Esophageal Mass Research Articles

Malignant Esophageal Glomus Tumor With CARMN::NOTCH2 Fusion: An Additional Tumor Underscoring the Frequent Tendency of Esophageal Glomus Tumors for Aggressive Behavior.

Malignant glomus tumors are rare tumors of pericytic origin with a propensity to develop in the upper gastrointestinal tract. Hereby we demonstrate a tumor of a 20-year-old man, who presented with dysphagia and an exophytic esophageal mass. Histologic examination of the resected mass revealed a multinodular tumor in the esophageal wall composed of epithelioid cells showing nesting and monomorphic atypia, staghorn vessels and scanty stroma. Immunohistochemically, the neoplastic cells were positive for SMA, and H-caldesmon, while desmin was negative. Collagen IV and laminin decorated a dense intercellular basal membrane meshwork. RNA-sequencing using TruSight RNA Pan-Cancer Panel revealed a CARMN::NOTCH2 fusion, that is a recurrent, frequently described and so far specific genetic alteration in glomus tumors. In spite of the adjuvant chemotherapy regimens, the patient died of disseminated metastatic disease 2 years after the diagnosis. Our patient presentation and the previous reports in the literature highlight the frequently aggressive behavior of glomus tumors arising in the esophagus.

One stone two birds - Submucosal tunneling endoscopic resection for a large esophageal submucosal mass and esophageal diverticulum.

A-35-year-old woman presented our hospital with half a year's history of solid food dysphagia. An upper gastrointestinal endoscopy revealed a large submucosal mass in an esophageal diverticulum near the gastroesophageal junction. Endoscopic ultrasound (EUS) confirmed a hypoechoic lesion arising from the muscularis propria layer with the size of 25*14 mm. Therefore, submucosal tunneling endoscopic resection (STER) was proposed to remove the large submucosal lesion in addition to targeted septotomy of the esophageal diverticula. A 2-cm longitudinal mucosal access was made at 3 cm above the submucosal lesion, and a submucosal longitudinal tunnel was created until the submucosal lesion revealed using a DualKnife (Olympus, Japan). Meticulous resection was performed with the DualKnife, and the lateral border of the lesion was dissected from muscularis propria layer. It was completely removed the lesion with en bolc resection, and dissected the septum of the diverticulum using the DualKnife. The tunnel access was closed with several hemoclips. Finally, it has been demonstrated to achieve a perfect outcome for the patient. The patient was discharged three days later with symptom resolved on follow-up and to date.

Oesophageal haematoma in a Cairn terrier presenting for impaired swallowing, retching and cervical pain

AbstractA 13‐year‐old spayed female Cairn terrier was referred for surgical resection of a large oesophageal mass. The dog was initially presented to the primary care veterinarian for several days of gagging. The mass was initially diagnosed on thoracic radiographs and confirmed via computed tomography and oesophagoscopy. Endoscopic biopsies were performed that were consistent with oesophagitis. The dog was then referred to The Ohio State University Veterinary Medical Center for surgical resection of the mass. On surgical approach, a small nodule was palpable in the oesophagus; however, a large mass was not found. Oesophagoscopy was repeated intraoperatively, which revealed a small nodule in the same region of the previously described mass. The small nodule was removed, and histopathology was consistent with lymphohistiocytic inflammation and previous haemorrhage, consistent with an oesophageal haematoma. The dog made a full recovery post‐operatively, with continued resolution of clinical signs reported 5 months after surgery.

Inflammatory Myofibroblastic Tumor of the Esophagus and Stomach Successfully Treated With ALK Inhibitor in a Pediatric Patient: A Case Report and Concise Review of Literature.

