esophageal cancer is the third most common gastrointestinal cancer . while 89% of reported esophageal cancers are of the squamous cell type , only 1.3% of them present as carcinosarcomas . carcinosarcoma of the esophagus is a rare malignant neoplasm consisting of both carcinomatous and sarcomatous components . although the oncogenesis of carcinosarcoma remains unclear , both metaplastic and collision concepts have been proposed . the former involves individual elements derived from a single common ancestor cell ( so - called carcinosarcoma ) , and the latter involves two individual stem cells that independently and simultaneously undergo malignant transformation ( true carcinosarcoma ) . the 5-year survival rates after treatment are quite similar to those reported for squamous cell carcinoma ( scc ) [ 3 , 4 ] . although the 3-year survival rate is higher for carcinosarcoma than for scc , the 5-year survival rate does not significantly differ between them . esophageal carcinosarcoma is usually treated by partial or total esophagectomy with regional lymph node dissection according to the protocols used for other esophageal cancers [ 3 , 4 , 5 ] . a few reports have described radiotherapy and chemotherapy for esophageal carcinosarcoma before or after surgery . one study found that radiotherapy could not control recurrent tumor growth after esophagectomy , whereas another found that chemotherapy and radiotherapy reduced primary lesions by 45% after surgery including an esophageal bypass with a stomach tube . however , the effects of treating esophageal carcinosarcoma by neoadjuvant radiotherapy before surgery have not been described . we describe a patient with a rapidly growing esophageal carcinosarcoma that was efficiently reduced by radiotherapy alone before surgical treatment . a previously healthy 69-year - old man was admitted to our hospital with dysphagia . his family and medical histories were unremarkable . neither lymphadenopathy nor thyroid swelling were evident and abdominal findings were normal . all laboratory data upon admission were within normal limits except for creatinine , which was 1.6 mg / dl . tumor marker levels were all within normal limits : scc antigen 1.3 ng / ml , carcinoembryonic antigen 1.9 ng / ml and carbohydrate antigen 19 - 9 11 u / l . a first esophagogastroduodenoscopy ( egd ) revealed a small nodular polypoid lesion about 10 mm in diameter with central ulceration in the lower esophagus ( fig . a second egd 1 month later showed that the tumor had expanded into a huge mass that occupied the esophageal lumen ( fig . 1c ) and part of the surface comprised normal esophageal epithelial mucosa ( fig . 1d , arrows ) . however , due to the size of the tumor the basal part could not be visualized by egd . however , biopsy specimens obtained from the esophageal mucosa surrounding the tumor revealed no malignancy . moreover , 1 month of treatment with a proton pump inhibitor essentially normalized the esophageal mucosa surrounding the tumor ( fig . thus , we considered that gastroesophageal reflux of the stomach contents had caused the transition of the surrounding esophageal mucosa . 1e , arrowheads ) , and we thus considered that the tumor had not invaded the muscularis propria . barium esophagography revealed a lobulated polypoid lesion about 6 cm in diameter with a relatively smooth surface , a central superficial irregularity and depression in the lower esophagus ( fig . a biopsy specimen showed that the tumor comprised poorly differentiated scc with spindle cell components ( fig . immunohistochemical evaluation of a biopsy specimen of the tumor obtained at the time of the first egd revealed that the scc cells were positive for cytokeratin ( fig . 3b ) . in contrast , the spindle - shaped tumor cells were positive for vimentin and negative for cytokeratin ( fig . whole body computed tomography found no evidence of metastasis . according to the guidelines for clinical and pathologic studies on carcinoma of the esophagus , 10th edition , a third egd 1 month after radiotherapy showed a remarkable reduction in the size of the tumor ( fig . barium esophagography also revealed a tumor about 1 cm in diameter with a smooth surface ( fig . he finally agreed to surgical treatment and underwent total esophagectomy with regional lymph node dissection . pathological examination revealed that the esophageal carcinosarcoma had invaded the lamina propria mucosa and that resected regional lymph nodes harbored no malignancy . at that time after surgical operation , the patient was followed up as an outpatient without adjuvant therapy . whole body computed tomography revealed bilateral lung metastasis 14 months later . however , the patient refused treatment for the metastasis and died 16 months after surgery . esophageal carcinosarcoma reportedly accounts for 0.472.4% of all esophageal tumors [ 4 , 8 , 9 ] . virchow   in 1865 investigated a rare malignant neoplasm consisting of carcinomatous and sarcomatous components and referred to it as carcinosarcoma . since then , such neoplasms have also been referred to as sarcomatoid carcinoma , pseudosarcoma or spindle cell carcinoma . in 1992 , ro et al .   