Esophageal squamous cell carcinoma associated with gastric adenocarcinoma

Esophageal Squamous Cell Carcinoma Associated With Gastric Adenocarcinoma JEAN-CHRISTOPHE SOUQUET, MD, FRANCOISE BERGER, MD, SYLVElTE BONVOISIN, MD, CHRISTIAN PARTENSKY, MD, JEAN BOULEZ, MD, FRANCOISE DESCOS, MD, AND RENE LAMBERT, MD

Adenocarcinoma of the stomach occurred in six of 425 consecutive patients with esophageal squamous cell cancer. In two cases, the gastric cancer, which was recognized at 17 and 29 months, respectively, after the nonsurgical treatment of the esophageal tumor, was treated by surgical resection. In three cases, the tumors which wefe diagnosed simultaneously, were treated by surgery (one case) resection of the gastric tumor and nonsurgical therapy for the esophageal tumor (one case), and nonsurgical therapy for both tumors (one case). In one case, a gastric cancer was resected 6 years before diagnosis of an esophageal tumor and a second cancer in the gastric stump. A nonsurgical protocol was then adopted for both tumors. The association of these two cancers raises questions concerning their epidemiology, diagnosis, prognosis, and management. There is room for nonsurgical multimodalityprotocols and, in association with surgery, survival was prolonged for more than 1 year in five of six patients. Cancer 63:786-790, 1989.

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is known to be associated with squamous cell cancer of the mouth, pharynx, and upper respiratory tract.',2 These tumors share com-mon epidemiologic factors such as alcohol and tobacco. A significant association with other types of tumors is hypothetical. Cancer of the prostate gland after esophageal cancer has been observed more frequently than expected in Connectic~t,~ but not in Denmark,4 in studies based on cancer register. However, an association with adenocarcinoma of the stomach has been reported in the Japanese This may only be coincidental due to the high frequency of gastric and esophageal tumors in that country.' In other countries with a lower incidence of these two cancers,' this association has only been mentioned in some retrospective QUAMOUS CELL CANCER OF THE ESOPHAGUS

had a gastric adenocarcinoma. Hence, the relative frequency of this association is 1.4%. In two cases (Patients 1 and 2), the gastric tumor followed the esophageal tumor. In three cases (Patients 3, 4, and 5), the two tumors were recognized simultaneously. In one case (Patient 6), the esophageal cancer followed the gastric tumor. The main characteristics of these patients are summarized in Table 1. The characteristics of esophageal and gastric tumors are summarized in Table 2. All pathologic features had been reviewed blindly by a pathologist (F.B.).

Esophageal Cancer First

We report on six patients with associated gastric adenocarcinoma and esophageal squamous cell cancer and describe the diagnostic circumstances and therapeutic consequences of this association. Case Reports Among a series of 425 consecutive patients with esophageal squamous cell cancer within a 6-year period, six patients also ~~

From the GastroenterologyUnit and INSERM U 45, HBpitaJ Edouard Hemot, Lyon, France. Address for reprints: Jean-Christophe Souquet, MD, Gastroenterology Unit, Pavillon Hbis, HBpital Edouard Herriot, 69437 Lyon Cedex 03, France. Accepted for publication August 22, 1988.

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Case 1: This patient was referred in October 1982 for nonsurgical treatment of a squamous cell cancer of the esophagus. He had recently suffered from severe alcoholic acute psychosis and was considered unsuitable for surgery. The stomach was normal at both endoscopy and barium meal examination. The treatment included destruction of the tumor by endoscopic N d YAG laser (six sessions within 2 weeks), followed by radiotherapy (500 cGy) associatedto two chemotherapy courses (5-fluorouracil [ 1 g/m2 per day from day 1 to day 41 and cisplatin [80 mg/m2 at day 21). In March 1983, 1 month after completion of radiotherapy, intraesophageal irradiation (approximately 180 cGy in 18 hours) was performed by an iridium wire placed in a temporary stent. The local evolution was marked by a radiationinduced ulcer of 1-month duration. 15 months later a slight esophageal stenosis occurred that was treated by endoscopic dilatations. Biopsy specimens did not show tumoral cells. Twentynine months after the diagnosis of the esophageal tumor (March 1985), a routine endoscopic examination showed a large adenocarcinoma of the upper part of the gastric corpus. An attempt at Nd:YAG laser destruction failed. As esophageal biopsy spec-

GASTRIC AND ESOPHAGEAL CANCERS

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imens were normal and no metastasis was found, a total gastrectomy was performed in September 1985. The following course of the patient has been uneventful, until the last control in July 1988 (namely, 69 months after the treatment of the esophageal tumor and 34 months after the gastrectomy). Case 2: This patient was referred in May 1982 for an esophageal squamous cell cancer. There was no extraesophageal tumoral extension at evaluation, but an alcoholic cirrhosis contraindicated surgery. The stomach was normal at both endoscopy and barium meal examination. The treatment, which included Nd:YAG laser photodestruction (three sessions), radiotherapy (500 cGy) with 5-fluorouracil chemotherapy, and intracavitary irradiation (180 cGy), was performed in August 1982 and led to an esophageal ulcer of 15 months duration without stenosis. Seventeen months after the beginning of treatment (September 1983), biopsy specimens of a small nodule of superficial appearance at the junction of the corpus and the antrum of the stomach showed a well-differentiated adenocarcinoma. After failure of NdYAG laser destruction, a partial gastrectomy was performed in November 1983. At surgery, the liver was found to be cirrhotic. In April 1985 (i.e.,at 35 months), endoscopy showed large varices and no tumoral recurrence. Ascites developed in January 1986, and a liver ultrasound examination showed two nodules in the right lobe. Ultrasound-guided cytoponction demonstrated an hepatocarcinoma. Alpha-fetoprotein was found at 148 ng/ml (normal [N],