CLINICAL CHALLENGES AND IMAGES IN GI
Bilal Hameed, Uma Mahadevan, and Kay Washington, Section Editors

An Unlikely Lesion to Be Identiﬁed in the Cervical Esophagus
Kyosuke Tanaka,1 Masaya Fujiwara,2 and Hideki Toyoda3
1Department of Endoscopy, 2Department of Pathology, Mie University Hospital, Tsu, and 3Happy GI Clinic, Kameyama, Japan

Question: A 69-year-old woman with a history of acute hepatitis A underwent esophagogastroduodenoscopy during anannual health check-up. The patient had no abdominal symptoms and laboratory test results were unremarkable. Esophagogastroduodenoscopy showed a slightly reddish mucosa in the cervical esophagus (two-thirds of the circumference;Figure A). A ﬂat elevated lesion of irregular shape was identiﬁed in the distal side of the slightly reddish mucosa (Figure B).
Chromoendoscopy with indigo carmine demonstrated a clear demarcation line around the circumference of the lesion(Figure C).
What is the diagnosis?
Look on page 611 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more
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Conﬂicts of interest
The authors disclose no conﬂicts.
© 2018 by the AGA Institute0016-5085/$36.00
https://doi.org/10.1053/j.gastro.2018.01.050

Gastroenterology 2018;155:610–612

CLINICAL CHALLENGES AND IMAGES IN GI
Answer to: Image 1 (Page 610): Adenocarcinoma Arising From Heterotopic
Gastric Mucosa in the Cervical Esophagus

Magnifying endoscopy with narrow band imaging (NBI-ME) showed an irregular vascular pattern and an irregularmicrostructural pattern on the lesion (Figure D, arrows). NBI-ME with spraying of 1.5% acetic acid clearly demonstrated anirregular microstructural pattern (Figure E, arrows). During the esophagogastroduodenoscopy, biopsies were also performed on the lesion. Pathologically, these specimens showed atypical glands. Based on NBI-ME and pathologic ﬁndings, thepresence of an adenoma or adenocarcinoma was suspected. Endoscopic submucosal dissection was performed owing to themalignant potential of the lesion (Figure F). The lesion (approximately 10 mm in diameter) was completely removed en bloc
without complications. Pathologic examination showed atypical glandular and papillary structures with enlarged hyperchromatic nuclei, in the normal heterotopic gastric mucosa and squamous epithelium (Figure G). A histopathologic diagnosis of intramucosal well-differentiated tubular adenocarcinoma arising from heterotopic gastric mucosa in the cervicalesophagus was ﬁnally established.
Esophageal adenocarcinomas arising from heterotopic gastric mucosa are extremely rare.1 Thus far, only 10 of >60
cases of adenocarcinoma arising from heterotopic gastric mucosa described in the literature have been treated endoscopically.2,3 In this case, owing to the subtle morphologic change, the lesion was unlikely to be identiﬁed by conventional
endoscopic view. Such irregular microvascular and irregular microsurface patterns could become an endoscopic hallmark of
cervical esophageal adenocarcinoma, similar to early gastric cancers. This case shows that careful observation using
magnifying endoscopy may be helpful for the detection and diagnosis of adenocarcinoma in cervical esophageal heterotopic
gastric mucosa.

Supplementary Material
Note: To access the supplementary material accompanying this article, visit the online version of Gastroenterology at
www.gastrojournal.org, and at https://doi.org/10.1053/j.gastro.2018.01.050.

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CLINICAL CHALLENGES AND IMAGES IN GIReferences
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Von Rahden BH, Stein HJ, Becker K, et al. Esophageal adenocarcinomas in heterotopic gastric mucosa: review and reportof a case with complete response to neoadjuvant radiochemotherapy. Dig Surg 2005;22:107–112.
Kadota T, Fujii S, Oono Y, et al. Adenocarcinoma arising from heterotopic gastric mucosa in the cervical esophagus andupper thoracic esophagus: two case reports and literature review. Expert Rev Gastroenterol Hepatol 2016;10:405–414.
Riddiough GE, Hornby ST, Asadi K, et al. Gastric adenocarcinoma of the upper oesophagus: A literature review and casereport. Int J Surg Case Rep 2017;30:205–214.

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