An inflammatory myofibroblastic tumor (IMT) is a rare mesenchymal neoplasm of borderline malignant potential. Nearly half of all IMTs have rearrangement of anaplastic lymphoma kinase (ALK) locus on chromosome 2p23 which can be treated with targeted therapy. Herein, we describe an unusual presentation of IMT involving an anatomical region rarely implicated in this disease process. A 15-year-old male patient came to the ER with dysphagia and coffee ground emesis. On esophagogastroscopy, a nodular luminal obstructing 30 × 50 mm mass in the lower esophagus was found, which was continuous with a large, partially circumferential gastric mass extending from the mid-body to the proximal antrum. Biopsies from esophageal and gastric masses revealed submucosal lesions composed of cytologically bland spindle and epithelioid cells, intermingled with inflammatory infiltrate, for which several immunohistochemical (IHC) stains were performed. The molecular study demonstrated ATIC::ALK fusion. Based on morphological, IHC, and molecular study findings, the diagnosis of ALK-positive IMT was rendered. Because surgical excision was deemed infeasible, the patient was started on ALK-inhibiting therapy with crizotinib. The patient responded well with no evidence of residual or recurrent disease on follow-up imaging or surveillance esophagogastroduodenoscopy. Crizotinib was ultimately discontinued after 10 months of therapy, and the patient continues to undergo surveillance imaging for monitoring of disease burden.

SMARCA4-Deficient Undifferentiated Esophageal Carcinoma: A Clinical Case Series and Literature Review

PurposeUndifferentiated carcinoma of the esophagus (UEC) is a rare malignancy. Deficiency in SMARCA genes, critical for chromatin regulation, has been observed in cases of UEC. Research in UEC is sparse, however, and we present a case series along with a comprehensive review of the literature.Case SeriesCase 1 is a 49-year-old female with abdominal pain and dysphagia and esophagogastroduodenoscopy (EGD) showing a friable mass at the gastroesophageal (GE) junction. Biopsies showed a poorly differentiated neoplasm and immunohistochemistry showed loss for SMARCA4. With metastatic disease, she agreed to undergo palliative chemotherapy and radiation, passing away at 4 months. Case 2 is an 88-year-old male with dysphagia, nausea, vomiting, and distal esophageal mass with biopsy showing a malignancy with loss of SMARCA4 expression. Due to extensive metastases, he was counseled on hospice care. Case 3 is a 53-year-old male with extensive alcohol and smoking history presenting with hematemesis, passing away shortly. Posthumous histopathology consistent with undifferentiated SMARCA4-deficient carcinoma of the esophagus. Results of the literature review indicate a predilection towards males (75.0%) and a variable age range (39–88 years). Majority (76.2%) reported with a distal esophagus location. Metastatic disease was common at initial presentation. Median survival was 2.60 months. Some were managed with chemotherapy and radiation.ConclusionsResearch in SMARCA-deficient UEC is very limited. It is more common in men, age is variable, and associated with Barret’s esophagus. Further research is necessary to better understand it and to establish treatment guidelines; however, it is clear that SMARCA4-deficient UEC carries a significantly poor prognosis.

Adenocarcinoma of the distal esophagus and esophageal-proventricular junction in a yellow-naped parrot.

A 57-y-old male yellow-naped parrot (Amazona auropalliata) was presented because of lethargy, inappetence, and weight loss. Hematology and serum biochemistry were unremarkable, and imaging revealed a mass in the distal esophagus at the coelomic inlet. The luminal diameter of the esophagus was reduced in this area, and passage of ingesta was limited. Following gavage feeding, the patient died and was submitted for autopsy. At postmortem examination, the noted mass effect was a thickening of the distal esophagus with adherent, coalescing, soft, pale-tan plaques on the mucosal surface. Additional gross findings included pale-tan, opaque feed material oozing from the dorsum of the lungs and covering the cranial air sacs. Histology of the esophagus, esophageal-proventricular junction, and proximal proventriculus revealed an unencapsulated, infiltrative, transmural neoplasm that extended from the mucosal surface deep into the muscularis, almost to the adventitia. The neoplasm was composed of cuboidal cells arranged in islands and tubules, consistent with an adenocarcinoma, a rarely reported entity in the esophagus of psittacine birds and to our knowledge not reported previously at the esophageal-proventricular junction.

