S2301 Dysphagia: An Unusual Primary Presentation of Non-Small Cell Lung Cancer

Abstract

Introduction: Respiratory symptoms predominate in patients with lung malignancies. Dysphagia as a presenting symptom is rare with only about 1%-2% of patients presenting with dysphagia as their cardinal symptom. We describe a rare case of a 56-year-old male presenting with only dysphagia in the setting of extrinsic esophageal compression secondary to non-small cell lung cancer. Case Description/Methods: A 56-year-old male with past medical history of hypertension, chronic obstructive pulmonary disease, and chronic tobacco use presented to the emergency department with complaint of persistent emesis for the past 3 months. The patient described the emesis as occurring minutes after eating a meal. He also admitted to loss of appetite, unintentional weight loss, and dysphagia to solids. On admission, the patient was normotensive and tachycardic to a heart rate of 108. CT chest was performed and revealed an 8.0 x 7.5 cm right mediastinal mass with obliteration of the right main pulmonary artery and right main bronchus along with multiple irregular and nodular opacities in the right lung and left lower lobe concerning for metastases. Pulmonology was consulted and performed a bronchoscopy which showed a large obstructing endobronchial lesion of the right mainstem bronchus; biopsies of the lesion were sent. The patient was diagnosed with metastatic non-small cell lung cancer. The patient’s hospital course was complicated by intractable emesis and development of shock. Repeat CT was performed and was remarkable for a moderate volume pneumomediastinum and a small to moderate size right pneumothorax. Gastroenterology was consulted for concerns of esophageal perforation vs. invasion. Esophagogastroduodenoscopy was performed and showed severe extrinsic stenosis 30-32 cm from the incisors. The area of stenosis measured 2 cm in length and was dilated. A 23mm x 120mm EndoMAXX fully covered stent was placed at the 26 cm to 38 cm region of the esophagus. Following stabilization, the patient was able to tolerate mechanical soft diet and thin liquids (Figure). Discussion: Dysphagia associated with lung cancer can occur via 3 mechanisms: mediastinal extrinsic esophageal compression, upper esophageal compression by lymph nodes, and radiation induced esophageal stenosis. Patients may experience decreased quality of life due to poor oral intake, malnutrition, and increased risk for infection. Lung malignancy associated dysphagia can be improved by both surgical and non-surgical interventions such as dilatation or esophageal stenting.Figure 1.: (A) Initial CT Chest findings of a right 8.0 x 7.5 cm mediastinal mass (B) Repeat CT Chest remarkable for a moderate volume pneumomediastinum and a small to moderate size right pneumothorax and (C) EGD imaging of a 23mm x 120mm EndoMAXX fully covered stent placed at the area of severe esophageal stenosis.