Successful Treatment of an Early Barrett’s Adenocarcinoma in a High-Risk Patient with Portal Hypertension: The “Band and Leave” Strategy

Abstract“Band and leave” strategy has been described for the resection of submucosal tumors of the digestive tract to reduce the complications related to deep submucosal resection such as bleeding and perforation. We present the case of a patient with multiple comorbidities, chronic liver disease, and portal hypertension diagnosed to have T1 adenocarcinoma in Barrett's esophagus overlying a column of varix. This was successfully treated by band ligation and allowing the neoplastic mucosa to slough. We propose this technique as an alternative therapeutic option for the management of early Barrett’s neoplasia in such high-risk patients with portal hypertension.

Surgically resected primary esophageal choriocarcinoma accompanied with Barrett’s adenocarcinoma: a case report

Background Choriocarcinomas are usually classified as either gestational or non-gestational. Primary choriocarcinomas in the gastrointestinal tract, especially primary choriocarcinomas in the esophagus, are extremely rare. We report a case of a rare primary esophageal choriocarcinoma mixed with squamous cell carcinoma-like components in association with Barrett’s adenocarcinoma. Case presentation A 58-year-old man visited the hospital, complaining of hematemesis and tarry stools. In emergency upper gastrointestinal endoscopy, a bleeding esophageal tumor was observed. Additionally, a contrast computed tomography (CT) scan showed a large hypervascular tumor 4.8 cm in diameter in the left kidney. He came to our institution for further examination and treatment of the esophageal tumor and kidney lesion. The patient had an easy bleeding elevated tumor 2 cm in diameter at the left wall of the middle thoracic esophagus and a left renal carcinoma. Histopathological diagnosis of the biopsy specimen of the esophageal tumor was a poorly differentiated carcinoma. However, a precise histological type diagnosis could not be obtained. In June 2016, mediastinoscopic transhiatal esophagectomy and posterior mediastinal gastric tube reconstruction were performed to treat his esophageal tumor. Histopathologically, most of the tumor comprised hCG-positive syncytiotrophoblasts. Therefore, we confirmed it as a primary esophageal choriocarcinoma. Furthermore, the tumor contained a poorly differentiated squamous cell carcinoma-like component that was also diagnosed as a choriocarcinoma using immunohistochemical staining and there was a small Barrett’s esophageal adenocarcinoma lesion in the Barrett's epithelium near the tumor. Three months after surgery, a CT scan demonstrated multiple lung metastatic nodules and multiple intrahepatic masses. Needle biopsy from the lung nodule showed a choriocarcinoma. Despite chemotherapy, the metastatic choriocarcinoma regrew rapidly and multiple bone metastases appeared. He died because of his esophageal choriocarcinoma 13 months after primary resection. Conclusions We encountered an extremely rare case of esophageal choriocarcinoma combined with squamous cell carcinoma-like components in association with a simultaneous Barrett’s adenocarcinoma that we followed for the entire course of his disease, from resection to end of life. Esophageal choriocarcinomas are rare with peculiar characteristics and very poor prognoses. Additional cases are needed to establish an appropriate future treatment.

576 P40, P63-NEGATIVE NON-SQUAMOUS CELL CARCINOMA OF ESOPHAGUS EXCEPT FOR ADENOCARCINOMA OF ESOPHAGOGASTRIC JUNCTION, REPORT OF TWO CASES

Esophageal cancer is the eighth most common human malignancy and the sixth most common cause of death from cancer worldwide. In Europe and the United States, the proportion of adenocarcinoma has increased due to the increase of Barrett's adenocarcinoma. On the other hands, in Japan most cases are squamous cell carcinoma and adenocarcinoma except esophagogstric junction including Barrett's adenocarcinoma is extremely rare. Methods We experienced two cases of tumors with morphologically no distinct squamous or glandular differentiation and confirmed not to be Barrett’s adenocarcinoma. No clear positive findings for p40 and p63 by immunohistochemistry. Case 1 is 69-year-old man. Esophagectomy was performed after neoadjuvant chemotherapy. Macroscopic findings of the resected specimen showed 59 × 43 mm of tumor (type 2) at upper to middle thoracic esophagus. Case 2 is 53-year-old man. Esophagectomy was performed without neoadjuvant chemotherapy. Macroscopic findings of the resected specimen showed 68 × 46 mm of tumor (type 1) at middle thoracic esophagus. Results Pathological examination revealed that the cancer cells showed mainly solid proliferation and no clear keratinization and gland formation was observed. The relationship with the duct of esophageal gland proper was not observed. Immunohistochemistry, tumor cells showed no neuroendocrine differentiation(ChromograninA-, synaptophysin-)and negative for p40, p63 and CK14, on the other hands tumor cells were positive for CK18. Conclusion By the WHO classification, in addition to adenocarcinoma of the esophagogastric junction, squamous cell carcinoma, neuroendocrine tumor, and salivary gland type tumor, there is an item of undifferentiated carcinoma. However, tumor cells of our cases had not such strong atypia, and immunohistochemical study showed glandular differentiation. Although we could not clarify the origin of tumor, it was suggested that there may be carcinoma other than adenocarcinoma of the esophagogastric junction, which may have glandular elements.

