Farooq P. Agha

Cisplatin, vinblastine, and mitoguazone chemotherapy for epidermoid and adenocarcinoma of the esophagus.

Thirty-six patients with adenocarcinoma or epidermoid carcinoma of the esophagus were entered into a phase II trial evaluating the combination of cisplatin 100 mg/m2 intravenously (IV) day 2, vinblastine 1.6 mg/m2 IV days 1 to 4, and mitoguazone (MGBG) 500 mg/m2 IV days 1 and 8. Twenty-nine patients (group A) were newly diagnosed with local-regional disease only and were candidates for transhiatal esophagectomy (THE). These patients received two courses of chemotherapy at 3-week intervals prior to surgery. Response was assessed by measuring changes in the primary tumor length and depth on serial biphasic contrast esophagrams and comparing this result with tumor measurements obtained from the surgical specimen. Complete (CR) and partial responders (PR) received three additional postoperative cycles. Seven patients had recurrent or metastatic disease (group B) and were treated every 4 weeks until disease progression. Of 34 patients evaluable for response, there was one pathologically confirmed CR and 15 PRs (47%). This consisted of 12 of 27 (44%) group A patients (seven of 11 epidermoid, five of 16 adenocarcinoma) and four of seven (57%) group B patients (two of four epidermoid, two of three adenocarcinoma). Toxicity included leukopenia in one third of treatment courses and thrombocytopenia in 21%. Nausea and vomiting occurred in 60% of patients, diarrhea in 18%, transient nephrotoxicity in 18%, peripheral neuropathy in 12%, and ototoxicity in 3%. Twenty-five group A patients underwent resection. Four chemotherapy nonresponders (NR) and one PR had known disease left at surgery; all others (80%) had gross total removal of their disease. The median survival time (MST) of the 29 group A patients was 14 months, with 21% alive at 36 months. The MST of group A chemotherapy responders was 15 months compared with 9 months for NRs (P = .032). Initial sites of recurrence in 14 patients were local-regional in six, distant only in six, both local-regional and distant in two. This regimen, administered in maximally tolerated doses, was active in epidermoid and adenocarcinoma histologies, recurrent disease and newly diagnosed patients. However, nearly all responses were PRs and the MST of resected patients was similar to a prior series of patients treated with esophagectomy alone. Observations from this pilot trial and those of others have led to a follow-up study, in progress, evaluating intensive preoperative chemotherapy and concurrent radiation therapy (RT).

Medication-induced esophagitis

Clinical, radiographic, and endoscopic features of medication-induced esophagitis (MIE) in 4 patients are described. When the clinical history and symptoms raise a high index of suspicion for MIE, a double-contrast esophagram or endoscopic examination should be performed. The proximal esophagus, particularly the aortic segment, and occasionally the distal esophagus are the sites most commonly affected by MIE. Superficial mucosal erosions, shallow ulcers, and subtle mucosal alterations can be demonstrated by double-contrast esophagrams if careful attention is paid during performance and interpretation of these studies in an appropriate clinical setting.

Esophageal involvement in epidermolysis bullosa dystrophica: Clinical and roentgenographic manifestations

Epidermolysis bullosa is a rare hereditary mechanobullous skin disorder. Four patients with esophageal involvement are reported. These cases and review of reported cases of epidermolysis bullosa dystrophica-recessive (EBD-R) showed distinct clinical and roentgenographie features of esophageal involvement: diffuse inflammatory changes, motility disorders, small blisters or bullae seen as constant nodular-filling defects, esophageal ulcers, scars, pseudodiverticula, transverse and circumferential webs, various size strictures, shortening of the esophagus with development of traction hiatal hernia and gastroesophageal reflux, perforation, and complete obstruction of the esophageal lumen. Dysphagia is reversible when caused by bullae or webs and permanent when due to cicatrizing strictures. The strictures may remain unchanged in size for many years despite variations in dysphagic symptoms.

Gastric interposition following transhiatal esophagectomy: Radiographic evaluation

Gastric interposition was achieved in 138 patients following transhiatal esophagectomy without thoracotomy. Among these, 33 had benign and 105 malignant lesions. All patients were evaluated on the 10th postoperative day with a barium swallow examination. However, if an anastomotic leak was suspected clinically before this time, a water-soluble contrast study was initially obtained. Early postoperative complications included anastomotic leaks (15), cricopharyngeal incoordination with aspiration (6), and gastric perforation (2). Late postoperative complications included anastomotic strictures (12), pyloric stenosis (4), recurrence of tumor (3), and transhiatal visceral herniation (2). Our technique of postoperative radiographic evaluation, particularly when a leak is suspected clinically, is discussed.

