CASE REPORTS

Radiation-Induced Esophageal Cancer: A Case Report and a Review of the Literature Tetsu SHIMIZU,Takao MATSUI, Osamu KIMURA,Michio MAETAand Shigemasa KOGA ABSTRACT: A 63 year old woman who had b e e n irradiated for thyroid carcinoma at 36 years of age developed a cervico-esophageal stricture, the biopsy specimens from which revealed squamous cell carcinoma. Total esophagectomy was performed and a small linear ulcer was found in the resected specimen. Histological examination revealed moderately differentiated squamous cell carcinoma with severe fibrosis around the tumor, indicating radiation-induced cervical esophageal cancer. T h e characteristics o f radiation-induced esophageal cancers described in the literature are reviewed in context o f the present case. KEY WORDS: cervical esophageal cancer, radiation-induced cancer, radiotherapy, pathology

INTRODUCTION

CASE REPORT

is well known that therapeutic doses of radiation are associated with an increased risk of neoplasms developing within the radiation field. 1-4 However, only a few cases of radiation-induced esophageal cancer have been reported in Japan and the clinical and histological characteristics have not yet been fully elucidated. We recently, treated a patient for cervical esophageal cancer who had received radiotherapy for thyroid carcinoma several years earlier. T h e clinical and pathological features of this case are discussed in relation to a review of the literature on this subject.

A 36 year old woman underwent extirpation of thyroid carcinoma and subsequent radiotherapy at a dose o f 2Gy )< 24, in total 48Gy, at another institution in 1961. She presented to our hospital in January, 1988, at the age of 63, with a 4-year history o f slight dysphagia. A barium esophagram showed a funnel-like, circular stricture in the cervical esophagus, measuring 2.5 cm (Fig. 1). Endosco W also revealed a circular stricture 17 cm below the dental arch, which bled easily. T h e endoscope could not be passed through this stricture (Fig. 2). Biopsy specimens from the stricture revealed a focus of squamous cell carcinoma, but tumor markers and other clinical data were all within normal limits. O n March 22, 1988 a subtotal esophagectomy, leaving 1.0 cm of cervical esophagus, was p e r f o r m e d a n d the alimentary tract reconstructed by a cervical esophago-gastrostomy. T h e operative findings revealed Stage I carcinoma based on the Japanese

It

The First Department of Surgery, Tottori University Schoolof Medicine, Yonago,Japan Reprint requests to: Tetsu Shimizu, MD, The First Department of Surgery, Tottori University School of Medicine, 36-1, Nishimachi, Yonago 683,Japan

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Fig. 3. Resected specimen showing a linear ulcer with well-defined margins in the cervical esophagus, measuring 1.3 X 1.4 cm~in area.

Fig. 1. Preoperative esophagram demonstrating a funnel-type circular stricture in the cervical esophagus, measuring 2.5 cm.

Fig. 2. Preoperative endoscopy also showing a circular stricture which bled easily, 17 cm below the dental arch. The endoscope could not pass beyond the stricture. G u i d e l i n e s for Clinical a n d P a t h o l o g i c Studies of Carcinoma of the Esophagus, ~ which terms Stage I as follows; Ao: no

b Fig. 4. Microscopic appearance. a. High-power view of the specimen demonstrating moderately differentiated squamous cell carcinoma (HE, X70). b. Severe fibrosis without inflammatory change in the area of carcinoma within the esophageal stricture (Azan, X10).

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invasion to the adventitia, N-: no lymph node metastasis, and Mo: n o organ metastasis. The resected specimen contained a small linear ulcer with a well-defined margin in the cervical esophagus measuring 1.3 X 1.4 cm ~ in area (Fig. 3). Histologically, the tumor was a moderately differentiated squamous cell carcinoma (Fig. 4a), invading the proper muscle with no metastasis to the lymph nodes (stage I). Severe fibrosis without any inflammatory changes, but with slight endoarteritis obliterance, was noted not only in the area of the carcinoma within the esophageal stricture (Fig; 4b), but also over the cervical esophagus, indicative o f chronic tissue injury, consistent with the effects of prior radiation. T h e patient's post-operative course was satisfactory, and she has now resumed leading a normal life. DISCUSSION Although there are no precise criteria for establishing the diagnosis of radiation-induced esophageal cancer, the following, as set out by Goolden were all met by the present case: 1,~ (1) a history of prior irradiation. (2) cancer within the radiation field. (3) gross tissue damage due to an extensive dose of radiation. (4) a long interval between radiotherapy and the development of malignancy. Applying the above-mentioned criteria, we reviewed the Japanese literature and found 24 patients of radiation-induced esophageal cancer reported over the past 30 years. The early history of all 25 patients, including our patient, are summarized in Table 1. The mean latent period between initial irradiation and diagnosis of esophageal cancer was 29.0 years, this being significantly longer (p

Radiation-induced esophageal cancer: a case report and a review of the literature.

A 63 year old woman who had been irradiated for thyroid carcinoma at 36 years of age developed a cervico-esophageal stricture, the biopsy specimens fr...
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