An Atypical Presentation of an Esophageal Squamous Cell Carcinoma With Pancreatic and Bone Metastases

Abstract

Background Consideration of pancreatic malignancy is divided between an exocrine versus an endocrine neoplasm. Within the umbrella of exocrine pancreatic malignancies, adenocarcinoma predominates at a rate of up to 80% of all pancreatic malignancies. The normal pancreas entirely lacks squamous cells. A finding of squamous cells in a discrete pancreatic lesion usually denotes an undiagnosed primary squamous malignancy from a distant anatomic site. We present a case of a metastatic squamous cell carcinoma of the esophagus with metastasis to the pancreas. Case presentation A 67-year-old man was transferred to our medical facility after presenting to an outside hospital with dyspnea, dysphagia and weight loss. The outside hospital's computed tomography (CT) images revealed a 9.6 cm cavitary lung lesion with air-fluid levels, pretracheal lymph nodes, hepatic mass as well as vertebral osteolytic lesion. Initial laboratory values at our hospital showed a white-blood cell count of 25200, hemoglobin of 10.3 mg/d with normal bilirubin and aminotransferases. An abdominal CT scan was obtained revealing a loculated right lower lobe fluid collection with multiple air-fluid levels. A large 9.0 x 8.7 x 10.0 cm cystic mass in the head of the pancreas was seen along with focal distal esophageal thickening and destructive soft tissue lesions in the L3 vertebral body and left lateral 6th rib. Endoscopy revealed a fungating mass in the distal esophagus with suspicion of fistulization to the lung. The lesion was biopsied. EUS revealed a hypoechoic lesion suggestive of a cyst in the head of the pancreas measuring 8.5 x 12.1 cm in maximal cross-sectional diameter. A diagnostic fine-needle aspiration was performed using a Boston ScientificTM 19-gauge needle using a trans-gastric approach. Pathology results showed the distal esophageal mass to be squamous cell carcinoma. Cytology examination of the pancreatic cyst revealed squamous cell carcinoma presumed to be from the primary esophageal squamous cell carcinoma. The vertebral lytic lesion biopsy was consistent with this histopathology as well. Discussion We present an unusual case of squamous cell carcinoma of the esophagus presenting with metastasis to the bone and pancreas as well as fistulization to the lung. The finding of squamous cells in the pancreas suggests a likely metastatic lesion.1761_A Figure 1. Endoscopic view of esophageal mass1761_B Figure 2. CT scan depicting liver fluid collection as well as pancreatic cyst. Endoscopic ultrasound view of complex pancreatic cyst