1826 74-Year-Old Man With Esophageal Adenocarcinoma and Right Sided Weakness: Is Brain Involved?

Abstract

INTRODUCTION: Esophageal cancer with an incidence of 4.3 per 100,000 per year and a death rate of 4.0 per 100,000 per year accounts for about 1% of all cancers diagnosed in the US. Within the past four decades, while the incidence of esophageal cancer has remained stable in the US, an increasing trend for the adenocarcinoma form has been observed in men mainly due to increased obesity and gastroesophageal reflux disorders. Remarkably, Hispanic-Americans have a lower rate of esophageal cancer. Brain metastasis from esophageal cancer is an extremely rare condition with an incidence of 0.6-1.5%. Here we report a Hispanic-American white patient with brain metastasis from esophageal adenocarcinoma. CASE DESCRIPTION/METHODS: 74-year-old Hispanic man with history of esophageal adenocarcinoma status post chemo-radiation with resection and gastric pull-through was referred to our hospital 4 years after surgery due to progressive left upper and lower extremity weakness, left facial droop and slurred speech for almost a month. He denied any prior history of headache, trauma, weakness or falls. Brain MRI showed a 61.6 x 47.3 x 45.0 mm heterogeneous/enhancing/intra-axial tumor projected at the level of the right supramarginal gyrus, and another smaller 9 mm intra-axial enhancing lesion in the medial aspect of the right superior temporal gyrus associated with perilesional vasogenic edema and 12 mm right to left midline shift (Figure 1). CT thorax, abdomen and pelvis did not reveal any mass or lymphadenopathy. The patient underwent a right-sided temporal craniotomy for resection of the temporal hemorrhagic tumor with a moderately hard capsule and significant fibrous adhesions invading the M2 branch of the middle cerebral artery with a small rim of tumor left along the back of the middle cerebral artery. He was scheduled for Whole Brain Radiation Therapy (WBRT) showing an improvement in his muscular strength. Pathology report demonstrated metastatic brain adenocarcinoma from the esophagus (Figure 1). DISCUSSION: Brain metastasis is a rare condition which should be suspected in patients with esophageal cancer and neurological manifestations. Routine preoperative neuroimaging is not recommended for identification of occult brain metastasis in esophageal cancer rather than in those with a primary esophageal tumor of >8 cm in diameter. Prognosis of this condition is overall poor and treatment should be personalized based on the patient’ general condition. When brain mass is resectable, surgery followed by WBRT is recommended.