Isolated Colonic Metastasis From Esophageal Adenocarcinoma

Abstract

Esophageal Cancer is the eighth most common cancer worldwide with an increasing incidence. Prognosis is highly dependent on the stage. Common sites of metastasis (mets) include lymph nodes, liver, lungs, bones and the adrenal glands. Staging is by computerized axial tomography scan (CT) and endoscopic ultrasound (EUS) for non- metastatic disease. Positron Emission Tomography (PET) improves sensitivity for distant metastasis. Despite all the above imaging techniques, occult metastatic disease is sometime difficult to diagnose preoperatively. Isolated esophageal adenicarcinoma(EsoA)with mets to the colon have not been reported in the English literature. A 60 year old male with a history of Barrett's esophagus presented with the complaint of dysphagia. An upper endoscopy (EGD) demonstrated an esophageal mass and biopsy was consistent with an adenocarcinoma, intestinal type, with foci of signet ring cell features. Staging with CT and EUS identified a T3N2M0 tumor. The patient was treated with neoadjuvant chemoradiation with the plan for an esophagectomy. His surgery was delayeddue to a new onset atrial fibrillation and stroke so chemotherapy was continued. Restaging PET/CT a year after presentation demonstrated no visible foci of mets. An esophagectomy with colonic interposition was considered so a preoperative colonoscopy was performed which demonstrated a colonic nodule with central ulceration in the proximal ascending colon. Biopsies were consistent with submucosal deposits of adenocarcinoma with signet cell features identical to the esophageal primary. Features that differentiate colonic mets from primary colonic adenocarcinoma include the submucosal location of the nodule and histologic characteristics consistent with the primary signet ring features. The finding of this colonic met avoided an unnecessary surgery, with significant morbidity and mortality, in a rather non curative setting. Extracolonic cancer with colonic mets are rare and have been reported in melanoma, breast cancer and lung cancer. They often are a manifestation of widespread mets. Metastatic esophageal squamous cell carcinoma to the colon has been rarely reported. This is the first reported case of an isolated colonic mets from esophageal adenocarcinoma not identified on prior imaging studies including PET/CT.Figure 1Figure 2