Esophageal Mass Research Articles

Endoscopic ultasound miniprobe assists submucosal tunnel endoscopic resection of an esophageal subepithelial lesion.

A 49-year-old woman undergoing screening esophagogastroscopy was found to have an esophageal subepithelial mass at 24 cm from incisors (Fig. 1A). Miniprobe and curvilinear endosonography revealed a 1.1 × 0.6 cm, homogeneously hypoechoic mass originating from muscularis propria adjacent to the aorta, exhibiting intraluminal protrusion (Fig. 1B and C). On her demand to remove the lesion, submucosal tunnel endoscopic resection (STER) was performed. Mucosal incision was made at 21 cm from incisors to initiate the tunnel, which was extended to 26 cm from incisors only to give no sign of the lesion (Fig. 1D).

ODP552 Hypercalcemic Crisis Due to PTH Secretion From a Poorly Differentiated Esophageal Neuroendocrine Tumor

Abstract Background Paraneoplastic secretion of PTH is described in a number of solid organ tumors. Hypercalcemia occurs in up to 30% of patients with malignancy. The most common cause of this phenomenon is PTHrP production. We present a rare case of PTH mediated hypercalcemic crisis from a tumor of presumed esophageal lineage. Clinical Case A 54-year-old man presented with several days of fatigue, lethargy and polyuria. Initial calcium was markedly elevated at 18.4 (8.3-10.1mg/dL). Past medical history included Barrett's esophagus, history of gastric bypass, and prior alcohol abuse. He also had progressive dysphagia and 30lb weight loss over the prior month. On examination, he had tachycardia, cachexia, and encephalopathy. Laboratory testing revealed an elevated PTH of 281 (nl 18.4-80.1pg/mL), creatinine 1.34mg/dL, and low phosphorus at 2.8 (nl 2.7-4.5mg/mL). Hypercalcemia was treated with IV fluids, calcitonin, and pamidronate. The calcium normalized but PTH remained 210pg/mL. Subsequent PTHrP and 1,25 di-hydroxy vitamin D levels were normal. Esophagogastroduodenoscopy (EGD) revealed a friable esophageal mass and biopsy identified a poorly differentiated carcinoma with neuroendocrine features, immunoreactive to synaptophysin and high Ki-67 index of 90%. Immunostains for chromogranin and PTH were negative. A CT of the chest, abdomen, and pelvis revealed diffuse metastases in the liver, lungs, and enlarged mediastinal lymph nodes. The source of primary tumor could not be fully identified from pathology but suspected to be esophageal. Parathyroid scan showed a subtle persistent uptake posterior to right side of trachea suspicious for a parathyroid adenoma, but that could not account for the severity of PTH elevation. He was readmitted in 1 month with recurrent symptomatic severe hypercalcemia to 18mg/dL and PTH to 619.4pg/mL. Again, he received IV fluids, calcitonin, and zoledronic acid. He received 3 cycles of platinum and etoposide based chemotherapy. After chemotherapy, PTH decreased to 123pg/mL and calcium to 9.7mg/dL but he continued to have rapid disease progression including jaundice, pathological bone fractures and orbital metastases. He elected hospice care and passed away in about 4 months from initial diagnosis. Final PTH was 916.8pg/mL. Conclusion PTH is a normally secreted by parathyroid gland chief cells, which are part of the embryonic neural crest cells found in various neuroendocrine tissues. It is plausible that malignancies with neuroendocrine features may secrete neuropeptides including PTHrP and PTH. Few case reports exist describing PTH secretion by neuroendocrine tumors, though most common are tumors of gastroenteropancreatic origin. PTH stain and focal chromogranin tends to be negative with poorly differentiated neuroendocrine tumors. PTH gene is usually intact and upregulation of the regulator sequence of PTH gene promotor is suspected to be the mechanism of elevated PTH levels and hypercalcemia. This case demonstrates the potential for poorly differentiated neuroendocrine malignancies to cause hypercalcemic crises from paraneoplastic secretion of PTH. Presentation: No date and time listed

