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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 16  |  Page : 50-53

Premalignant and malignant lesions of the esophagus: A single-institutional experience


1 Department of Pathology, University College Hospital; Department of Pathology, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
2 Department of Pathology, University College Hospital, Ibadan, Oyo State, Nigeria
3 Department of Anatomical Pathology, Edo University, Iyamho, Edo State, Nigeria
4 Department of Medicine, University College Hospital, Ibadan, Oyo State, Nigeria

Date of Submission18-Jun-2020
Date of Decision11-Sep-2020
Date of Acceptance21-Sep-2020
Date of Web Publication26-Nov-2020

Correspondence Address:
Dr. Mustapha A Ajani
Department of Pathology, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Oyo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/nnjcr.nnjcr_22_20

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  Abstract 


Background: Esophageal malignancy is a highly aggressive tumor with a poor prognosis. A number of lesions occurring in the esophagus are associated with a high risk of malignant transformation. While the patterns of esophageal cancers have been documented in a number of African countries, there is a limited data on the Nigerian situation. This study was aimed at reviewing the histological patterns of premalignant and malignant lesions of the esophagus. Methods: This was a 10-year retrospective study of histologically confirmed premalignant and malignant lesions of the esophagus seen at the University College Hospital, Ibadan, between January 2009 and December 2018. Data retrieved from the departmental records were analyzed using the SPSS computer software version 20.0. Results: There were 45 cases diagnosed with premalignant lesions and 32 cases diagnosed with malignant lesions out of the 363 biopsies during the study period. The most common premalignant lesion was Barret's esophagus (68.9%). Premalignant lesions were more common in males (64.4%). The mean age for patients with a diagnosis of premalignant lesions was 55 years. The mean age at the diagnosis for esophageal cancer was 61.5 years. Squamous cell carcinoma was the predominant histological subtype seen (65.6%) with adenocarcinomas accounting for the remainder of cases (35.4%). Conclusion: Squamous cell carcinoma is the most common malignancy of the esophagus in our study. Adenocarcinomas of the esophagus were not as rare as documented in previous African studies. This finding may imply a changing pattern in esophageal malignancies in tandem with the pattern in Western countries.

Keywords: Esophageal cancer, malignant lesions, premalignant lesions


How to cite this article:
Ajani MA, Adegoke OO, Nwanji ID, Omenai SA, Akande KO. Premalignant and malignant lesions of the esophagus: A single-institutional experience. N Niger J Clin Res 2020;9:50-3

How to cite this URL:
Ajani MA, Adegoke OO, Nwanji ID, Omenai SA, Akande KO. Premalignant and malignant lesions of the esophagus: A single-institutional experience. N Niger J Clin Res [serial online] 2020 [cited 2021 Jan 19];9:50-3. Available from: https://www.mdcan-uath.org/text.asp?2020/9/16/50/301639




  Introduction Top


Esophageal cancer is a highly aggressive tumor with a poor prognosis. It is the seventh-most common cause of cancer worldwide and the sixth-most prevalent cause of cancer mortality worldwide. Mortality-to-incidence ratio of esophageal cancers is nearly 90%, and it ranks high among the cancers with particularly poor prognosis.[1]

Esophageal cancer is most common in developing countries.[2] In Africa, the mortality-to-incidence ratio is even higher, nearing 100%.[3] In addition, the epidemiology of esophageal cancer in African nations has changed over the past decades with studies showing an increasing trend in the prevalence with a predominance of cases in Southern and Eastern Africa.[3] In Nigeria, even though esophageal cancer is a relatively uncommon cancer (accounting for 0.5% of cancers among Nigerians in 2018), the mortality to incidence ratio is similar to that seen in other African Countries where esophageal cancer is more common.[1]

Tobacco smoking and alcohol consumption are the main risk factors associated with the development of esophageal malignancy with a few studies suggesting a synergistic role in causation of esophageal carcinoma.[4],[5] Other identified risk factors include the consumption of fungal mycotoxins and human papillomavirus infection of the esophagus.[6],[7] A family history of esophageal cancer has been demonstrated to increase the risk of esophageal carcinoma suggesting a role for genetic susceptibility in the pathogenesis of esophageal cancer.[8]

There is a number of premalignant lesions of the esophagus which are associated with an increased risk of developing esophageal carcinoma. Such lesions include Barrett's esophagus, squamous epithelial dysplasia of the esophagus, and achalasia, although it is not a mucosal lesion.[9],[10] Patients with any of these lesions are followed up with active surveillance.

The lower two-thirds of the esophagus are the most frequent site for the development of esophageal cancer.[11] Histologically, the most common esophageal malignancies are carcinomas, the two main types being squamous cell carcinoma and adenocarcinoma:[2] the middle third of the esophagus is the most common site for former, whereas the lower third is the most common site for later.[11]

Globally, esophageal squamous cell cancer is the most common subtype, and it is the predominant subtype found in developing countries.[12],[13],[14]

This study was conducted to review the clinicopathological features of esophageal cancer in the University College Hospital, Ibadan, during the past 10 years, providing a baseline data for further studies.


