Case Report - Clinical Practice (2022) Volume 19, Issue 2
An unusual presentation of oesophagal carcinoma with multifocal malignant disease: A case report
- Corresponding Author:
- Zeeshan Tariq
Homer Stryker School of Medicine
Bronson Cancer Care Center, United States
E-mail: tariqz@bronsonhg.org
Received: 03 February, 2022, Manuscript No. fmcp-22-53269 Editor assigned: 10 February, 2022, PreQC No. fmcp-22-53269 Reviewed: 18 February, 2022, QC No. fmcp-22-53269 Revised: 20 February, 2022, Manuscript No. fmcp-22-53269 Published: 25 February, 2022, DOI. 10.37532/ fmcp.2022.19(2).1859-1861
Abstract
We are presenting a case report of metastatic oesophagal carcinoma with an atypical and rare presentation. Unfortunately, most of the patients with oesophagal carcinoma do present with advanced stage and we do not have any screening modalities available at this time to detect oesophagal cancer at an early stage. Our patient presented with musculoskeletal metastases at the time of initial presentation which is not common. The purpose of this case presentation is also to signify the importance of unusual presentation that could be helpful in the early detection and management of metastatic oesophagal carcinoma.
Introduction
Oesophagal carcinoma generally carries a poor prognosis with many cases being diagnosed later in the disease course. The two most common types of oesophagal cancer include adenocarcinoma, which is the most common subtype in Caucasians in the United States, and squamous cell carcinoma. Both of these subtypes make up 95% of all oesophagal carcinomas [1]. According to the American Cancer Society, in 2021 over 19,000 new oesophagal cancer cases will be diagnosed with over 15,000 deaths from oesophagal cancer [2]. Risk factors for adenocarcinoma of the oesophagus include advanced age, male sex, GERD, obesity, smoking, and Barrett’s oesophagus [1,3]. Even with an increase in technology, prevention strategies, and oesophagal cancer screenings have been lacking and advanced disease with metastasis is a common initial presentation for this disease. The most common sites of metastasis include the liver, lymph nodes, lung, bone, and brain [4]. Advanced oesophagal carcinomas with distant metastases carry a 5-year relative survival rate of 4% [5]. In this report, we describe an unusual presentation of oesophagal adenocarcinoma with multiple musculocutaneous metastases.
Case Presentation
A 67-year-old Caucasian male with a medical history significant for gastroesophageal reflux disease, alcohol abuse, and a 160 pack-year smoker, presented to the VA with dysphagia, weight loss, and regurgitation of undigested food for the past 4 months. In the past 2 weeks, the patient reported his symptoms had worsened, progressing from dysphagia with solid food only to now liquids. He had lost 30 pounds in the past 4 months and 8 pounds in the past 2 weeks. He also mentioned that for the past month he had noticed a large painful lump on his left deltoid that had been increasing in size. An esophagogastroduodenoscopy was performed and a large, submucosal ulcerating mass was found in the middle third of the oesophagus. The mass and stricture measured 3-4 cm and were partially obstructing and circumferential. Oesophageal biopsies confirmed moderately differentiated adenocarcinoma of the distal oesophagus. CT scan of the chest and abdomen with contrast demonstrated an oesophagal neoplasm with prominent wall thickening and multiple metastatic nodules in the soft tissues and left adrenal gland. PET-CT correlated with these findings which showed segmental thickening and metabolic activity within the mid and distal oesophagus measuring approximately 9 cm in length. Focal FDG uptake was appreciated in the right lobe of the thyroid, left trapezius muscle, left subscapularis muscle, proximal right arm anterior to the humerus, right infraspinatus muscle, paraspinal muscles, right iliacus, bilateral gluteus medius, left buttock adjacent to the ischial tuberosity, left adrenal gland, and the subcutaneous tissues of the left neck. MRI of the shoulder showed three enhancing lesions in the left deltoid with the largest lesion measuring 4.3 cm × 3.4 cm × 2.4 cm. A needle biopsy of the left neck mass was performed and showed stage IV metastatic adenocarcinoma. After starting a palliative course of radiation therapy the patient showed improvement in the size of multiple subcutaneous masses, but surprisingly new masses continued to arise. Immune markers were negative for HER2 and positive for Programmed Death-Ligand 1 (PDL-1) and a Combined Positive Score of 5 (CPS-5). He was started on palliative chemotherapy with Cisplatin IV (80 mg/m2) on day 1 every 21 days for up to 6 cycles and 5- fluorouracil IV (800 mg/m2) on days 1-5 every 21 days for up to 6 cycles. In addition, immunotherapy was started on Pembrolizumab IV (200 mg) every 21 days for up to 2 years.
Discussion
This case demonstrates an unusual presentation of oesophagal adenocarcinoma with multifocal metastasis to unique areas including the muscles and subcutaneous tissues. Limited literature and very few case reports have described patients with similar metastatic findings. One case report described a squamous cell carcinoma of the oesophagus with diffuse, painless skin nodules that confirmed metastases [6]. Another systemic review of oesophagal cancer to unusual sites found that multiple muscles and skin metastases were described in only 7% of cases and that 91% of cases involving multiple muscles and skin metastases were synchronously found with the initial diagnosis of oesophagal cancer [7].
Conclusion
This case report highlights the importance of having a high clinical suspicion for patients with risk factors for oesophagal carcinoma who can present with sudden onset of the skin or muscle metastases, though this clinical presentation is uncommon.
Financial disclosure
There are no financial conflicts of interest to disclose.
References
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