Esophageal Cancer with Metastasis to the Brain

Abstract

Purpose: Though rare, esophageal cancer with metastasis to the brain is becoming common with advances in therapy and imaging. A 74-year-old man with a medical history of hypertension and hypercholesterolemia was diagnosed with distal esophageal adenocarcinoma in June 2009. Prior to that the patient unintentionally lost 15 kg in 5 months and had difficulty swallowing both solids and liquids. An esophagectomy was performed, and he was subsequently treated with adjuvant chemotherapy including carboplatin, paclitaxel, as well as radiation therapy. In May, 2012, positron emission tomography was performed, which showed increased uptake in the left supraclavicular node and paraesophageal nodes (T3N1M0). Biopsy was performed, which showed tumour recurrence, which was positive for human epidermal growth factor receptor 2 (HER-2) antigen. The patient was started on capecitabine, oxaliplatin, and trastuzumab. The patient received five cycles only, because he developed diarrhea, weight loss (common side effects of capecitabine), and cardiac dysfunction (common side effects of trastuzumab). In January, 2013, the patient presented to the emergency department with complaints of lethargy and confusion, with subsequent transfer to intensive care unit. Brain MRI revealed an intra-axial hemorrhagic mass in the right temporal lobe with extensive vasogenic edema (Figure 1). The mass was resected, and it stained positive for CDX2, consistent with primary metastatic esophageal adenocarcinoma (Figure 2). Patient was scheduled for whole brain radiation therapy (WBRT) but became septic secondary to pneumonia while in the hospital. The patient was started on intravenous hydration and norepinephrine drip. Piperacillin, tazobactam, levofloxacin, and vancomycin were started. Blood cultures were negative. The patient remained on blood pressure support until his family decided to discontinue the treatment. The patient was enrolled in hospice care. Esophageal adenocarcinoma is a common cancer with an estimated 17,990 new cases and 15,210 new esophageal cancer-related deaths in 2013. Esophageal adenocarcinoma most commonly affects the distal esophagus and is common among people of Caucasian descent. The death rates are high, approaching >75% at 5 years after diagnosis. Distant metastasis to the liver, lungs, adrenals, and bones has been reported. However, distant metastasis to the brain is a rare finding with about 100 reported cases. This is likely because brain imaging is usually not performed in asymptomatic patients. Improved survival was noted in patients with single lesions who underwent resection and WBRT. In conclusion, esophageal cancer though rarely found in the brain, but can be treated if detected early.