  Methods Top


This was a retrospective study of patients with a histological diagnosis of esophageal cancer and premalignant lesions of the esophagus seen at the University College Hospital, Ibadan, from January 2009 to December 2018.

The University College Hospital, Ibadan, is a tertiary teaching hospital located in Oyo State, South-Western Nigeria. It is a 1000-bed capacity hospital that serves the city of Ibadan and environs.

The age and sex of patients were retrieved from the records archived within the department. Statistical data analysis was performed using the SPSS software version 20.0 (SPSS, Inc., Chicago, IL, USA). Data were summarized in the form of proportions and frequency tables for the categorical variables. Continuous variables were summarized using means, median, mode, and standard deviation. P values were computed for the categorical variables using the Chi-square test and the Fisher's exact test, depending on the size of the dataset. P < 0.05 was considered to constitute a statistically significant difference.


  Results Top


There were a total of 363 esophageal biopsies during the study period. The vast majority (361) of the biopsies were endoscopic with only two esophagectomies. There were 45 (12.4%) premalignant lesions and 32 (8.8%) cases malignant lesions during the study period. Premalignant conditions were more common in males (29/45) [Figure 1]. The mean age at the diagnosis for esophageal cancer was 61.5 ± 13 years while the peak age was the seventh decade [Figure 2]. The mean age for patients with a diagnosis of premalignant lesions was 55 ± 16 years. The peak age group for the diagnosis of a premalignant lesion was the sixth decade. There was no significant difference in the mean age of premalignant and malignant lesions.
Figure 1: Age/sex distribution of patients with premalignant esophageal lesions

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Figure 2: Age/sex distribution of patients with esophageal carcinoma

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Premalignant lesions comprised Barret's esophagus in 68.9% [Figure 3] and squamous dysplastic lesions constituting 31.1% of cases. For dysplastic lesions, the diagnosis was low-grade dysplasia in 11 (78.6%) cases and high grade in three (21.4%) cases.
Figure 3: Photomicrograph showing Barrett esophagitis composed of benign gastric type glands (arrow) underlying native esophageal squamous epithelial cell layer. There is also vascular congestion and infiltrates of lymphocytes and plasma cells (H and E, ×100)

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Squamous cell carcinoma was the predominant histological subtype seen in 65.6% of cases [Figure 4]. Adenocarcinomas accounted for the remainder of cases [Figure 5]. Both carcinomas were more common in males, and there was no significant difference in the prevalence of squamous cell carcinoma and adenocarcinoma in males and females (P = 1.000). There was no significant difference in the mean age of patients diagnosed with squamous cell carcinoma when compared with the diagnosis of adenocarcinoma (P = 0.919).
Figure 4: Photomicrograph showing squamous cell carcinoma of the esophagus composed of invasive nests of malignant squamous cells with the areas of keratin pearls formation (arrows) (H and E, ×100)

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Figure 5: Photomicrograph showing esophageal adenocarcinoma composed of well-formed invasive glands infiltrating the esophageal stroma (H and E, ×100)

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  Discussion Top


Premalignant lesions peaked in the sixth decade, one decade earlier than malignant esophageal lesions that peaked in the seventh decade. There was no statistical difference in the mean age of patients having premalignant lesions and those with outright malignant esophageal tumors (P = 0.097). Mao et al. reported a peak in the eighth decade for malignant neoplasm of the esophagus, with a gradual increase from the sixth decade.[15] This underscores the need for active surveillance of patients, diagnosed with any of the premalignant conditions. Lifestyle modification and complete endoscopic mucosal resection can be curative.[15],[16]

The male-to-female ratio for premalignant and malignant esophageal lesions was 1.8:1 and 2.2:1, respectively. This male predominance, particularly for esophageal malignancy is in keeping with findings from other African countries, as documented by Kachala in a systematic review of esophageal malignancy on the African continent.[3] This is also similar to the findings in Asians that it was as high as 3:1.[15]

The prevalent histological subtype of esophageal cancer seen in this study was squamous cell carcinoma with an incidence of 65.6% compared with 34.4% for adenocarcinomas (a ratio of 1.9:1). Our finding was similar to a study done in Tanzania where squamous cell carcinoma accounted for 96% of esophageal cancers.[17] However, adenocarcinomas are the major histological type of esophageal cancer in some other African studies, which is similar to Western countries.[11],[17] The high incidence of squamous cell carcinoma may be attributable to lifestyle behavior, such as smoking and drinking which varies from one geographical location to other.[17] However, as this study did not document all risk factors, this cannot be proven with certainty. Nonetheless, the predominance of Barret's esophagitis over squamous dysplasia may point to a strong presence of risk factors driving a possible future increase in adenocarcinomas which may surpass squamous cell carcinomas as a fewer number of persons indulge in alcohol abuse and smoking.[18],[19]


