1832 Adenocarcinoma Arising From a Cervical Esophageal Inlet Patch: The Malignant Potential of a Small Lesion

Abstract

INTRODUCTION: Inlet patches (IP) are heterotopic lesions consisting of gastric mucosa. Commonly located in the cervical esophagus, it is believed that they are remnants of fetal columnar epithelium. A rare complication of IP is the development of esophageal adenocarcinoma. We report a case of a 59-year-old male with intractable cough and dysphagia that was found to have a malignant transformation of an IP. CASE DESCRIPTION/METHODS: A 59-year-old white male, with heart failure, obesity, and smoking history, presented with 5 months of cough, bilateral neck pain, globus sensation, and progressive dysphagia. Barium swallow noted an irregularity at the distal cervical esophagus and esophagogastroduodenoscopy (EGD) revealed a stricture extending 17 to 20 cm from the incisors. Pathological analysis from random biopsies returned negative for dysplasia or malignancy. Routine laboratory analysis was unremarkable. The patient returned two years later, complaining of progressive dysphagia. Repeat EGD was performed and immunohistochemical staining on repeat biopsy revealed adenocarcinoma that was: CK7+, CK20-, and variable for CDX2. Pathology revealed adenocarcinoma of the cervical esophagus, invading at least the lamina propria, arising from ectopic gastric mucosa (a cervical IP). The patient was deemed a poor surgical candidate and was treated with palliative carboplatin and paclitaxel with adjuvant radiation therapy. DISCUSSION: Most IPs are asymptomatic and are discovered incidentally during EGD, but rarely they may present with reflux, esophagitis, stricture or ulcer formation and produce symptoms of throat pain, dysphagia and globus esophagus. Their prevalence varies from less than 1% to 14%. The incidence of adenocarcinoma arising from a cervical IP is reported to be 1.5% or less. Our patient developed proximal esophageal adenocarcinoma from a cervical IP. EGD images showed no continuity of non-malignant mucosa with the stomach. In addition, the absence of goblet cells indicates a high likelihood that this malignancy originated from the cervical IP. Currently, there are no guidelines to guide the management of incidentally discovered IPs. Some studies recommend routine endoscopic surveillance, although prospective data have failed to demonstrate long-term benefits. With mounting evidence, it is clear that IPs carry significant clinical importance due to their malignant potential. This case demonstrates the need for increased awareness in identifying and managing these lesions discovered during routine endoscopy.