Esophagogastroduodenoscopy findings that do no not explain dysphagia are associated with underutilization of high-resolution manometry.

In patients with dysphagia that is not explained by upper endoscopy, high-resolution esophageal manometry (HRM) is the next logical step in diagnostic testing. This study investigated predictors of failure to refer for HRM after an upper endoscopy that was performed for but did not explain dysphagia. This was a retrospective cohort study of patients >18 years of age who underwent esophagogastroduodenoscopy (EGD) for dysphagia from 2015 to 2021. Patients with EGD findings that explained dysphagia (e.g. esophageal mass, eosinophilic esophagitis, Schatzki ring, etc.) were excluded from the main analyses. The primary outcome was failure to refer for HRM within 1 year of the index non-diagnostic EGD. We also investigated delayed referral for HRM, defined as HRM performed after the median. Multivariable logistic regression modeling was used to identify risk factors that independently predicted failure to refer for HRM, conditioned on the providing endoscopist. Among 2132 patients who underwent EGD for dysphagia, 1240 (58.2%) did not have findings to explain dysphagia on the index EGD. Of these 1240 patients, 148 (11.9%) underwent HRM within 1 year of index EGD. Endoscopic findings (e.g. hiatal hernia, tortuous esophagus, Barrett's esophagus, surgically altered anatomy not involving the gastroesophageal junction, and esophageal varices) perceived to explain dysphagia were independently associated with failure to refer for HRM (adjusted odds ratio 0.45, 95% confidence interval 0.25-0.80). Of the 148 patients who underwent HRM within 1 year of index EGD, 29.7% were diagnosed with a disorder of esophagogastric junction outflow, 17.6% with a disorder of peristalsis, and 2.0% with both disorders of esophagogastric outflow and peristalsis. The diagnosis made by HRM was similar among those who had incidental EGD findings that were non-diagnostic for dysphagia compared with those who had completely normal EGD findings. Demographic factors including race/ethnicity, insurance type, and income were not associated with failure to refer for HRM or delayed HRM. Patients with dysphagia and endoscopic findings unrelated to dysphagia have a similar prevalence of esophageal motility disorders to those with normal endoscopic examinations, yet these patients are less likely to undergo HRM. Provider education is indicated to increase HRM referral in these patients.

Oesophageal plasmacytoma in a dog: Outcome following surgical excision guided by computed tomographic features and oesophagoscopy biopsy findings

AbstractA 10‐year‐old, female, spayed golden retriever crossbreed dog was referred for persistent vomiting and hypersalivation after eating. Thoracic radiographs showed a small, circular soft tissue opacityin the region of the mid‐caudal thoracic oesophagus An intraluminal, pedunculated mid‐caudal thoracic oesophageal mass was identified on subsequent computed tomography of the thorax. Oesophagoscopy guided endoscopic biopsies were consistent with a plasmacytoma, a neoplasm rarely diagnosed in the canine oesophagus. Thoracotomy via a rib pivot method, longitudinal oesophagotomy and partial longitudinal oesophagectomy were performed with successful mass excision. Histopathology confirmed the diagnosis of plasmacytoma excised with complete surgical margins, and the dog's clinical signs resolved. Repeat computed tomography and oesophagoscopy 7 months following surgical excision showed no recurrence, and the dog remained clinically well.

Giant fibroepithelial polyp of the esophagus successfully managed endoscopically.