  Conclusion Top


The most common premalignant lesion seen in this study is Barret's oesophagus which is a precursor lesion for esophageal adenocarcinoma. Esophageal squamous cell carcinoma is the most predominant histological type of esophageal malignancy. Adenocarcinomas of the oesophagus were not as uncommon as seen in other African studies and with the increasing incidence of Barret's esophagus, there might be a changing pattern of esophageal malignancies in tandem with the pattern in Western countries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424.  Back to cited text no. 1
    
2.
Abbas G, Krasna M. Overview of esophageal cancer. Ann Cardiothorac Surg 2017;6:131-6.  Back to cited text no. 2
    
3.
Kachala R. Systematic review: Epidemiology of oesophageal cancer in sub-Saharan Africa. Malawi Med J 2010;22:65-70.  Back to cited text no. 3
    
4.
Hashibe M, Boffetta P, Janout V, Zaridze D, Shangina O, Mates D, et al. Esophageal cancer in Central and Eastern Europe: Tobacco and alcohol. Int J Cancer 2007;120:1518-22.  Back to cited text no. 4
    
5.
Castellsagué X, Muñoz N, De Stefani E, Victoria CG, Castelletto R, Rolon PA, et al. Independent and joint effects of tobacco smoking and alcohol drinking on the risk of oesophageal cancer in men and women. Int J Cancer 1999;82:657-64.  Back to cited text no. 5
    
6.
Xue KS, Tang L, Sun G, Wang S, Hu X, Wang JS. Mycotoxin exposure is associated with increased risk of esophageal squamous cell carcinoma in Huaian area, China. BMC Cancer 2019;19:1218.  Back to cited text no. 6
    
7.
Guo L, Liu S, Zhang S, Chen Q, Zhang M, Quan P, et al. Human papillomavirus-related esophageal cancer survival: A systematic review and meta-analysis. Medicine (Baltimore) 2016;95:e5318.  Back to cited text no. 7
    
8.
Chen T, Cheng H, Chen X, Yuan Z, Yang X, Zhuang M, et al. Family history of esophageal cancer increases the risk of esophageal squamous cell carcinoma. Sci Rep 2015;5:16038.  Back to cited text no. 8
    
9.
Kroupa R. Premalignant conditions of the esophagus. Klin Onkol 2013;26:S17-21.  Back to cited text no. 9
    
10.
Latchford A, Jankowski JA. Premalignant lesions of the oesophagus: Identification to management. In: Upper Gastrointestinal Surgery. Springer Specialist Surgery Series. London: Springer; 2005. p. 259-69.  Back to cited text no. 10
    
11.
Alema ON, Iva B. Cancer of the esophagus: Histopathological sub-types in Northern Uganda. Afr Health Sci 2014;14:17-21.  Back to cited text no. 11
    
12.
Arnold M, Soerjomataram I, Ferlay J, Forman D. Global incidence of oesophageal cancer by histological subtype in 2012. Gut 2015;64:381-7.  Back to cited text no. 12
    
13.
Tettey M, Edwin F, Aniteye E, Sereboe L, Tamatey M, Ofosu- Appiah E, et al. The changing epidemiology of esophageal cancer in sub-Saharan Africa the case of Ghana. Pan Afr Med J 2012;13:6.  Back to cited text no. 13
    
14.
Lepage C, Drouillard A, Jouve JL, Faivre J. Epidemiology and risk factors for oesophageal adenocarcinoma. Dig liver Dis 2013;45:625-9.  Back to cited text no. 14
    
15.
Mao WM, Zheng WH, Ling ZQ. Epidemiologic risk factors for esophageal cancer development. Asian Pac J Cancer Prev 2011;12:2461-6.  Back to cited text no. 15
    
16.
Ciocirlan M, Lapalus MG, Hervieu V, Souquet JC, Napoléon B, Scoazec JY, et al. Endoscopic mucosal resection for squamous premalignant and early malignant lesions of the esophagus. Endoscopy 2007;39:24-9.  Back to cited text no. 16
    
17.
Mchembe MD, Rambau PF, Chalya PL, Jaka H, Koy M, Mahalu W. Endoscopic and clinicopathological patterns of esophageal cancer in Tanzania: Experiences from two tertiary health institutions. World J Surg Oncol 2013;11:257.  Back to cited text no. 17
    
18.
Elhadi AA, Mirghani HO, Ibrahim Y, Albalawi IA. Pattern of esophageal cancer in Sudan. Am J Clin Exp Med 2016;4:166-9.  Back to cited text no. 18
    
19.
Gao YT, McLaughlin JK, Blot WJ, Ji BT, Benichou J, Dai Q, et al. Risk factors for esophageal cancer in Shanghai, China. I. Role of cigarette smoking and alcohol drinking. Int J Cancer 1994;58:192-6.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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