Controversies in the Management of Adenocarcinoma of the Esophagus and Esophagogastric Junction.

In the past, adenocarcinomas were thought to occur rarely in the esophagus and to comprise a small percentage of the tumors. In recent years the incidence has risen so that they represent 25% to 35% of all esophageal tumors. Epidemiological studies have shown that the tumor is more common in men than women ( approximately 8:1) and in whites than non-whites ( approximately 7:1). The most common associated condition is Barrett's esophagus, but the evaluation is clouded by the inconsistent definition of Barrett's esophagus in the gastroenterology literature. The diagnosis of Barrett's esophagus requires the identification of metaplastic glandular epithelium with goblet cells in the esophagus. The management of adenocarcinomas of the esophagus is difficult to evaluate because the tumors are frequently included with squamous carcinomas of the esophagus or adenocarcinomas of the gastric cardia. Esophageal adenocarcinomas are associated with a high rate of local recurrence when treated with surgery or radiation alone. Their pattern of spread is different from that of gastric carcinomas in that peritoneal seeding is uncommon and liver and pulmonary parenchymal metastases are less common, whereas pleural and bony metastases are more common. This would suggest that they should be analyzed as a separate clinical entity. In the absence of prospective trials, the reported experience suggests that these patients should be considered for combined surgery and preoperative or postoperative chemotherapy and radiation. Patients who are not candidates for surgery can receive effective and durable palliation from chemosensitized radiation. There are theoretical advantages to both preoperative and postoperative therapy and the selection of treatment programs should be individualized.