High-Grade Dysplasia in Heterotopic Gastric Mucosa in the Upper Esophagus after Radiotherapy: Successful Eradication 2 Years after Endoscopic Treatment by Argon Plasma Coagulation

The incidence of heterotopic gastric mucosa in the upper part of the esophagus has been estimated at between 0.1 % and 10 % [1]. Only nine cases of upper esophageal adenocarcinoma arising from ectopic gastric mucosa have been reported [2].

Between 1985 and 1987, a 51-year-old man was treated for a pharyngeal tumor by surgery and cervical radiotherapy (60 Gy). He had a history of chronic alcohol intake and smoking, and surgery for intracranial aneurysm in 1980. In January 1997, a flexible esophagoscopy revealed apparently benign heterotopic gastric mucosa of the cervical esophagus with a small elevation (Figure [1]), and a peptic esophagitis above a hiatal hernia. Histological investigation showed high-grade dysplasia in heterotopic gastric mucosa. There was no weight loss. On physical examination, no cervical mass could be demonstrated and there was no anemia.

Figure 1Endoscopic view of high-grade hyperplasia in heterotopic gastric mucosa. Before endoscopic therapy (a); during argon plasma coagulation (b); after argon plasma coagulation (c); 2 years after the end of endoscopic therapy by argon plasma coagulation and acid suppression (d)

Between November 1997 and July 1998, the patient underwent six sessions of argon plasma coagulation (APC) with the ERBE Argon Beamer II (Erbe Elektromedizin, Tübingen, Germany) (Figure [1 b]), and he received a course of omeprazole 40 mg b. i. d. No complication was observed during and after the endoscopic treatment (Figure [1 c]). The 2-year follow-up endoscopies showed erythematous mucosa with eradication of high-grade dysplasia and heterotopic gastric mucosa (Figure [1 d]), which was confirmed histologically. The patient was reluctant to continue omeprazole treatment.

This case report provides evidence of the malignant potential of heterotopic gastric mucosa of the upper esophagus. The diagnosis of high-grade dysplasia in follow-up endoscopies of a heterotopic gastric mucosa of the upper esophagus was made 2 years after cervical external radiation with a dose of 60 Gy, suggesting that evolution of inlet patches may be favored by cervical radiation.

To our knowledge this is the first report to describe these nonsurgical methods of eradicating high-grade dysplasia and metaplasia in heterotopic gastric mucosa, and of preventing development of esophageal adenocarcinoma. This case underlines the necessity for careful inspection of the upper third of the esophagus at endoscopy, especially in patients with previous histories of esophageal radiation.

References

• 1 Maconi G, Pace F, Vago L, et al.. Prevalence and clinical features of heterotopic gastric mucosa in the upper oesophagus (inlet patch).  Eur J Gastroenterol Hepatol. 2000;  12 745-749
• 2 Takagi A, Ema Y, Horii S, et al.. Early adenocarcinoma arising from ectopic gastric mucosa in the cervical esophagus.  Gastrointest Endosc. 1995;  41 167-170