A Rare Presentation of Synchronous Esophageal and Pancreatic Adenocarcinoma with Metastasis

Abstract

Purpose: Most cases of multiple cancers with esophageal adenocarcinoma are associated with head and neck cancers or gastric cancers. We report a rare case of synchronous esophageal and pancreatic adenocarcinoma. Methods: A 59-year-old Caucasian male with a history of alcohol abuse and a 40-pack year smoking history presented with a chief complaint of severe epigastric abdominal pain, anorexia, and a 25-pound weight loss over 6 months. On admission, he was afebrile and in mild distress. Physical examination revealed tenderness to palpation in the mid-epigastric region. Laboratory examination revealed a total bilirubin 3.4 mg/dL [0.2–1.2 mg/dL], direct bilirubin 2.1 mg/dL [0.0–0.3 mg/dL], alkaline phosphatase 708 IU/L [50–136 IU/L]. Abdominal CT scan showed intrahepatic biliary dilatation, common bile duct 1.5 cm in diameter, and mild pancreatic duct dilatation, with no obvious abnormal density or enhancing lesion in the pancreas. Bilateral adrenal gland masses, 3.5 cm on the left, 2.6 cm on the right, were also noted. EGD showed a circumferential mass in the distal esophagus, extending from 35 to 40 cm from the incisors. Biopsies revealed poorly differentiated adenocarcinoma. A subsequent EUS showed that the esophageal mass extended through the muscularis propria. In addition, a 9.1 × 6 mm hypoechoic left lobe liver nodule, a 2.5 × 1.6 cm left adrenal mass involving the body and tail of the pancreas with upstream ductal dilatation, and a 2.3 × 1.9 cm mass in the head of the pancreas were observed. FNA of the pancreatic body mass and celiac node showed malignant cells consistent with adenocarcinoma. Ascitic fluid obtained during the EUS showed reactive mesothelial cells. Results: ERCP revealed a stricture in the head of the pancreas and a 2 cm distal common bile duct stricture with marked dilation of the proximal bile duct. A 10 × 40 mm metal biliary stent was successfully placed across the stricture. An EGD followed with successful placement of a covered 10 cm esophageal stent. The patient was referred for palliative chemoradiation followed by systemic chemotherapy. However, the patient and his family opted for hospice care. He died two months later. Conclusion: In order to be considered synchronous secondary to a dual primary source, each cancer must appear malignant and distinct. In addition, the probability of one being a metastatic lesion of the other must be excluded. Although a distinction may be based on histology, as CA 19-9 stain is very specific for pancreatic cancer, up to 55% of esophageal adenocarcinomas will stain for CA 19-9 as well. This patient was considered to have two primaries due to the location of the mass in the head of the pancreas, which is the usual presentation for a primary pancreatic tumor.