S2436 A Rare Case of a Large Esophageal Gastrointestinal Stromal Tumor

Introduction: Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms, accounting for approximately 1 to 2 percent of primary gastrointestinal (GI) cancers. Presenting symptoms include abdominal pain, nausea, vomiting, early satiety, bleeding, and dysphagia, but vary depending on primary tumor location. Most tumors are discovered incidentally with the majority found in the stomach (40 to 60 percent) followed by small bowel (25-30 percent), colon and rectum (5-15 percent). We present a case of an elderly patient diagnosed with esophageal GIST after he was found to have an incidental esophageal mass on imaging. Case Description/Methods: 80-year-old male with PMH of HTN, HLD, DM2, CKD Stage III, COPD, former tobacco user was referred for an upper endoscopy for evaluation of an incidental finding on CT scan. CT demonstrated a mass arising from the distal esophagus, measuring 6.5 x 7.5 cm. Patient denied any dysphagia, abdominal pain, nausea, vomiting, weight loss, hematemesis, or melena. Endoscopy showed submucosal mass in the distal esophagus (Figure). Biopsy was inconclusive and subsequent EUS-guided fine needle biopsy was performed. Upper endoscopic ultrasound (EUS) showed an intramural lesion in the distal esophagus arising from the muscularis propria. Pathology results confirmed GIST, positive for CD117 and DOG-1. Further testing revealed a mutation in the KIT gene exon 11. Patient is currently undergoing neoadjuvant therapy with imatinib mesylate with anticipated surgical resection. Discussion: This is a rare case of a large esophageal GIST. Most mesenchymal esophageal tumors are leiomyomas, and GIST only accounts for 0.7% of them. EUS with fine need aspiration biopsy is the most accurate method for diagnosis and definite diagnosis is made histologically. Majority of GISTs, expresses the CD117 antigen, a KIT receptor tyrosine kinase. Another commonly found mutation is the platelet derived growth factor (PDGFRA) tyrosine kinase gene. Tumor size and mitotic rate are used for prognostication, with increased malignancy risk seen in tumor size > 3 cm with irregular margins. Tumor location is also a key factor in risk stratification; non gastric primary location has higher rates of metastases. Liver and peritoneum are the most common sites of metastatic GISTs. Treatment focuses on surgical resection and neoadjuvant therapy with imatinib. Given significant implication for its management, esophageal GIST should be considered in differential diagnosis and distinguished from more common esophageal leiomyomas.Figure 1.: Submucosal mass in distal esophagus.

S2408 A Case of Advanced Esophageal Carcinosarcoma

Introduction: The majority of esophageal cancers are classified histologically as squamous cell carcinomas or adenocarcinomas. We present a case of a 69-year-old man, presented with progressive dysphagia, found to have an esophageal carcinosarcoma, a rare etiology of esophageal cancer. Case Description/Methods: A 69-year-old man, an everyday smoker with a history of ongoing alcohol use, presented for the evaluation of unintentional weight loss and progressive dysphagia of 2 months duration. Upper endoscopy revealed a large, 6 cm in diameter, partially obstructing ulcerating mass in the mid esophagus. PET/CT revealed intense FDG uptake in the esophageal mass, mediastinal lymph nodes, T6 and T10 ribs suggestive of metastatic disease. Surgical pathology of the tumor was consistent with a high grade squamous cell carcinoma mixed with a high grade spindle cell sarcoma (carcinosarcoma). The patient was started on chemoradiation including Paclitaxel, Carboplatin. Improvement of symptoms and CT findings was documented with treatment (Figure). Discussion: Esophageal cancer ranks seventh in incidence and sixth in cancer-related mortality. The majority of esophageal cancers are classified histologically as squamous cell carcinomas or adenocarcinomas. When 2 distinct malignant components, both carcinomatous and sarcomatous are present histologically, the tumor is classified as esophageal carcinosarcoma (ECS). The pathogenesis is debatable, with some arguing that it is an initial carcinoma, facilitating a simultaneous secondary development of sarcoma, while others hypothesize a single cell origin. Carcinosarcomas were documented in tumors of the uterus, breast, thyroid, lung and gastrointestinal tract. ECSs have a rare incidence, accounting for approximately 1.5% of all esophageal tumors. It has been noted that ECS tumors have different clinical behaviors when compared to squamous cell carcinomas or adenocarcinomas. ECS tumors were noted to have a calculated doubling time of 2.2 months, with predominantly exogenous polypoid growth, perhaps explaining the earlier symptom of dysphagia, earlier diagnosis and more favorable 5 year survival rate. Given their rarity, no standard protocol has been developed to treat ECS tumors. Resection, regional lymph node dissection, radiotherapy and chemotherapy have all been utilized. Our case presentation further enriches the literature regarding rare, advanced esophageal adenocarcinoma tumors responding to systemic therapy.Figure 1.: A, B - Endoscopic findings. A large protruding, 6 cm in diameter partially obstructing ulcerating mass in the mid esophagus. C - Intense FDG uptake by the esophageal tumor in the esophagus (green arrow) and intense FDG uptake in the posterior/lateral aspect of the right T6 rib (yellow circle). D - Intensely avid subcarinal lymph node (yellow circle).

