CC BY-NC-ND 4.0 · Endosc Int Open 2018; 06(12): E1406-E1409
DOI: 10.1055/a-0751-2812
Case report
Owner and Copyright © Georg Thieme Verlag KG 2018

Primary adenocarcinoma arising in esophageal colon interposition for corrosive esophageal injury: a case report and review of the literature

Diogo Turiani Hourneaux De Moura
1  Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
,
Igor Braga Ribeiro
1  Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
,
Martin Coronel
1  Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
,
Eduardo Turiani Hourneaux De Moura
1  Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
,
Joana Rita Carvalho
2  Department of Gastroenterology and Hepatology, North Lisbon Hospital Center, University of Lisbon, Portugal
,
Elisa Ryoka Baba
1  Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
,
Eduardo Guimarães Hourneaux De Moura
1  Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
› Author Affiliations
Further Information

Corresponding author

Igor Braga Ribeiro, MD
Av. Dr Enéas de Carvalho Aguiar, 225
6o andar, bloco 3
Cerqueira Cesar ZIP Code 05403-010
São Paulo, SP
Brasil   
Fax: +55112661-6467   

Publication History

submitted 21 June 2018

accepted after revision 05 September 2018

Publication Date:
23 November 2018 (online)

 

Abstract

Background and study aims Colon interposition for benign strictures is associated with significant perioperative complications that carry high morbidity and mortality. Although rarely reported in the literature, adenocarcinoma can occur as a late complication in an interposed colonic segment. We report a case of a late-stage adenocarcinoma in a colonic interposition performed for benign esophageal stricture.


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Introduction

Esophageal reconstruction with colon interposition after esophagectomy caused by caustic ingestion or malignant neoplasms has been standardized for almost a century [1] [2] [3]. The colon is chosen due to its size, extension, excellent blood supply, good resistance to gastric reflux and low disease incidence [1] [4]. Even with a 5 % to 8 % mortality due to benign lesions, this type of surgery is not free from serious early or late complications, such as dehiscence of sutures leading to mediastinitis, necrosis of the anastomotic site, formation of fibrosis, and strictures [5].

Presence of malignant neoplasm in colonic interpositions post-esophagectomy is extremely rare. A review of the literature using the electronic database Medline (PubMed), reported only 11 cases ([Table 1]), all with a common outcome, the death of the patient.

Table 1

Adenocarcinoma in colon interposition: literature review.

Authors

Year of publication

Surgical indication

Delay before occurrence (year)

Cheng et al. [1]

2015

Corrosive

15

Tranchart H et al. [9]

2014

Corrosive

19

Aryal MR et al. [2]

2013

Corrosive

30

Shersher DD et al. [11]

2011

Corrosive

40

Bando et al. [12]

2010

Squamous cell carcinoma

14

Sikorszki et al. [10]

2010

Corrosive

44

Kuwabara et al. [13]

2009

Esophageal cancer

 9

Roos et al. [6]

2007

Corrosive

40

Hsieh et al. [14]

2005

Corrosive

39

Martín et al. [7]

2005

Corrosive

14

Liau et al. [5]

2004

Esophageal cancer

30

Altorjay et al. [15]

1995

Corrosive

 5

Lee et al. [16]

1994

Squamous cell carcinoma

20

Theile et al. [17]

1992

Adenocarcinoma

12

Houghton et al. [3]

1989

Corrosive

20

Haerr et al. [18]

1987

Squamous cell carcinoma

 9

Licata et al. [19]

1978

Corrosive

11

Goldsmith et al. [4]

1968

Squamous cell carcinoma

 2


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Case report

We report the case of a 63-year-old Hispanic female with a history of smoking habits (54 packs per year) and chronic obstructive pulmonary disease; she also had a previous history of squamous cell carcinoma of the cervix, cured after a total hysterectomy, 15 years earlier.

At age 33, the woman attempted suicide with caustic soda intake. Initially treated with endoscopic dilation with bougies, she remained asymptomatic for 20 years. Then, her symptoms including dysphagia and severe malnutrition (body mass index 17.1) returned, and new dilations with bougies by endoscopy were performed. However, at that, time she did not response to dilations, and after 2 years, she was referred for subtotal esophagectomy with colonic graft interposition. A colonoscopy was performed before surgery to rule out lesions. Eight years after surgery, the patient was referred to our endoscopy unit due to severe progressive dysphagia of 3 years’ duration and significant weight loss (8 kilos in 2 months).

