Primary Esophageal Adenocarcinoma With Colon Metastases After Esophagectomy

Abstract

Esophageal carcinoma is an aggressive cancer with predominance to squamous cell variation worldwide, but in the United States, adenocarcinoma is more common. Risk factors for esophageal adenocarcinoma (AC) include gastric acid reflux and tobacco use leading to an increase in oxidative stress resulting in inflammation and increase cellular turnover with metaplasia. Esophageal AC presents with manifestations of dysphagia, weight loss, malnutrition and advanced disease with dyspnea, cough or hoarseness. Esophageal AC can metastasize to the lung, liver, bone, celiac lymph nodes with rare spread to the colon. We present a case of primary esophageal AC status post chemoradiation and esophagectomy with metastatic disease found as asymptomatic colon polyps. Our patient is a 70 year-old male smoker presenting with dysphagia and weight loss of twenty pounds over 4 weeks. Esophagogastroduodenoscopy and endoscopic ultrasound revealed a nearly occlusive, friable mass invading the muscularis propria with celiac lymphadenopathy and biopsies confirming invasive, poorly differentiated AC without distant metastasis. Concomitant chemoradiation was initiated prior to surgical resection. An esophagectomy was performed with pathology consistent with prior biopsies. Routine CT scan four months later with enlarged para-aortic lymphadenopathy and liver lesions resulted in a colonoscopy to question the primary cancer. Colonoscopy exposed nodules throughout descending and ascending colon; biopsies consistent with similar immunoprofile as previous esophageal AC and liver lesions. Colon nodules were deemed consistent as metastasis from previous esophageal adenocarcinoma. Patient was started on FOLFOX therapy. Primary esophageal AC typically presents with advanced disease resulting in the likelihood of metastatic disease. Metastatic spread within the gastrointestinal tract, more specifically the colon, is rare with few case reports. Most case reports are of squamous cell carcinoma metastasizing, which can be explained by higher prevalence of disease worldwide. A definite challenge in this case is to determine the primary cancer. Colon nodules offer no differentiation from primary or secondary cancers with no particular features to be appreciated on imaging or endoscopy. Most nodules are asymptomatic and could be developing at the same time as the esophageal carcinoma. Treatment is based on the primary cancer with chemoradiation and surgical resection if applicable.