S2449 A Unique Case of Simultaneous Anal Squamous Cell Carcinoma and Esophageal Squamous Cell Carcinoma

Introduction: Anal cancer (AC) is uncommon and comprises only 3% of all digestive system malignancies. It is associated with HPV, tobacco use, and HIV. Esophageal cancer (EC) is the 8th most common cancer and 6th most common cause of death worldwide. Among other associations, HPV and tobacco use has been strongly linked to development of esophageal SCC. Though they have similar risk factors, the literature is limited when it comes to cases of simultaneous anal SCC and esophageal SCC. Case Description/Methods: A 50-year-old male with history of tobacco use presented with dysphagia, dyspnea, and weight loss. His symptoms were progressive with 20 lbs. of weight loss in 3 months. He initially had solid food dysphagia which progressed to liquids and constant regurgitation of food. His cough and dyspnea were acute and worsened 1 week prior to his presentation. He endorsed a bulging growth around his anus that grew over several months. He was found to have a left lower lobe necrotizing pneumonia (NP) on CT scan as well as thickening of the esophagus with liver lesions suspicious for metastatic disease. Labs showed leukocytosis, macrocytic anemia, and a mild transaminitis. He was tested for tuberculosis and HIV which was negative. He underwent an EGD which showed a large, friable, fungating esophageal mass whose biopsies showed SCC. For his anal lesion, he underwent an excisional biopsy which was positive for SCC as well. The patient was treated with antibiotics for his NP with a plan of 6 weeks of therapy followed by repeat imaging to determine if any surgical interventions would be needed. Oncology planned for palliative chemoimmunotherapy once his NP resolved. To improve his dysphagia, a palliative esophageal stent was placed (Figure). Discussion: This patient had both a primary anal SCC and esophageal SCC with his only risk factor being tobacco use. Though both AC and EC commonly metastasizes to the liver, EC is more likely to metastasize. For esophageal SCC, local lymph node invasion typically occurs early since the lymphatics are in the lamina propria rather than beneath the muscularis mucosa. In this case, the patient presented with a NP and though no definitive fistula was noted on imaging, local invasion of esophageal SCC can present with fistulizing disease. Unfortunately, Stage 4 esophageal SCC is incurable though systemic therapies may provide a palliative effect and survival benefit. In this case, an endoscopic esophageal stent was placed for palliation of his dysphagia while awaiting chemoimmunotherapy.Figure 1.: Image A demonstrates the CT scan finding of esophageal wall thickening. Image B is the EGD finding of a large, friable, fungating, circumferential esophageal mass. Image C shows the successful placement of an esophageal stent for palliative treatment of the patient’s dysphagia.

S2326 Gastroesophageal Junction Adenocarcinoma With Metastases to the Dorsum of the Tongue: A Rare Case Report

