Faculty Bibliography

BACKGROUND: In Western countries, esophageal squamous cell carcinoma is usually advanced at presentation and is rarely diagnosed in situ. The authors studied an in situ squamous cell carcinoma that occupied the entire mucosa of a 9 cm length of esophagus, causing dysphagia for solid food in a woman aged 68 years. METHODS: The esophagectomy specimen contained a circumferential region of depressed tan mucosa in the middle and lower thirds, bordered above and below by normal squamous mucosa, without ulcer, stricture, or mass. The entire lesion was submitted for histology and evaluated with immunostains for cytokeratins and markers of Paget's cells, p53 mutation, and proliferation. RESULTS: The lesion involved 45 cm2 of mucosa. Large, atypical cells with frequent mitoses occupied the basal layers of the squamous epithelium and were often separated from more superficial maturing cells by acantholysis. Pagetoid spread of tumor cells into nonneoplastic surface and gland duct epithelium was prominent. The tumor cells expressed cytokeratins of low molecular weight, p53 gene product, and proliferating cell nuclear antigen (PCNA), but lacked markers usually seen in Paget's cells in the breast or vulva. No invasion was evident. CONCLUSIONS: This extensive in situ squamous cell carcinoma of the esophagus resulted from pagetoid spread of tumor cells. These cells had a phenotype suggestive of origin from primitive epidermal stem cells and also had overexpressed p53 and PCNA, but they lacked the capacity to penetrate the basement membrane. Flat, erythematous areas of esophageal mucosa seen during endoscopy could represent early squamous cell carcinoma and should be biopsied

OBJECTIVES: The purpose of this study was to determine the computed tomography (CT) findings in idiopathic achalasia and in the pseudoachalasia of malignancy. METHODS: We identified 12 patients with the manometric diagnosis of achalasia who also had CT scans available for review: eight had idiopathic achalasia, and four had pseudoachalasia. As controls, we selected nine patients with endoscopically obvious esophageal cancer who also had CT scans. The CT scans were blindly reviewed to determine esophageal wall thickness, symmetry of the esophageal wall, presence of esophageal dilation or mass, and a radiological diagnosis. RESULTS: Six of the eight patients with achalasia had a dilated esophagus. Five had symmetric wall thickening >5 mm (range 7-10 mm) at the gastroesophageal junction. One patient with a 10-mm wall thickening was incorrectly diagnosed with a mass. All others were correctly diagnosed with achalasia. Three of the four patients with pseudoachalasia had esophageal dilation. Two had an obvious esophageal mass. The other two were given an indefinite diagnosis: one had asymmetric wall thickening (11 mm) at the gastroesophageal junction, and the other had symmetric thickening of 18 mm. Eight of the nine patients with obvious esophageal cancer had a mass on CT; the other patient had asymmetric wall thickening of 6 mm at the gastroesophageal junction and was given an indefinite diagnosis. CONCLUSIONS: Most achalasia patients have CT findings of esophageal dilation and mild, symmetric wall thickening. Therefore, symmetric esophageal wall thickening (<10 mm) should not dissuade one from the diagnosis of achalasia. Most pseudoachalasia patients have CT findings of esophageal dilation, more marked and/or asymmetric wall thickening, or mass. In this group, asymmetric or marked thickening (>10 mm) indicated pseudoachalasia. Therefore, CT can be helpful in differentiating between achalasia and the pseudoachalasia of malignancy

This article reports radiologic and manometric findings in dysphagia aortica, with particular attention to the gastroesophageal (GE) junction. Records of three patients, ages 70-78 years, with clinical/radiologic dysphagia aortica were compared to those in control groups. Subsequently, manometric findings of such vascular compression were sought in 10 consecutive patients > or = 65 years old with dysphagia. The three patients with dysphagia aortica had radiologic/endoscopic evidence for compression at the GE junction. Manometric studies, performed in two of them, showed evidence at the GE junction for superimposed rhythmic contractions at 60-72/min (maximum amplitudes, 35 mm Hg), consistent with vascular compression. One patient had marked elevation of 'sphincter' pressure to 110 mm Hg and 'poor relaxation' of the 'sphincter.' One of 10 patients with dysphagia had rhythmic contractions of 20 mm Hg; a barium study subsequently showed aortic compression at the GE junction. There are characteristic manometric findings that may help to identify symptomatic vascular compression of the esophagus in the elderly

OBJECTIVES: We undertook this study to determine the utility of various clinical findings and tests in the diagnosis of pseudoachalasia. METHODS: We reviewed the clinical, endoscopic, esophagographic, CT, and manometric findings of five patients with pseudoachalasia of malignancy. These patients were identified from our large group of 206 patients with manometrically diagnosed achalasia who were seen over the past 8 yr. For each pseudoachalasia patient, the two consecutively seen patients with idiopathic achalasia were chosen to comprise a control group. RESULTS: The pseudoachalasia patients, as compared to the control group, had shorter duration of dysphagia (9.6 +/- 8.6 months vs 54.3 +/- 44.2 months, p < 0.05). They had similar weight loss (15.6 +/- 12.8 lbs vs 14.3 +/- 18.4 lbs, p = NS), but weight loss/time, where time is months of symptoms, was greater in the pseudoachalasia group (1.8 +/- 1.8 lbs/month vs 0.5 +/- 0.5 lbs/month, p < 0.05). There was, however, substantial overlap between the groups in all these parameters. Barium esophagography failed to reveal cancer in any of the pseudoachalasia patients. There was difficult passage of the endoscope through the gastroesophageal junction in all patients with pseudoachalasia, but endoscopic biopsy diagnosed cancer in only two of them. CT scans gave no clear evidence of malignancy in any patient, although three scans had nonspecific findings that, in retrospect, probably indicated malignancy. There were no distinguishing manometric findings. CONCLUSIONS: When pseudoachalasia is suspected on the basis of a constellation of findings, such as advanced age, rapid weight loss, and difficulty in passing the endoscope through the gastroesophageal junction of a nondilated esophagus, negative findings on biopsy and CT scans should not lead to a false reassurance of a benign disorder, and repeated biopsy and scans or surgical exploration may lead to the diagnosis of pseudoachalasia

This study was undertaken to determine the prevalence of vascular compression in manometric tracings and to determine whether these findings had any clinical significance. Vascular compression, defined as a localized area of elevated intraesophageal resting pressure > 4 mm Hg with superimposed cyclic pressure spikes with a frequency of 60-100/min, was noted in 55 of 241 consecutive tracings. The groups with and without vascular compression were similar with regard to mean age, sex, and prevalence of dysphagia. Radiographs were available for 29 of the 55 and showed compression in 18, but there was no relationship with the manometric findings, except for a trend towards finding a positive esophagogram with amplitudes > 16 mm Hg. Eleven tracings showed absent 'relaxation' of this elevation of pressure in response to swallows, and five of six available esophagograms showed a corresponding area of compression. We conclude that manometric evidence of vascular compression is common and generally has no clear relationship with esophagographic findings or dysphagia. However, the combined findings of marked increases in pressure and absence of relaxation in response to swallows may indicate evidence for a vascular cause of dysphagia

The aim of this study was to evaluate plain film findings of the chest in instrumental esophageal perforation. We hypothesized that such 'clean' perforations, often detected early, would be associated with a low frequency of abnormal plain film findings. Fifteen patients with instrumental esophageal perforation were identified, and their records and radiographs were reviewed. Twelve (80%) of the patients had abnormalities suggestive of perforation. The most common (60%) abnormality seen was pneumomediastinum. The second most common (33%) finding was a density adjacent to the descending aorta in the left cardiophrenic angle, resulting in loss of contour of the descending aorta at the level of the left diaphragm. We concluded that plain films, even when taken shortly after instrumentation, provide useful information regarding the presence of esophageal perforation

Although concern about perforation has led physicians to perform pneumatic dilation for achalasia with routine contrast radiography immediately afterwards and with hospitalization, the need for these precautions has not been demonstrated. In contrast, we have routinely performed pneumatic dilations without contrast studies or hospitalization, and we hereby present our experience. During a recent six-year period, 110 pneumatic dilations were performed, and 71 of the last 73 were performed as outpatients with about 5-8 hr of clinical monitoring. Detailed review of 100 records showed that only 15 patients underwent contrast studies because of pain or fever. Perforation occurred in seven of the 15 patients, all of whom underwent surgery successfully. Short-term follow-up in patients who did not sustain perforation showed good or excellent results in 82%. Thus, it has been our experience that pneumatic dilation could be safely performed in achalasia without routine use of contrast studies or hospitalization