Esophageal Cancer Requiring Multiple Biopsies in a Lung Transplant Recipient with Previously Normal Objective Studies

Abstract

<h3>Introduction</h3> Esophageal cancer is a relatively rare malignancy in lung transplant (LT) recipients. <h3>Case Report</h3> We report the case of a 61-year-old man with a history of bilateral LT (08/2017) for COPD who presented 4 years after transplant with a 1-month complaint of dysphagia to solids (mainly large pills) only. He had no history of reflux disease; routine, prior esophagram, EGD, and gastric emptying studies were grossly normal; no evidence of Barrett's esophagus. We performed an EGD that found a 2-cm long focal stricture in the proximal/mid-esophagus. A biopsy from the region confirmed atypical squamous epithelium but not dysplasia or malignancy. A chest CT showed scattered, bilateral solid and ground-glass sub-centimeter pulmonary nodules and circumferential thickening of the proximal/mid-esophagus. At this time, the primary concern was esophageal stricture possibly related to gastroduodenal aspiration. Meanwhile, surveillance bronchoscopies showed no evidence of ACR, granulomatous inflammation, or malignancy. We performed a second EGD with limited ultrasound assessment for esophageal stent placement at the stricture. Unfortunately, biopsy at this time revealed moderately differentiated, keratinizing, invasive squamous cell carcinoma. Given this finding, we performed robotic bronchoscopy with EBUS-guided FNA of the right upper lobe and right lower lobe pulmonary nodules; pathology was non-diagnostic. An abdomen/pelvis CT showed no intraabdominal or intrapelvic malignancy concerns. A follow-up PET/CT showed increased metabolic activity in the proximal esophagus surrounding the esophageal stent and in the distal esophagus. There was no focal uptake involving the previously identified pulmonary nodules. The patient was informed and shared the decision to start definitive chemoradiotherapy with weekly carboplatin and paclitaxel. <h3>Summary</h3> Suspicion for this malignancy was particularly low given no previous history of reflux disease, grossly normal objective studies to date, and a first biopsy not diagnostic for dysplasia or malignancy. Nonetheless, esophageal stricturing with complaint of dysphagia to solids only should raise concern for malignancy.