An 68-year-old woman complained of substernal discomfort and occasional regurgitation of a fleshy mass into her mouth. There was no history of weight loss, dysphagia or dyspnea. Upper endoscopy revealed a polypoid digitiform mass with a single pedicle arising from the upper esophagus and extending 8 cm downward. A CT scan demonstrated an elongated intraluminal esophageal mass extending from the cervical esophagus with a longitudinal length of more than 7 cm. Endoscopic ultrasound revealed a subepithelial lesion sparing the muscularis propria layer. The decision was made to proceed with endoscopic polypectomy, which was successfully performed using a hot snare after prophylactic hemostasis with an endoloop. Histology revealed a fibrovascular polyp. The patient had an uneventful recovery and became asymptomatic. We present this case due to its rarity and atypical presentation.

Elevated FAPI Activity in Ulcerative Fungal Esophagitis.

We report a case of ulcerative fungal esophagitis with elevated activity of 18F-FDG and 68Ga-FAPI (fibroblast-activating protein inhibitor). Our findings suggest that ulcerative fungal esophagitis should be considered in the differential diagnosis of cancer-like esophageal mass with increased 68Ga-FAPI uptake.

Submucosal tunneling endoscopic full-thickness resection for management of a rare case of esophageal GI stromal tumor

Video 1The mass was identified at the upper- to mid-esophagus, 25 cm from the central incisors. No varices were seen on further examination of the esophagus. A 4-mm injector force needle was used to create a large submucosal injection using BlueBoost lifting agent proximal to the mass. A longitudinal mucosal incision was then made using the hybrid T-type electrocautery knife, 20 cm from the central incisors.The cutting current was the preset Endocut Q mode, and the coagulation setting was spray coag mode, effect 2 and 40 W.Next, tunnel creation by submucosal dissection was performed with a focus on keeping the submucosal space as clean as possible. Carbon dioxide was used for insufflation to prevent pneumoperitoneum.A smooth-surfaced oval mass was identified originating from the muscularis propria layer. Dissection was extended 2 cm distally beyond the mass. Next, resection of the mass was performed. First, the mucosal surface of the mass was dissected. Dissection began at the distal portion, proceeded to the left and right lateral borders, and then continued toward the proximal portion. The mass was dissected away from the muscularis propria.We focused on freeing the mass, ensuring this esophageal mass was intact throughout dissection. The attached bands of muscularis propria at the distal portion were carefully resected completely.Water irrigation was used at this time to ensure better visualization for resection. The remaining attached bands of muscularis propria were resected, ensuring complete en bloc resection. Afterward, the mass was suctioned into the cap and carefully retrieved as shown, and then sent to pathology for processing.The entire defect bed was inspected post-resection, and no perforation or bleeding was identified.The mucosal defect was completely closed with through-the-scope hemostatic clips in a longitudinal fashion beginning with approximation of the defect at the distal portion.

Primary Esophageal Mucosa-associated Lymphoid Tissue Lymphoma: A Rare Case Report and Review of Other Published Data

The gastrointestinal tract is the most common extranodal site for lymphomas, and mucosa-associated lymphoid tissue lymphoma is the second most common histological lymphoma subtype. However, primary esophageal mucosa-associated lymphoid tissue lymphomas are extremely rare. Few such cases are documented, and the reports demonstrate inconsistent diagnostic and therapeutic strategies. Herein, a 54-year-old man was referred to our hospital for treatment of dysphagia. Esophagogastroduodenoscopy revealed a large, horseshoe-shaped subepithelial mass in the upper esophagus. Endoscopic ultrasonography and computed tomography revealed that the mass was well-demarcated and confined to the muscularis mucosa, with no abnormalities in other organs or lymph nodes. The mass was presumptively diagnosed as benign, and the patient underwent endoscopic mucosal dissection for pathological confirmation and symptom relief. Pathological examination of the dissection specimen revealed that it was a primary esophageal mucosa-associated lymphoid tissue lymphoma. As the patient had an elevated immunoglobulin G level and <i>Helicobacter pylori</i> infection, we administered adjuvant eradication therapy. The patient remains under surveillance and is free of lymphoma recurrence 36 months postoperatively. This case report demonstrates that endoscopic resection and <i>H. pylori</i> eradication are effective treatment strategies for early-stage esophageal mucosa-associated lymphoid tissue lymphoma.