Introduction: Gastroesophageal Junction (GEJ) cancer is an invasive disease with a poor prognosis and commonly presents at an advanced stage. Metastases of GEJ cancer are most frequently seen in the lung, liver, and distant lymph nodes. Here, we are reporting for the first time in the literature metastatic GEJ adenocarcinoma (AC) to the oral cavity. Case Description/Methods: A-72-year-old male presented with severe dysphagia to solids and liquids, and weight loss for 1 month. Evaluation with upper endoscopy revealed a tumor nearly obliterating the lumen at the GEJ, 42 cm from the incisors (Figure A). Biopsy confirmed the diagnosis of AC of the GEJ (Figure B), and genetic testing showed: MSI: Stable, PDL 1%, and HER-2: negative. The patient was evaluated further Positron emission tomography (PET) scan which showed a hypermetabolic soft tissue process in the GEJ, numerous bilateral hypermetabolic mediastinal and retroperitoneal lymph nodes, and interestingly a small area of focal activity on the right floor of the mouth (Figure C). Biopsy of the tongue lesion confirmed stage IV AC of GEJ origin (Figure D). The case was then discussed in our multidisciplinary tumor board. The decision was to proceed as per NCCN guidelines with palliative radiation therapy (RT) for severe dysphagia and sequentially FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin) chemotherapy, the patient did not receive immunotherapy as his PD-L1 is 1%. PET scan after completion of radiotherapy and 5 cycles of FOLFOX showed no evidence of disease (Figure 5). Discussion: GEJ cancer is a devastating disease that commonly presents at an advanced stage and bears a dismal prognosis. The metastatic pattern of this disease frequently involves the liver, lung, distant lymph nodes, peritoneum, and bone. Studies have shown 2 major differences in the metastatic pattern according to the histological subtype; AC tends to metastasize to the liver, peritoneum, and bone. Whereas squamous cell carcinoma most commonly metastasizes to the lungs. However, the overlap between both categories exists. To the best of our knowledge, we are reporting for the first time in the literature GEJ AC with metastasis to the oral cavity. Management of patients with advanced, unresectable GEJ cancer represents a challenging scenario. External beam radiation therapy with concurrent chemotherapy is the standard approach for patients with unresectable disease. Our patient had a wonderful response both clinically and radiologically with negative follow-up FDG PET.Figure 1.: A: Esophageal mass nearly obliter 1-5.

S2363 Pagetoid Spread of Esophageal Adenocarcinoma

Introduction: Pagetoid spread refers to the “upward spreading” of cancer cells into the upper dermis from below. In the esophagus, it is a rare finding seen with poorly differentiated adenocarcinomas and is associated with deeper invasion. Case Description/Methods: A 75-year-old male with history of diabetes, hypertension, and hyperlipidemia presented to the gastroenterology clinic for dysphagia to solids. He reported that his symptoms started intermittently approximately 3 weeks prior and had gradually progressed. He denied a history of acid reflux, heartburn, or prior episodes of dysphagia. He also reported an unintentional loss of 10 pounds over the past 5 months. His medications included lisinopril, metformin, pioglitazone, and simvastatin. He denied a history of tobacco or alcohol use and had no family history of gastrointestinal malignancy. Physical exam was unremarkable. To further evaluate his dysphagia, an esophagogastroduodenoscopy was performed, revealing a small fungating mass in the distal esophagus near the gastroesophageal junction. Superior to this in the distal and mid-esophagus, there was a long segment of circumferential induration with irregular, reticulated erosions (Figure). Biopsies of the lesion revealed esophageal adenocarcinoma with pagetoid spread into overlying squamous epithelium, arising in Barrett mucosa with high-grade dysplasia. Endoscopic ultrasound was subsequently performed, revealing a mass measuring 12 mm in thickness with sonographic evidence of invasion into the adventitia and one malignant appearing lymph node in the lower paraoesophageal mediastinum (staged T3, N1). Discussion: Upper endoscopy is highly sensitive and specific for diagnosing esophageal cancer. However, in cases where there may not be an obvious fungating tumor, the presence of indurated mucosa with reticular erosions should alert the endoscopist to the presence of malignancy, possibly with pagetoid spread and deep invasion, as was seen in this patient.Figure 1.: Circumferential induration with irregular, reticulated erosions found in the mid esophagus during upper endoscopy.

S2406 A Case of Cervical Esophageal Adenocarcinoma Arising From Gastric Inlet Patch: A Benign Lesion With Malignant Potential

