1. An Unusual Presentation of Esophageal Cancer: A Case Report and Review of Literature. Abraham Yacoub M.D.1, Regina Frants, M.D., F.A.C.P.2, Leslie Bank, M.D., F.A.C.G.1, Jagmohan Sidhu, M.D., F.C.A.P.3, Peter Nicholson, M.D.4 United Health Services Department of Gastroenterology (1), Pulmonary and Critical Care (2), Pathology (3), Radiology (4)
INTRODUCTION
We present a case of a 49-year-old white female who complained of a chronic cough for one year. Computed Tomography (CT) of the chest revealed abnormal thickening of the thoracic esophagus. Esophagogastroduodenoscopy (EGD) revealed diffuse multiple masses in the esophagus, which appeared separate. Histopathology of the masses revealed adenocarcinoma.
DISCUSSION
This case is unique due to a number of atypical features.
Firstly, the patient had respiratory symptoms rather than gastroenterology symptoms. The most common symptoms for esophageal cancer are dysphagia, odynophagia, and weight loss [2,3]. Our patient presented with a chronic cough. Esophageal cancer can present with respiratory symptoms of cough and lung infection [16]. Advantages include long length, acid resistance, and typically excellent blood supply [3].
Secondly, EAC arises from the distal third of the esophagus [20]. The unusual location and distribution of the tumor in our case was very rare. Evidence of polyps or cancer in the segment of the large intestine interposed between the upper esophagus and the stomach have previously been documented [2,3,23-41]. However, screening the interposed colon segment is rarely emphasized.
Thirdly, common risk factors for EAC are Barrett’s esophagus caused by chronic GERD, low socioeconomic status, obesity, and male gender [21-23]. Higher alcohol consumption was not associated with increased risk of EAC [24]. Our patient did not have any risk factors to suspect esophageal cancer.
CASE PRESENTATION
A 49-yr-old white female with a history of hypothyroidism and anxiety was referred to our gastroenterology clinic by the pulmonologist for an abnormal finding on the CT scan of the chest.
Was evaluated by her pulmonologist for a chronic cough of one year duration
Despite of three courses of antibiotics, the cough continued to worsen
Denied any medical history of GERD, esophagitis, or aspiration pneumonia. Denied any tobacco smoking. Denied any chest pains, heartburn, N/V, dysphagia, odynophagia, and weight loss.
Vital signs and physical examination were unremarkable except for expiratory wheezing in the anterior and posterior lobes
Figure 2. Hematoxylin and eosin (H&E) stain (x100) showing luminal part of malignant glands of adenocarcinoma and submucosal invasive adenocarcinoma showing extracellular mucin. Arc-shaped pink-colored smooth muscle fibers of muscularis mucosae separate the malignant mucosa in the left half of the picture from the submucosal invasive adenocarcinoma in the right half.
CONCLUSION
We present a case of an atypical feature of esophageal cancer. It is important for clinicians to keep esophageal cancer in the differential diagnosis in patients presenting with the symptoms previously mentioned.
REFERENCES
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Figure 1. The scope was advanced into the esophagus and almost immediately, a 22 cm friable fungating mass was seen. There were multiple esophageal masses, which appeared separate. Esophageal biopsies were obtained from three different sites, the 25 cm, 30 cm, and 35 cm from the incisors.
ACKNOWLEDGEMENT
We thank Jessica Hrebin, Information Analyst 1, and Barbara Bank for their help.
Figure 3. CT scan of the chest (coronal view) showing circumferential thickening and irregular enlargement of the esophagus with wall thickening and dilatation.