An Unusual Presentation of Metastatic Esophageal Cancer

Abstract

Esophageal cancer is the 6th leading cause of death from cancer and the 5-year survival rate is dismal around 15%-25%. Metastatic spread to the intestinal tract is extremely rare and thus there are no guidelines suggesting preoperative colonoscopy. Here we present a case of esophageal adenocarcinoma which metastasized to the colon, an event that has so far been unreported in the literature. A 70 year old male with a past medical history of poorly differentiated pT3N1 esophageal adenocarcinoma diagnosed in June 2013 presented to the hospital in December 2015 with shortness of breath and weakness for the preceding two weeks. Patient's initial staging workup included CT of his chest, abdomen and pelvis and PET-CT which demonstrated a PET-avid lesion in his left upper lung. He received neoadjuvant chemotherapy with EOF (Epirubicin, Oxaliplatin and Fluorouracil) for five cycles and subsequently underwent both esophagectomy and left upper lobe wedge resection for his malignancies. He declined further adjuvant chemotherapy after his surgery. On admission, CT of the chest revealed a new pulmonary embolus. He was started on a heparin drip and subsequently had two episodes of hematochezia. Given his history of malignancy and new pulmonary embolus upper and lower endoscopy were pursued. EGD revealed a healthy anastomosis at 21 cm from the incisors. Colonoscopy revealed innumerable friable polypoid lesions, some with overlying exudate, measuring 5-30 mm in size found diffusely throughout the colon. Pathology from the biopsies revealed poorly differentiated adenocarcinoma with positive staining for cytokeratin AE1/AE3, CK7 and CDX2 and negative for HER2, CK20, P40, LCA (CD45), neuroendocrine and melanoma markers. Review of his prior pathology from his esophageal tumor demonstrated a matching immunologic profile consistent with the diagnosis of poorly differentiated metastatic esophageal adenocarcinoma. The patient was referred for systemic chemotherapy; however, he unfortunately expired one week after the diagnosis.Figure 1Esophageal adenocarcinoma is becoming more prevalent in the United States and yet remains a very deadly cancer. Despite strict staging protocols preoperatively, we present a case of esophageal adenocarcinoma metastasizing diffusely to the colon. Although rare and a previously unreported condition, it does raise the question of whether colonoscopic surveillance should be included in the staging guidelines for esophageal adenocarcinoma preoperatively.Figure 2