S1971 Femur Fracture as Initial Presentation of Esophageal Squamous Cell Carcinoma

Abstract

INTRODUCTION: Squamous Cell Carcinoma (SCC) of the esophagus is a highly malignant tumor that can progress rapidly without treatment. Given the highly malignant potential of SCC, approximately 50% of patients are found to have metastatic disease at initial diagnosis. However, according to one study, esophageal adenocarcinoma is 3 times more likely to metastasize to the bone than SCC. Our patient presented uniquely with a bone metastasis from SCC resulting in a pathologic femur fracture. CASE DESCRIPTION/METHODS: A 65-year-old male presented to the emergency department with complaints of severe left leg pain. He reports being woken up from a nightmare with the pain at which point he noticed an obvious deformity of his left upper leg. Radiographs of his left leg were concerning for a pathologic fracture of the distal femur within a large underlying lytic lesion. Interestingly, he had presented to the ED two months prior with complaints of left leg pain and had a normal femur radiograph at that time. Given concerns for metastatic disease a CT Chest/Abdomen/Pelvis was obtained and revealed central esophageal wall thickening with mediastinal lymphadenopathy and right sided pleural effusion. He also had additional lytic bone lesions of the right 8th rib and left iliac bone. Esophagogastroduodenoscopy was performed given esophageal thickening and revealed malignant appearing esophageal stenosis suspicious for squamous cell carcinoma. Biopsies were taken and confirmed the diagnosis of Invasive Keratinizing Squamous Cell Carcinoma. CT Guided bone biopsy of left femur lesion revealed the same pathology (Figure 9) confirming the diagnosis of metastatic esophageal squamous cell carcinoma. Intramedullary nail fixation of his left femur was performed along with placement of PEG tube and port for initiation of chemotherapy with Carboplatin/Paclitaxel. He eventually passed away from complications of his disease. DISCUSSION: Historically, esophageal SCC accounted for most cases of esophageal cancer, however over the past few decades esophageal adenocarcinoma has taken over as the most common esophageal malignancy. Given our patient's recent history of stroke, his previous complaints of dysphagia were not worked up further. Two months prior to this presentation he reported left leg pain and had an unremarkable radiograph of the left femur. This case highlights the importance of obtaining a timely and detailed history and physical examination to avoid delaying diagnostic and therapeutic measures for esophageal cancer.Figure 1.: Pathologic distal femur fracture with underlying lytic bone lesion.Figure 2.: Femur biopsy showing metastatic squamous cell carcinoma with malignant squamous cells forming keratin pearls and invading fibrous stroma surrounding the bone.Figure 3.: Malignant appearing esophageal stenosis.