An Unusual and Rare Case of Esophageal Stricture as a Result of Systemic Chemotherapy for Solid Malignancy

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Esophageal stricture secondary to isolated chemotherapy is exceptionally rare. We present the case of a patient receiving adjuvant chemotherapy who subsequently developed acute, severe esophageal stricture. A 34 year old male with a diagnosis of metastatic testicular seminoma presented to the hospital following a left orchiectomy for initiation of chemotherapy. He was started on Etoposide and Cisplatin chemotherapy and received an initial five days of therapy. Two weeks following the first cycle of chemotherapy, the patient developed symptoms of dysphagia and odynophagia, and all other review of systems was negative. He had no prior history of caustic ingestions or radiation therapy. The primary team noted oral thrush which was empirically treated with antifungal therapy. As symptoms persisted throughout the second and third cycles of therapy, a gastroenterology consult was called. On exam, patients vitals were stable, physical exam was unremarkable with resolution of thrush, and initial labs were consistent with primary malignancy. Gastrograffin esophogram revealed a narrowing in the distal third of the esophagus. CT scan revealed esophageal distension to the level of the GE junction. On EGD, a site of moderate stenosis measuring 1cm x 9mm was found 29 cm from the incisors which was traversed with mild resistance. An additional site of stenosis was found 30 cm from the incisors. A severe stenosis with a luminal diameter of 3 mm was found 6 cm further. A pediatric endoscope was used due to severity of stenosis. Histopathologic examination revealed nonspecific esophagitis. Cytology was negative for malignancy. No fungal elements were noted. Patient was offered but refused treatment with endoscopic dilation. The patient opted for a laproscopic PEG tube placement to optimize nutrition. The acute onset of esophageal stricture, without any prior radiation treatment or secondary causes of dysphagia led to the diagnosis of esophageal stricture secondary to use of systemic chemotherapy. We suspect esophageal stricture as complication of systemic chemotherapy as the patient had no history of long standing acid reflux or known exposure to established nonpeptic causes of stricture. This unexpected adverse outcome is likely caused by an interplay of mucosal damage associated with chemotherapy and the rapidly proliferating cells that line the gastrointestinal tract. These findings should prompt further investigation into the pathways of such a rare isolated injury.Figure: Gastrograffin esophogram showing generalized distal narrowing of the distal esophagus.Figure: Endoscopic view of severe stenotic stricture at 36 cm from incisors measure 3 mm in inner diameter.Figure: Endoscopic view of esophagus with visualization of stricture and friable mucosa.