A CARCINOMATOUS CALVARIAL COMPLAINT

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Scalp lesions have a wide spectrum of causes and in one study 7.8% were malignant, most commonly dermatologic neoplasms[1]. Of patients with any skull lesions who underwent surgery for diagnosis, cure, or palliation of symptoms, 13% of those masses were first presenting symptom of metastatic cancer[2]. We present a patient with a scalp lesion from a less recognized primary to reinforce that patients may not have presenting symptoms from their primarily affected organ. CASE PRESENTATION: 61 year old male who initially presented to his primary care physician with a scalp nodule that had been present for 7 months. He had initially attributed the lesion to a mild head trauma. Past medical history was significant for gastroesophageal reflux, coronary artery disease, ischemic cardiomyopathy, and tobacco use. The patient also complained of left elbow pain and fatigue. The initial work-up included a CT head, which demonstrated a 4.2cmx4cmx2.7cm dural-based mass eroding through the calvarium left of midline with dystrophic calcifications and associated edema and numerous dural and cerebral lesions consistent with metastatic cancer. X-ray of his left elbow showed a proximal ulnar osteolytic lesion. CT chest/abdomen/pelvis was significant for small hiatal hernia with diffuse thickening of the lower esophagus and prominent mediastinal and gastric lymph nodes. Neurosurgery performed a biopsy on the prominent brain mass, which showed metastatic poorly differentiated carcinoma with adenosquamous features of enteric origin. PET-CT showed likely origin of cancer in distal esophagus with suspicious gastroesophageal lymphadenopathy. No lesions in liver, lungs, or adrenal glands. There were multiple metastases in the brain and vertex calvarial areas in addition to another hypermetabolic lesion in the left ulna. The patient was started on palliative chemotherapy with FOLFOX and whole brain radiation. DISCUSSION: Esophageal cancer is a disease associated with high mortality and an increasing incidence in the United States. Risk factors include Barrett esophagus, GERD, smoking, and obesity. Common presenting symptoms include dysphagia, weight loss, heartburn, regurgitation, retrosternal pain, fatigue, and anemia. Esophageal cancer is metastatic in 18% of cases at diagnosis. The most common sites of metastasis are abdominal lymph nodes, liver, and lung. Brain metastases were present in only 2%[3]. Screening for esophageal cancer is not recommended for the general population in the United States because it is rare and there is a lack of evidence that screening improves survival. CONCLUSIONS: Clinicians should have a high suspicion for slowly growing head masses and bone pain in patients with significant risk factors for cancer. Esophageal cancer is a highly aggressive malignancy that does not always present with dysphagia or heartburn. Reference #1: Turk CC, Bacanli AB, Kara NN. Incidence and clinical significance of lesions presenting as a scalp mass in adult patients. Acta Neurochirurgica. 2015 Feb, 157(2): 217-223. Reference #2: Stark AM, Eichmann T, Mehdorn HM. Skull metastases: clinical features, differential diagnosis, and review of the literature. Surgical Neurology. 2003 Sep; 60(3): 219-25. Reference #3: Quint LE, Hepburn LM, Francis IR, Whyte RI, Orringer MB. Incidence and distribution of distant metastases from newly diagnosed esophageal carcinoma. Cancer. 1995 Oct 1; 76(7): 1120-5. DISCLOSURES: No relevant relationships by jayanth keshavamurthy, source=Web Response No relevant relationships by Eugene Quarshie, source=Web Response No relevant relationships by Varsha Taskar, source=Web Response No relevant relationships by Thomas Whitton, source=Web Response