Barrett's esophagus complicating achalasia after esophagomyotomy: a clinical, radiologic, and pathologic study of 70 patients with achalasia and related motor disorders

Of 70 patients with achalasia and related motor disorders, 3 developed Barretts esophagus 5, 8, and 15 years after esophagomyotomy. One of the three had dysplastic changes in the Barretts mucosa. Although an increased incidence of gastroesophageal reflux, esophagitis, and stricture are well-known complications after esophagomyotomy, the development of Barretts mucosa has been only recently recognized. Diagnosis of Barretts esophagus in such patients is difficult and requires a high index of awareness by the radiologist and an endoscopic biopsy for definitive diagnosis. The cumulative effects of achalasia and Barretts esophagus predispose these patients to higher risks of developing esophageal carcinoma.

Radiologic diagnosis of Barrett's esophagus: Critical analysis of 65 cases

A recent increase in the number of Barretts esophagis being diagnosed is probably directly related to a proportional increase in endoscopic biopsies of the esophagus and awareness of premalignant potential of Barretts mucosa. While the endoscopist can detect Barretts mucosa with fair degree of accuracy, the radiologic diagnosis of Barretts esophagus still remains a diagnostic challenge despite several well established radiologic features. We reviewed 65 patients with pathologically proven Barretts esophagus and found a wide spectrum of radiologic features. These include hiatus hernia in 49, gastroesophageal reflux in 38, strictures in 32, esophagitis in 20, and characteristic Barretts ulcer in 12. In addition ascending or migrating strictures were found in 10, mucosal pattern simulating areae gastricae in 5, cricopharyngeal dysfunction in 4, and fixed spiral folds in 3 patients. This constellation of radiologic features, some of which have not been previously emphasized, should further assist radiologists in suggesting the diagnosis of Barretts esophagus.A recent increase in the number of Barretts esophagis being diagnosed is probably directly related to a proportional increase in endoscopic biopsies of the esophagus and awareness of premalignant potential of Barretts mucosa. While the endoscopist can detect Barretts mucosa with fair degree of accuracy, the radiologic diagnosis of Barretts esophagus still remains a diagnostic challenge despite several well established radiologic features. We reviewed 65 patients with pathologically proven Barretts esophagus and found a wide spectrum of radiologic features. These include hiatus hernia in 49, gastroesophageal reflux in 38, strictures in 32, esophagitis in 20, and characteristic Barretts ulcer in 12. In addition ascending or migrating strictures were found in 10, mucosal pattern simulating areae gastricae in 5, cricopharyngeal dysfunction in 4, and fixed spiral folds in 3 patients. This constellation of radiologic features, some of which have not been previously emphasized, should further assist radiologists in suggesting the diagnosis of Barretts esophagus.

Esophagitis caused by nonsteroidal anti-inflammatory medication: case reports and review of the literature on pill-induced esophageal injury.

We report six cases of pill-induced esophageal injury, two of which were caused by the nonsteroidal anti-inflammatory medications ibuprofen and piroxicam, which have not been implicated previously in pill-induced injury.

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.

Fibrolamellar hepatocarcinoma: clinical, radiologic, and pathologic features.

Three new cases of an unusual subtype of hepatocellular carcinoma (HCC) referred to as fibrolamellar hepatocarcinoma (FLHC) recently seen at our institution are described. This report focuses on the clinical, radiologic, and pathologic features of this rare subset of HCC. All three patients were under 30 years of age with no previous history of hepatitis or cirrhosis. Each had had subacute symptoms for 5 months to 1 year before medical attention was sought and/or diagnosis of FLHC was established. There was no reliable correlation with oral contraceptive use in the 2 female patients. Serum alpha-1-fetoprotein levels were normal with only mild elevation of liver enzymes. The CT features, although not specific, were suggestive of an aggressive tumor with amorphous calcification in 2 of the 3 cases. Angiographically all tumors were hypervascular without any evidence of arterioportal shunting or venous invasion of major vessels. The clinical and radiologic recognition of these tumors is important since the surgical resectibility rate and 2- and 5-year survival rates are higher than those applicable to conventional HCC.

Successful transcatheter embolic control of significant arterioportal fistula: a serious complication of liver biopsy

Hepatic arterioportal fistula (APF) has been described in severe cirrhosis (Viamonte et al, 1968; Okuda et al, 1973), regenerating liver nodules (Farrel et al, 1972), hepatoma (Viamonte et al, 1968), metastatic vascular tumours (Itzchak et al, 1974), cavernous haemangioma (Winograd & Palubinskas, 1977), hepatic artery aneurysm rupturing into the portal vein (Foster & Sand Bloon, 1961), trauma (Gran et al, 1958), and, rarely, Budd-Chiari syndrome (Itzchak et al, 1974). Percutaneous liver biopsy has become indispensable in the diagnosis of liver disease and the incidence of complication is relatively small. The first documented case of APF complicating liver biopsy was reported by Preger (1967); several reports have appeared since (Debray et al, 1968; Wallace et al, 1972; Okuda et al, 1974; Baer, 1977). A 71-year-old white female was admitted to a local hospital following a haematemesis. She was transfused with two units of packed cells. An upper gastrointestinal examination revealed oesophageal varices. Th...