Secondary Achalasia Research Articles

Secondary neoplasms of the esophagus.

A review of 62 cases of esophageal involvement by secondary neoplasms is reported. The common routes of esophageal involvement are by direct extension of the tumor from the contiguous or adjacent organs (45.2%), via mediastinal nodes (35.5%), and hematogenous spread from a distant primary (19.3%). In the first 2 modes of esophageal involvement, the diagnosis is usually obvious but hematogenous metastases to the esophagus usually pose a diagnostic challenge. Radiologically, hematogenous metastases show a spectrum of features consisting of a short segment of progressive stricture with normal to minimally irregular mucosa, a submucosal mass with or without ulceration, a polypoid mass or masses, and defects in esophageal motility including secondary achalasia. Since endoscopy and biopsy have limited diagnostic yield, radiologic diagnosis plays a key role in the diagnosis of secondary neoplasms of the esophagus irrespective of their mode of spread to the esophagus.

Early esophageal cancer.

Early esophageal cancer (EEC) accounted for only seven (4.7%) of 148 cases of esophageal cancer diagnosed at the authors' hospital between 1977 and 1984. Two patients with EEC had squamous cell carcinoma and five had adenocarcinoma arising in Barrett's mucosa. All seven patients had associated clinical findings, including low-grade gastrointestinal bleeding (three cases), odynophagia (one case), and chronic reflux symptoms due to underlying reflux esophagitis and Barrett esophagus (three cases). Since Barrett esophagus is a premalignant condition, the high proportion of adenocarcinomas in this series presumably reflects the more frequent radiologic evaluation of symptomatic patients with Barrett esophagus. On esophagography, four patients had 3-4.5-cm polypoid intraluminal masses that could not be distinguished radiographically from advanced esophageal carcinoma. In the other three patients, esophagrams revealed secondary achalasia, irregular flattening of the esophageal wall, and diffuse nodularity of the mucosa. The authors conclude that "early" esophageal cancers are not necessarily small cancers, since they may undergo considerable intraluminal or intramural growth and still be classified histologically as EEC. Radiologists should be aware of these findings, since EEC has an excellent prognosis with a 5-year survival approaching 90%.

Failure of clinical criteria to distinguish between primary achalasia and achalasia secondary to tumor.

Three clinical criteria have been reported to distinguish patients with primary achalasia from patients with achalasia secondary to tumor invasion of the gastroesophageal junction. These criteria (age greater than 50 years, duration of symptoms less than one year, and weight loss greater than 15 pounds) are important because of their potential use for deciding between pneumatic dilation and exploratory surgery. In the present investigation we assessed the frequency of these criteria alone and in combination in 79 patients with primary and in two patients with secondary achalasia seen at our institution over a 9 1/2-year period. Our results indicate that while these criteria are highly sensitive and moderately specific, their predictive value for distinguishing secondary achalasia from primary achalasia is exceedingly low. For this reason, early exploratory surgery is not indicated in patients with newly diagnosed achalasia who meet these criteria unless there is prior radiologic or endoscopic evidence for tumor.

Achalasia secondary to carcinoma: manometric and clinical features.

The clinical and diagnostic features of a secondary type of achalasia of the esophagus are described in seven patients with various types of malignancies. Patients with secondary achalasia presented with dysphagia of short duration and marked weight loss; mean age was 64 years. Esophageal manometry showed features identical to those of idiopathic primary achalasia: aperistalsis, poor lower esophageal sphincter relaxation, and elevated sphincter pressure. Endoscopy and barium swallow showed evidence of a tumor in only two cases. Various types of malignancies may produce a secondary form of achalasia that has diagnostic features identical to those of primary achalasia and is best identified by its clinical presentation.