342. VIDEO-ASSISTED THORACOSCOPIC ENUCLEATION OF BENIGN SCHWANNOMA MISDIAGNOSED AS MALIGNANT LESION ON F-18 FDG PET/CT IN ESOPHAGEAL SUBMUCOSAL TUMOR

Abstract Background Esophageal SMT is a rare disease, and most of them are benign. Esophageal schwannoma accounts for about 2% among esophageal SMT. Recently, F-18 FDG PET/CT has been widely used to confirm malignancy or to identify other metastatic lesions in cancer patients. However, even benign tumors often show an elevated SUV, and in the case of schwannomas, various values of SUV have been reported, which seems to limit differentiation from other malignant peripheral nerve sheath tumors. Case A 56-year-old female patient was incidentally found with extrinsic compressing mass at 22 cm from the incisor. An endoscopic ultrasonography and chest CT showed a 3.4 cm sized homogenous well-defined mass in upper esophagus, leiomyoma or gastrointestinal stromal tumor was suspected. SUV was elevated on PET-CT was performed to identify malignancy and metastatic lesions. When confirmed as malignant, additional surgery was planned, and enucleation was performed for primary diagnosis and treatment. The esophageal bulging was confirmed. After dividing the esophageal muscle, and underwent enucleation. In immunohistochemical staining, S-100 protein showed positive findings, which could be diagnosed as schwannoma. Conclusion Due to the characteristics of esophageal SMT, FDG uptake may be observed on PET-CT, but if there is no evidence of metastasis, it is likely to proceed with treatment according to the benign disease. Then, if immunohistochemistry examination is diagnosed as malignancy, it would be desirable to apply additional stage surgery.

Surgical management of complete esophageal obstruction in graded Murrah buffalo (Bubalus bubalis) - A case report

A seven-year-old, advance pregnant graded Murrah buffalo was presented with sudden onset of profuse salivation, anorexia, severe tympany and generalized discomfort. Palpation revealed enlarged cervical esophageal mass with pain and gagging reflex. Plain lateral radiography of neck showed presence obstructed mass in cervical esophageal lumen. The obstructed mass was removed via esophagotomy under deep sedation and local infiltration anaesthesia with uneventful recovery.

Predicting reflux symptom recurrence: The impact of gastroesophageal junction indicators and body mass index among outpatients.

The present study aimed to evaluate the efficacy of the prediction model in predicting reflux symptom recurrence among outpatients with reflux esophagitis (RE). A total of 261 outpatients diagnosed with RE complicated by anatomical alterations at the gastroesophageal junction and reflux symptoms were included in the study. Through follow-up, patients were divided into a General group (149 cases) and a Recurrent group (112 cases). Receiver operating characteristic curves of the related factors and prediction model were analyzed to compare the efficacy of each element in predicting reflux recurrence. A prediction model was constructed for predicting reflux recurrence using the axial length of the hiatal hernia (HH), the diameter of the esophageal hiatus, Hill classification, and body mass index (BMI) as risk factors. The cutoff values of the aforementioned factors for predicting reflux recurrence were: an axial length of HH >2 cm, esophageal hiatus diameter ≥3 cm, Hill grade >III, and BMI >25.1 kg/m2. The multivariate prediction model constructed using the aforementioned four indicators together with chronic atrophic gastritis and Helicobacter pylori infection had the area under the curve of 0.801 (95% confidence interval: 0.748-0.854), and the cutoff value of 46.8 had a sensitivity and specificity of 71.4% and 75.8%, respectively. The predictive model in the present study can be used for the primary assessment of reflux recurrence in patients with RE.