proposed the following histological criteria for carcinosarcoma : concurrent malignant epithelial and spindle cell components with transitional areas in between and a sarcomatoid component expressing an epithelial phenotype . according to these criteria , the guidelines for clinical and pathological studies on carcinoma of the esophagus , 9th edition classified esophageal carcinosarcoma as so - called carcinosarcoma , pseudosarcoma and true carcinosarcoma therefore , a classification of subtypes might not be essential for considering the clinical outcomes and features of carcinosarcoma , and the tumor in our patient was classified as esophageal carcinosarcoma according to the guidelines for clinical and pathologic studies on carcinoma of the esophagus , 10th edition . among 87 patients with carcinosarcoma described in the literature , 83 ( 95.4% ) , 3 ( 3.4% ) and 1 ( 1.1% ) were treated by surgical resection , local excision and endoscopic resection , respectively . regional lymph nodes were involved in 31 of 59 patients ( 52.5% ) [ 3 , 13 ] . another review of 57 patients with esophageal carcinosarcoma described that 54 patients ( 94.7% ) were treated by curative resection , of whom 15 ( 27.8% ) received additional treatment , including chemotherapy ( n = 8) , chemoradiotherapy ( n = 6 ) and radiotherapy alone ( n = 1 ) . sanada et al .   reported that chemotherapy ( 5-fluorouracil plus docetaxel ) and radiotherapy ( 66 gy ) for 2 months achieved a 45% reduction rate for primary lesions after surgery comprising an esophageal bypass with a stomach tube . on the other hand , iwaya et al .   reported that radiotherapy could not control recurrent tumor growth after esophagectomy . in the review by sanada et al . these two reports are published in the japanese literature and can not be found by searching pubmed ( national library of medicine ) . however , esophageal carcinosarcoma treated by radiotherapy alone before surgery has not been described . the review described by mccort   concluded that the prognosis is more favorable for carcinosarcoma than for scc . xu et al .   reported that the carcinomatous component of the tumor is usually at an early stage at the time of diagnosis and that the incidence of lymph node metastasis is thus low . however , the 5-year survival rates after treatment are similar to those reported for scc [ 3 , 4 ] , since 5 years after surgery for carcinosarcoma , only 9 ( 16.4% ) of 55 patients remained alive and free of disease or had died of unrelated causes . although the 3-year survival rate was higher for carcinosarcoma than for scc ( 62.8 vs. 28.1% ) , the 5-year survival rates did not significantly differ between them ( carcinosarcoma 26.7% vs. scc 22.4% ) . thus , the prognosis is not as favorable as previously believed , due to the high possibility of hematogenous metastasis occurring later . the tumor in our patient was diagnosed as stage i at initial hospitalization and treated by neoadjuvant radiotherapy followed by total esophagectomy with regional lymph node dissection . esophageal carcinosarcoma within stage i is generally treated by surgical resection , the same therapy as for esophageal scc according to the guidelines for diagnosis and treatment of carcinoma of the esophagus . during initial hospitalization , the patient refused surgical treatment but accepted chemoradiotherapy . due to renal dysfunction ( 1.6 mg / dl of creatinine and 33.9 ml / min of estimated creatinine clearance ) , chemotherapy such as cisplatin plus 5-fluorouracil the patient declined the chemotherapy and provided informed consent to treatment with radiotherapy alone , which was not a standard therapy for esophageal carcinosarcoma based on the guidelines for diagnosis and treatment of carcinoma of the esophagus . therefore , the patient was treated by neoadjuvant radiotherapy ( 40 gy ) without chemotherapy to reduce the tumor and improve his dysphagia , and then he finally accepted surgical treatment . however , he died 16 months later due to lung metastasis which we considered was caused by late hematogenous metastasis . the neoadjuvant radiotherapy ameliorated his symptom such as dysphagia and improved his quality of life although he finally died . the neoadjuvant radiotherapy for esophageal carcinosarcoma was considered to have contributed to the subsequent surgery and his prolonged survival time . in conclusion , we describe a rapidly growing esophageal carcinosarcoma that was reduced by radiotherapy alone before surgical treatment . thus , radiotherapy alone might be a useful candidate for neoadjuvant therapy of esophageal carcinosarcomas .
esophageal carcinosarcoma is a rare malignant neoplasm consisting of both carcinomatous and sarcomatous components . 
 it is generally treated by surgery , radiotherapy and chemotherapy according to the protocols used for other esophageal cancers . however , the treatment of esophageal carcinosarcoma by radiotherapy alone before surgery has not been previously described . 
 we report a patient with a rapidly growing esophageal carcinosarcoma that was efficiently reduced by neoadjuvant radiotherapy alone . 
 a previously healthy 69-year - old man was admitted with dysphagia . 
 initial esophagogastroduodenoscopy ( egd ) revealed a small nodular polypoid lesion of about 10 mm in the middle esophagus . a second 
 egd 1 month later showed that the tumor had expanded into a huge mass . 
 a biopsy specimen revealed that the tumor comprised squamous cell carcinoma with spindle cell components , and the tumor was diagnosed as carcinosarcoma which was diagnosed as stage i ( t1bn0m0 ) . due to renal dysfunction , 
 the patient was treated with neoadjuvant radiotherapy ( 40 gy ) without chemotherapy . 
 a third egd 1 month later revealed remarkable tumor reduction . 
 he then underwent total esophagectomy with regional lymph node dissection ( pstage 0 , pt1an0m0 ) . 
 after surgical operation , the patient was followed up without adjuvant therapy . 
 whole body computed tomography revealed lung metastasis 14 months after surgery , and the patient died 2 months later . 
 the neoadjuvant radiotherapy for esophageal carcinosarcoma was considered to have contributed to the subsequent surgery and his prolonged survival time . 
 thus , radiotherapy alone might be a suitable neoadjuvant therapy for esophageal carcinosarcomas .