Teaching Case

Retrosternal burning and recently occurred dysphagia

A 70 year old male affected by chronic retrosternal burning due to gastroesophageal reflux, recently developed progressive dysphagia. Double contrast esophagograms showed an irregular narrowing extending for 7 cm in the distal portion of the esophagus due to an infiltrating lesion. The mucosa proximal to this tumour showed sign of esophagitis with widening of edematous longitudinal folds and the presence of transverse esophageal folds, but there were no erosions or ulcerations. Transverse folds (feline esophagus) are a transient motility phenomenon seen with increased frequency in patients with gastroesophageal reflux, esophagitis, or ulcers. A voluminous sliding hiatal hernia was also observed in the portion distal to the tumour. Endoscopy and biopsy confirmed the radiological diagnosis; histological findings revealed adenocarcinoma in Barrett's esophagus. Thoracic and abdominal CT was performed to assess the extension and resectability of the tumour. CT demonstrated a focal wall tickening of the esophagus with an irregular lumen and the absence of obliteration of the fat planes between the esophagus and adjacent structures particularly the aorta.

Primary adenocarcinoma comprises about 2% of carcinomas of the esophagus. They present as ulcerating, stenosing or fungoid lesions. Adenocarcinoma probably arise from columnar-lined esophagus, esophageal glands, or heterotopic gastric mucosa (Barrett's esophagus). Barrett's esophagus is recognized as precancerous lesion leading to adenocarcinoma of esophagus, and radiologically is characterized by a reticular pattern or deep ulcers and strictures. This metaplasia is presumed to occur as a complication of reflux esophagitis, expecially in view of the frequency with this syndrome is associated with a sliding hiatal hernia and a demonstrable gastroesophageal reflux. The prognosis of adenocarcinoma is the same as squamous cell carcinoma and strictly dependent on the surgical resectability of the lesion.