Upper gastrointestinal endoscopy (UGIE) excluded disease in the esophagus-colon anastomosis, however, an irregular, ulcerated, friable lesion, measuring 8 cm in length, causing stenosis of the organ, was diagnosed 18 cm from the incisors ([Fig. 1]). Tissue biopsies were properly taken and anatomopathological examination showed a moderately differentiated invasive colonic adenocarcinoma ([Fig. 2]). Computed tomography (CT) showed a colonic graft tumor and suspicious lesions in the left and right lung, which were confirmed to be metastatic after biopsy ([Fig. 3] and [Fig. 4]). After a multidisciplinary meeting, a palliative approach was recommended due to the patient’s poor functional status and comorbidities. She patient was started on chemotherapy and radiotherapy and died 2 months after the diagnosis.

Zoom Image
Fig. 1 Upper gastrointestinal endoscopy view of the esophageal lesion. a Proximal portion of lesion in transposed colon. b Vegetative and infiltrative lesion. c Medial portion of lesion causing sub-stenosis of organ lumen. d, e Revision of the lesion.
Zoom Image
Fig. 2 Microscopic image with magnification of 400x. Label: Moderately differentiated invasive adenocarcinoma
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Fig. 3 Computed tomography showing colonic graft tumor.
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Fig. 4 Computed tomography showing suspicious lesions in the chest.

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Discussion

Most reported cases of esophageal cancers arising in colonic graft after esophageal surgery are due to incomplete resection of the primary tumor [3] [6] [7]. However, the etiopathogenesis of malignancy in postsurgical caustic stenosis is not yet fully understood [1] [2]. Previous presence of polyps, colitis, chronic reflux disease and inflammation produced by food stasis are postulated etiologies for dysplastic transformation and evolution to malignant neoplasm [8]. A positive family history of colon carcinoma is also considered a risk factor [9] [10].

Patients most often present with progressive dysphagia. Respiratory symptoms due to invasion or compression have also been reported. Biopsies performed during UGIE are the gold standard for confirming the diagnosis [1] [11]. Treatment consists of complete surgical resection and might include gastric interposition, jejunal graft, and Roux-en-Y esophagojejunostomy [11]. Endoscopic resection can be curative and is recommended for early neoplasms limited to the mucosa [5] [12]. A palliative approach with radiotherapy, chemotherapy and placement of self-expanding metallic stents is possible mostly in patients whose condition is inoperable cases or who have poor functional status [1] [2] [8] [10].

There are no available guidelines for follow-up of patients with colonic transposition esophageal surgery. We believe that preoperative or intraoperative colonoscopy and a follow-up with UGIE every 5 years can successfully prevent malignant lesions [1].


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Conclusion

Adenocarcinoma is a very rare although possible and most often fatal late complication of colon interposition esophageal surgery. There are no available guidelines for follow-up of patients with colonic transposition esophageal surgery. More studies of this condition are needed.


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Competing interests

None

Acknowledgements

We thank the patient and her family for her trust and cooperation for this case report.


Corresponding author

Igor Braga Ribeiro, MD
Av. Dr Enéas de Carvalho Aguiar, 225
6o andar, bloco 3
Cerqueira Cesar ZIP Code 05403-010
São Paulo, SP
Brasil   
Fax: +55112661-6467   


  
Zoom Image
Fig. 1 Upper gastrointestinal endoscopy view of the esophageal lesion. a Proximal portion of lesion in transposed colon. b Vegetative and infiltrative lesion. c Medial portion of lesion causing sub-stenosis of organ lumen. d, e Revision of the lesion.
Zoom Image
Fig. 2 Microscopic image with magnification of 400x. Label: Moderately differentiated invasive adenocarcinoma
Zoom Image
Fig. 3 Computed tomography showing colonic graft tumor.
Zoom Image
Fig. 4 Computed tomography showing suspicious lesions in the chest.