Introduction: Esophageal adenocarcinoma is typically localized to the distal third of the esophagus. It is associated with long-standing acid reflux and resultant Barrett’s esophagus. In contrast, adenocarcinoma in the proximal esophagus without Barrett’s metaplasia is extremely rare. A gastric inlet patch (GIP) is a lesion of ectopic gastric mucosa usually found in the cervical esophagus and is considered a benign lesion. However, albeit rare, malignant transformation of GIP can occur. Here, we present a case of cervical esophageal adenocarcinoma arising from gastric inlet patch. Case Description/Methods: A 50-year-old male with GERD presented with a 6-month history of progressive dysphagia to solids and liquids and 20-pound weight loss. He reported a 1 pack-year smoking history but quit 30 years prior and consumed alcohol socially. Family history was negative for esophageal cancer. Upper endoscopy (HQ190F) showed a malignant stricture (2 cm long, 6mm diameter) at 18 cm from the incisors and a gastric inlet patch adjacent to the stricture. The endoscope was downsized (XP190N), and the stricture was dilated (24F) and traversed. The Z-line was at 40 cm with Barrett’s esophagus extending from 36 cm to 40 cm. Pathology of biopsies from the stricture showed acute and chronic inflammation with increased intraepithelial eosinophils suggestive of acid reflux. CT scan of the neck with contrast showed a heterogeneously enhancing ill-defined mass involving the cervical esophagus below the cricoid cartilage indenting the posterior margin of the trachea. Bronchoscopy was negative for bronchogenic cancer. Endoscopic ultrasound showed a non-circumferential hypoechoic mass in the cervical esophagus 18 cm from the incisors extending to 20 cm. The mass was predominantly extrinsic but was also noted to have a luminal component and poorly defined endosonographic borders. Pathology of FNAB showed moderately differentiated adenocarcinoma (Figure). Discussion: Proximal esophageal adenocarcinoma is extremely rare, making up less than 1% of esophageal cancers. Case studies have been published associating GIP and esophageal adenocarcinoma, but the pathogenesis of malignant transformation remains unclear. There are no established screening guidelines for ectopic gastric mucosa and routine biopsies are not recommended as dysplasia within GIP is rare. GIP may be overlooked during EGD and NBI exam may improve detection rates. Our case re-emphasizes careful examination of GIP and to strongly consider biopsy if abnormal.Figure 1.: A) Endoscopic view of malignant stricture 18 cm from incisors. Gastric inlet patch (arrow) adjacent to stricture. B) Endoscopic ultrasound image at the level of esophageal stricture showing irregular hypodensity suggestive of malignancy. C) Pathology of biopsy performed through fine needle aspiration (EUS) of upper esophageal mass demonstrating moderately differentiated adenocarcinoma, cribriform pattern, with mild nuclear pleomorphism, abundant mitoses, and apoptosis (H&E, 10x).

S2349 Not Just Another Food Bolus: Large Cell Neuroendocrine Carcinoma of the Esophagus Presenting as Acute Esophageal Food Impaction

Introduction: Food impactions arise due to structural or functional abnormalities along the GI tract most commonly at the esophagus. The differential diagnosis is broad but importantly includes malignancy. Here we highlight a rare case of food impaction secondary to high-grade neuroendocrine carcinoma. Case Description/Methods: A 71-year-old male with a history of asthma presented with trouble swallowing and epigastric pain 5 hours after eating a chicken sandwich. He had been experiencing dysphagia and odynophagia for the past 2 months, but symptoms were especially severe on day of presentation to the point that he was unable to eat or drink anything afterwards given persistent regurgitation. Urgent EGD showed a food impaction of the distal esophagus, which was successfully removed through suction cap revealing a circumferential fungating and necrotic appearing mass at 28 cm from the incisors (Figure). Biopsies were obtained, but the mass could not be traversed. Subsequent CT CAP showed a 6.7 cm distal esophageal mass correlating with endoscopic findings as well as nonregional lymphadenopathy concerning for metastatic disease. Pathology unfortunately revealed high-grade neuroendocrine carcinoma WHO grade 3 with small and large cell features. Patient was deemed not a surgical candidate given metastatic disease and was started on palliative chemotherapy. Discussion: Neuroendocrine carcinoma is a rare type of esophageal malignancy with an incidence of 0.4-2% of cases. Prognosis is usually poor given its aggressive nature and advanced stage at initial diagnosis. Treatment depends on the extent of disease. For those with limited disease, esophagectomy with lymph node dissection +/- adjuvant chemotherapy is warranted. On the other hand, extended disease relies upon palliative chemotherapy +/- adjuvant radiotherapy. Clinicians must maintain neuroendocrine carcinoma as part of their differential for food impaction given the life-altering implications that such a diagnosis holds.Figure 1.: EGD showing fungating and necrotic appearing mass at distal esophagus.