A rare cause of dysphagia in children: Squamous cell carcinoma of the esophagus: A case report and review of literature

Globally, an estimated 572 000 cases occurred in 2018 of malignant tumors of the esophagus but in children and adolescents, this cancer is a rare disease. Through this case report, i tried to analyze the clinical, paraclinical, therapeutic and prognostic profile of squamous cell carcinoma of the esophagus in children. This 10 years old female school child is presented with a complaint of worsening of difficulty of swallowing of 01 week duration. She had Symptoms complex of TB for the last 3 months. FNAC from right axillary, bilateral inguinal LNs, discrete with pus oozing sinus tract about 2x2 cm Microscopy shows caseous necrotic material= suggestive of TB. SAM (NE) + Severe Pneumonia + R/O Diss TB (Lung, LN) + Tungiasis was considered and anti TB was started but the patient was deteriorating. After one month course in the hospital the patient condition was deteriorating, the dysphagia become worsened. CHEST CT SCAN of the child was taken and the Finding: there is multifocal coalescing tree in bud opacity in posterior segment of the right upper lobe and superior segment of the lower lobe on the same side. There is consolidation with bronchiectasis changes on the left lower lobe. Multiple enlarged Para tracheal, sub carinal and Para esophageal nodes noted. There is circumferential wall thickening of the mid and part of proximal esophagus with no fat plane from the enlarged adjacent nodes. Calcified right axillary nodes visualized. the Impression was Bilateral pulmonary opacities with mediastinal LAPs (likely 2ry to TB) + circumferential wall thickening of mid and part of proximal esophagus DDx: Esophageal malignant mass with mediastinal nodal deposits and aspiration pneumonia- so needs clinical correlation and endoscopic study. Esophageal biopsy was taken and section shows nests and single cells of malignant squamous cells having high N/C ratio hyper chromatic nucleo and dense eosinophilic cytoplasm along with keratin pearls along with monocular infiltration and atypical mitosis invading in to desmoplastic stroma. Conclusion: Squamous cell carcinoma The child was transferred to oncology ward for chemotherapy and radiotherapy after one week of ward stay the patient passed away. Malignant esophageal tumors in children and adolescents are extremely rare conditions. The ingestion of caustic products and smoking are currently the most well-known risk factors for this disease, factors not found in our patient. Dysphagia is the main clinical sign of squamous cell carcinoma of the esophagus. Thus, in the event of dysphagia in children or adolescents, a mediastinal process should be considered, and a paraclinical assessment should be carried out. Since squamous cell carcinoma of the esophagus is a rare malignant tumor in children, the interest of this case report is to underline the importance of evoking a malignant esophageal process in children who present a notion of dysphagia to solids then to liquids, associated with an alteration of the general condition and anemia.

Demystify esophageal submucosal tumor: angiomas.

A 51-year-old man presented to the gastroenterology department with a history of abdominal discomfort. Computed tomography was unremarkable. Upper gastrointestinal endoscopy showed a submucosal mass lesion at the esophagus, with a 36cm distance from the incisors. The esophageal submucosal mass lesion with mixed echo was confirmed by endoscopic ultrasound (EUS). Endoscopic submucosal dissection (ESD) was performed, and the mass lesion was resected in a whole piece. Histopathological examination showed lymphatic and blood vessels, which demonstrated an esophageal vascular tumor. Further immunohistochemistry revealed tumor cells that stained positive for CD34 and D2-40.

Comparison of ultrasound measured gastric volume in term-pregnant patients posted for elective cesarean section with nonpregnant elective surgery patients---An observational study

