A 14-Year Study of 398 Esophageal Adenocarcinomas Diagnosed Among 156,256 EGDs Performed at Two Large Hospitals: An Inlet Patch Is Proposed as a Significant Risk Factor for Proximal Esophageal Adenocarcinoma.

BACKGROUND: An association between inlet patches and proximal esophageal adenocarcinomas is currently suspected because of numerous case reports of simultaneous occurrence of both diseases.

AIMS: To analyze whether inlet patches are significantly associated with proximal esophageal adenocarcinomas in a large population.

METHODS: Computerized search of pathology and EGD reports revealed 398 cases of esophageal adenocarcinomas among 156,236 EGDs (performed on 106,510 patients) diagnosed by histopathology performed at Royal Oak/Troy, William Beaumont Hospitals, 2003-2016. Adenocarcinomas localized as distal, middle, or proximal; and characterized as associated versus unassociated with inlet patches. Medical records were reviewed. Endoscopic photographs, radiologic images, and pathologic slides were re-reviewed. Two researchers independently performed systematic computerized literature searches; cases of simultaneous diseases identified by consensus.

RESULTS: Adenocarcinoma locations included: distal-381, middle-14, and proximal esophagus-3. Five patients had inlet patches with esophageal adenocarcinomas located at: distal-2, middle-0, and proximal esophagus-3 (relative frequency of inlet patches with cancers of distal/middle esophagus = 2/395 [.5%] vs. proximal esophagus = 3/3 [100%], p < .000001, 95% OR CI > 50.1, Fisher's exact test). Cases of proximal esophageal adenocarcinomas within inlet patches included: (1) Seventy-eight-year-old man presented with dysphagia. Neck CT showed proximal esophageal mass. EGD revealed semi-circumferential, multinodular, 3.0 × 1.5 cm mass within inlet patch. Histopathology of biopsies revealed moderately-to-poorly differentiated adenocarcinoma. Patient received chemoradiotherapy and expired 2 years later. (2) Seventy-nine-year-old man presented with anorexia and weight loss. EGD demonstrated proximal esophageal mass within inlet patch. Histopathology of biopsies revealed poorly differentiated, signet ring cell adenocarcinoma. Chest CT revealed 3.4 × 2.1-cm-proximal esophageal mass. Patient expired 4 months later. (3) Sixty-year-old man presented with dysphagia. EGD revealed 4-cm-long, semi-circumferential, proximal esophageal mass within inlet patch. Histopathology of biopsies revealed poorly differentiated adenocarcinoma. Patient underwent emergency esophagectomy for esophageal perforation 2 weeks after initiating chemoradiotherapy, and died shortly thereafter. Literature review revealed 39 cases of simultaneous disease.

STUDY LIMITATIONS: Potential underreporting by endoscopists of inlet patches at EGD.

CONCLUSIONS: Study supplements 39 previously reported cases of simultaneous disease, by adding three new cases, and by novel report of statistically significant association between these two entities, which has important implications in the pathophysiology of proximal esophageal adenocarcinoma.