. Adenocarcinoma. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/esophagusadenocarcinoma.html. Accessed April 23rd, 2019.
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:
- Extent of residual carcinoma predicts survival based on 3 groups:
- P0 (0% residual carcinoma)
- P1 (1 - 50% residual carcinoma)
- P2 (> 50% residual carcinoma, Am J Surg Pathol 2007;31:58)
- 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)
- Extent of residual carcinoma predicts survival based on 3 groups:
Case reports
- 51 year old man with collision tumor with papillary adenocarcinoma and neuroendocrine carcinoma (Arch Pathol Lab Med 2000;124:411)
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
AFIP images
Adenocarcinoma in Barrett esophagus
Contributed by
Mark R. Wick, M.D.
In Barrett metaplasia
Contributed by
Dr. Elliot Weisenberg
Adenocarcinoma
Images hosted on other servers:
Polypoid tumor
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
AFIP images
Arising from Barrett epithelium
Contributed by
Mark R. Wick, M.D.
Metaplasia
Contributed by
Dr. Elliot Weisenberg
In lymphatics
Images hosted on other servers:
Arising from
Barrett epithelium:
moderately
differentiated
Adenocarcinoma / neuroendocrine carcinoma collision tumor
Positive stains
- Rarely needed for diagnosis
- PAS, Alcian blue and mucicarmine (for mucin), usually CK7 and CK19 (Am J Surg Pathol 2002;26:1213), AMACR (Hum Pathol 2006;37:1601); focal positivity is common for somatostatin and serotonin (Histopathology 1987;11:53)
Negative stains
Electron microscopy images
Images hosted on other servers:
Adenocarcinoma (site unspecified)
Differential diagnosis
- High grade dysplasia (no single cell invasion, no infiltration of submucosa or muscularis mucosae), metastatic or adjacent gastric carcinoma (signet ring cells may be present; often CK20+ in background of intestinal metaplasia)
- Note per AJCC criteria, cancers of the gastroesophageal junction are staged as esophageal carcinomas
Additional references