O129 CLASSIFICATION OF BARRETT’S CARCINOMA SPECIMENS BY HYPERSPECTRAL IMAGING (HSI)

Aim Hyperspectral imaging (HSI) technology combines imaging with spectroscopy and can be used for the classification of malignant and non-malignant cells. Thereby HSI combined with artificial intelligent algorithms can be used to predict tumor cells in in Barrett’s carcinoma specimens. Methods HSI imaging records light between the visual and near-infrared light (500-1000nm). For a first feasibility study, this technique was used to discriminate between squamous epithelium and esophageal adenocarcinoma and 45 specimens from Barrett’s carcinoma patients were recorded. In 22 of the 45 investigated specimens contained also squamous epithelium. The specimens were fixed routinely after resection in paraformaldehyde, were sliced to 3μm, and were stained by haematoxylin and eosin (HE). A non-parametric supervised classification learning algorithm (K-nearest neighbours (k-NN)) was used for discrimination. Results Barrett’s adenocarcinoma cells were recorded by HSI in all 45 investigated cases. Squamous epithelium and Barrett’s adenocarcinoma cells displayed differences in the absorbance between the wave lengths of 500 to 700 nm. For both, the squamous epithelium and the Barrett’s adenocarcinoma cells, the intra group variances of the investigated specimens were quite low. 333,275 and 74,000 spectra could be measured from Barrett’s adenocarcinoma and from squamous epithelium, respectively. Specificity, sensitivity and precision with a k-NN (k=5) classifier were 0.74, 0.92 and 0.94 for the presence of Barrett’s adenocarcinoma cells. Conclusions HE-stained squamous epithelium and Barrett’s adenocarcinoma cells showed specific spectral alterations, when measured by HSI. These characteristics could be used in the future to develop a computer-assisted algorithm to discriminate semi-automated for tumor cells Barrett’s carcinoma specimens, which will help to foster decision-making support in histopathological diagnosis.

Strong Intra-Esophageal Reflux May Contribute to the Development of Barrett’s Adenocarcinoma and Affect the Localization

<b><i>Background:</i></b> There has been no study that has directly measured the esophageal reflux factors in Barrett’s adenocarcinoma (BA) using 24-h multichannel intraluminal impedance-pH monitoring (24-h MII-pH). We aimed to clarify the esophageal reflux factors in Barrett’s esophagus (BE) and BA and the factors that determine the location of BA with 24-h MII-pH. <b><i>Methods:</i></b> We performed 24-h MII-pH in 26 patients with superficial BA treated endoscopically (BA group) and 13 patients with BE (BE group) and examined the esophageal reflux factors (esophageal acid exposure time [AET], bolus exposure (acid, weakly acid, and alkaline), and number of reflux episodes. In the BA group, there were 16 cases in which the lesions were localized in an area in contact with the esophagogastric junction (EGJ; EGJ group), and 10 cases in which the lesions were proximal to the BE and separated from the EGJ (non-EGJ group). <b><i>Results:</i></b> Total reflux in the bolus exposure in the BA group showed higher values compared to that in the BE group. The total of acid and weakly acid reflux of bolus exposure was significantly higher in the BA group than that in the BE group. The BA group also had greater numbers of total reflux episodes than the BE group. As for the cancer locations in BE, the cases in which the lesions were located proximally and separated from the EGJ had more AET and total reflux and acid reflux indicated by bolus exposure compared to the lesions adjacent to the EGJ. <b><i>Conclusions:</i></b> Stronger gastro-esophageal reflux appeared to be an important factor in the development of adenocarcinoma from BE. In addition, the cancer location in BE may be related to the intensity of esophageal reflux.