NYU Medicine Grand Rounds Clinical Vignette Cindy Fang PGY2 5/28/2014 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

49 year old man with progressive dysphagia, chest pain, and weight loss of 25 pounds for two months Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Difficulty eating solid food for six months, then progressed to difficulty swallowing liquid for the last two months Lost 25 pounds in the last year Ranitidine and omeprazole did not relieve symptoms Severe odynophagia for the last month prompted presentation to the ED History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Additional History Past Medical History: Psoriasis Past Surgical History: Tonsillectomy Social History: Former one pack daily smoker for thirty years, quit six months ago Former heavy alcohol use, quit six months ago Family History: Father: deceased, kidney cancer, age unknown Allergies: No known drug allergies Medications: Clobetasol over affected area twice weekly Omeprazole and ranitidine as needed U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Physical Examination General: Young well developed man in mild discomfort Vital Signs: T: 98 BP: 127/64 HR: 89 RR: 16 and O2 sat: 97% on room air Oral mucosa slightly dry Mild temporal wasting Mild tenderness to sternal palpation Remainder of physical exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Laboratory Findings CBC: hemoglobin 11.9 g/dL Remainder of CBC was within normal limits Basic Metabolic panel: Sodium 134, Calcium 11.9 Remainder of basic was within normal limits Hepatic panel: within normal limits Parathyroid hormone: <3 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Other Studies Chest X-Ray: Mass- like soft tissue density in the subcarina with proximal esophageal dilatation U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Other Studies Chest CT: 6.7cmx5.2cx.10cm Large obstructing mid esophageal mass, involvement of the wall of the aorta can not be entirely excluded. Enlarged right paraesophageal lymph node. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Esophageal neoplasm Working or Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Hospital Day 1: –Esophagogastroduodenoscopy was performed –Patient was placed on NPO and standing fluid for hypercalcemia –IV morphine standing and as needed for pain –Codeine as needed for cough Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Hospital Day 2-7: –Palliative care was consulted for pain control, goals of care, social support in face of potential new diagnosis of cancer –Standing morphine was gradually transitioned to fentanyl patch with morphine prn for break through Hospital Day 7: –Pathology results returned as Invasive squamous cell carcinoma, moderately differentiated –Family meeting with medicine team, palliative care, and oncology team Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Hospital Day 8: –Esophageal stent placement –Patient discussed at oncology and GI tumor board with surgical and radiation oncology Hospital Day 11 –Patient discharged on fentanyl patch, oral morphine as needed, tolerating soft solid food –Plan to start chemotherapy followed by chemoradiation after discharge Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS