Dysphagia: An Unusual Primary Presentation of SCLC

Abstract

Introduction: Small cell lung cancer usually presents with weight loss, cough and chest pain however dysphagia as its first presentation is extremely rare. Extrinsic compression from enlarged mediastinal structures is a known and rare cause of mechanical esophageal dysphagia usually from vascular rings or thyroid enlargement. We describe an unusual case of small cell lung cancer invading into the mediastinum leading to dysphagia as the first symptom resulting in its diagnosis. Case: We present a case of a 54 yo female with past history of DM, hypothyroidism and 30 PY smoking history who presented with dysphagia to solid foods of 1 months duration accompanied by chest pain, but no odynophagia. She was only able to tolerate pureed foods and liquids. She had lost around 20 lbs in 4 months. On exam she had decreased breath sounds b/l and mild lower extremity edema. CXR showed large left sided mass. CT thorax revealed a 14.7cmx11.8cmx10.4cm mass causing compression and deviation of the trachea and esophagus to the right. Biopsy revealed SCLC and the patient was started on cisplatin and etoposide. Radiation therapy was subsequently started to relieve compressive symptoms. Discussion: Small cell lung cancers are rapidly expanding, centrally occurring tumors. The most common presentation is cough (50-75%), hemoptysis (20-50%), or chest pain due to mediastinal, pleural or chest wall extension (20-40%). Dysphagia is a rare presenting complaint, but when present, is due to metastasis to the GI tract and not due to extrinsic compression. SCLC is an unusual but important differential of dysphagia given the rapidly expanding nature of the tumor and different treatment course. Our case is different in that the dysphagia was due to extrinsic tumor compressing the esophagus. Diagnosis is dependent on imaging. Treatment includes chemo and radiation therapy by decreasing tumor burden. Conclusion: Dysphagia is an alarm symptoms for GI malignancies and work up includes fluoroscopic imaging and EGD. In a patient with dysphagia and a history of weight loss, it is important not only to consider GI etiologies, but also lung pathology, especially centrally located tumors like small cell that can cause extrinsic compression on the esophagus. This differential needs to be recognized for early intervention and follow up.Figure 1Figure 2Figure 3