Background: The pregnant patients undergoing anesthesia are at increased risk of aspiration due to decreased lower esophageal sphincter tone and mass effect of gravid uterus on gastric antrum. Ultrasound used as a noninvasive bedside imaging tool to measure gastric volume in term pregnant patients immediately before elective caesarian section (CS) may help in reducing aspiration induced morbidity and mortality. Methods: This observational prospective case--control study was conducted in 33 nonlaboring term pregnant patients immediately before elective CS and 30 nonpregnant patients immediately before elective surgeries, enrolled according to inclusion and exclusion criteria. A 2-5 MHz curvilinear probe was used to scan the participants in supine and right lateral decubitus (RLD) position in pre-recovery room. Visibility, qualitative grading (0,1, 2), anteroposterior (AP), and craniocaudal (CC) diameter, and cross-sectional area (CSA) of gastric antrum was measured. Gastric volume was derived from CSA using equations formulated by previous investigators. Results: Gastric antrum was visible in 27 (82%) of pregnant and 30 (100%) of nonpregnant patients in supine position (P = 0.014). In RLD position, 25 (75.7%) pregnant and 29 (96.7%) nonpregnant patients had antrum visible (P = 0.018). The qualitative grading was comparable (P = 0.064) in both the groups. In supine position, (P = 0.615), CSA in cm2 was 3.37 ± 1.31 and 3.54 ± 1.33, while in RLD position (P = 0.012), CSA was 3.98 ± 1.13 and 5.09 ± 1.85, in pregnant and nonpregnant patients, respectively. Conclusion: Gravid uterus sometimes impedes visualization of antrum by ultrasound in term pregnant patients immediately before elective CS and shows clinically similar gastric CSA when compared to nonpregnant patients, though statistically different in RLD position. Trial registration number- NCT03380637

925: ACUTE RESPIRATORY FAILURE WITH PNEUMOTHORAX DUE TO ESOPHAGOPLEURAL FISTULA AND ESOPHAGEAL CARCINOMA

Introduction: Esophagopleural (EPF) is a rare but serious condition that may occur secondary to esophageal instrumentation, malignancy, or as a complication following surgical thoracic procedures. The unfamiliarity of this condition, along with non-specific clinical presentations and elusive imaging makes it a diagnostic challenge. We present an interesting case of EPF causing acute respiratory failure. Description: A 58-year-old female with 40-pack-year smoking history was diagnosed with esophageal carcinoma and presented with dysphagia, shortness of breath, and hematemesis. On arrival, the patient was hypoxic and hypercarbic (PCO2 60mmHg) and in frank respiratory distress requiring intubation and admission to the ICU. Chest x-ray showed a large right pneumothorax and left lung consolidation. A right chest tube was placed, and broad-spectrum antibiotics were started. CT chest with oral contrast revealed contrast extravasation into the bilateral mainstem bronchi, and an esophageal bronchial fistulous communication between the esophageal mass and right pleural space. Esophagogastroduodenoscopy was performed with the placement of an esophageal metallic stent. 2 days later, the patient was extubated to nasal cannula and the chest tube was subsequently removed. Discussion: EPF is an uncommon condition despite the proximity of the trachea and esophagus. Anatomically, the esophagus is in direct contact with the pleura for a considerable distance on the right side, whereas on the left side, the aorta lies in between the esophagus and the pleura, except for a short distance just above the diaphragm. Thus, processes in the esophagus can spread more easily into the right side of the pleura rather than the left as in our patient. In patients with esophageal cancer, the incidence of EPF is 5-15%. Radiological signs of EPF depend upon the site, duration, and severity of perforation; and more importantly, the integrity of the pleura. Esophagographic studies may confirm the presence of EPF, although rarely indicated in the era of CT. Therapeutic strategies for EPF include micro-invasive treatment guided by endoscopy, stent implantation and surgery. Stent placement has a high success rate and is the most used modality given the high morbidity and mortality associated with surgery.

Black pigmented dysphagia.

A 63-year-old male of Turkish origin was referred to our department for further investigation of dysphagia for solids since 2 years with recent occurrence of food impaction. The patient had no significant medical history besides smoking. There was no mention of weight loss or other systemic complaints. Upper gastrointestinal endoscopy showed a large subobstructive pedunculated mass in the lower thoracic esophagus. The lesion was remarkably pigmented and seemed to be infused with Chinese ink (see figure 1). Biopsies were taken.