S2899 A Rare Case of Small Cell Lung Cancer in the Posterior Mediastinum Diagnosed With Endoscopic Ultrasound-Guided Fine Needle Biopsy

Introduction: Lung cancer is the leading cause of cancer mortality worldwide, accounting for 2 million diagnoses and 1.8 million deaths in 2020.1 10-15% of all lung cancers are small cell lung cancer (SCLC), an aggressive form that grows more rapidly and metastasizes more easily than NSCLC. Thus, in patients with suspected lung cancer, a tissue diagnosis is crucial. Here, we present a unique case of a man with a posterior mediastinal mass for whom obtaining a tissue diagnosis presented a diagnostic challenge. Case Description/Methods: A 49 y/o M, with a 30 pack-year smoking history, presented with worsening left-sided chest pain and a 10-pound unintentional weight loss over 2 months. Vital signs and physical exam were unremarkable. Labs demonstrated a mild anemia (Hb 11-12, MCV 82) and elevated inflammatory markers (ESR 54, CRP 70.9). CT scan demonstrated a 12.0x10.7x8.4 cm hypodense soft tissue density mass in the left posterior mediastinum, extending from the level of T1 to T7 vertebral bodies. The mass displaced the trachea, esophagus, and adjacent vessels. Several enlarged mediastinal lymph nodes were seen, the largest measuring up to 1.5 cm. However, there was no lymphadenopathy seen elsewhere and no convincing evidence of metastatic disease in the abdomen or pelvis. CT surgery recommended a CT-guided biopsy with IR vs. endoscopic bronchial US-guided biopsy. IR was unable to find a safe access point to go in for the biopsy as there was no window, as the lung was seen overlying the mass. The patient was discharged, and he returned the next week for outpatient EUS-FNB, which demonstrated a 72x39 mm mediastinal mass (Fig 1A). EUS-FNB was performed and EUS-guided transesophageal biopsies were performed. He was also found to have erosive gastritis, healing superficial sub-cm gastric ulcers, and multiple healing superficial duodenal ulcers. Pathology results demonstrated SCLC (Fig 1B-E) and H. pylori. He was treated with standard quadruple therapy, referred to his PCP to confirm eradication in 6 weeks, and referred to Oncology. For stage III-b SCLC treatment, he completed external beam RT and chemotherapy. Repeat PETCT demonstrated a decrease in the residual mass to 5.5x3.5x5.8 cm. Discussion: For patients presenting with a posterior mediastinal mass, for whom IR may not be able to perform a biopsy, obtaining a tissue diagnosis may be a diagnostic challenge. EUS-FNB provides a useful tool to assess the mediastinum and can provide timely diagnosis and staging of patients with rare forms of lung cancer.Figure 1.: A) A posterior mediastinal mass vs. esophageal mass measuring 72.1 mm by 39.2 mm was identified status-post EUS with FNB x 6. This mass appeared to arise from the muscularis propria of the esophagus; however, an extrinsic mediastinal mass could not be definitively ruled out due to the severe compressive effects of the mass on the esophagus. Mediastinal mass, needle biopsy: -Minute fragments of malignant neoplasm with necrosis. -Tumor cells are positive for AE1/3, CAM5.2, Chromogranin, Synaptophysin, CD56 and negative for p40, CD3, CD20, and CD45. Ki-67 demonstrats about 60% positivity. Combined with morphological features, this immunoprofile supports the diagnosis of small cell carcinoma. B) Hematoxylin and eosin (H&E) stain. C) CAM5.2. D) CD56. E) Chromogranin.

S2846 Liquid Nitrogen Cryoablation Alone Is an Effective Palliative Treatment for Metastatic Esophageal Squamous Cell Carcinoma

Introduction: In 2012, Esophageal squamous cell carcinoma (ESCC) was reported as the most common type of esophageal cancer in the world. In patients with metastatic ESCC, the mainstay of palliative management includes radiation therapy and esophageal stenting. Endoscopic cryoablation has emerged as a minimally invasive treatment for malignant esophageal neoplasm. The administration of liquid nitrogen, achieving a temperature of -85°C, causes transient tissue ischemia and recruitment of immune cells resulting in localized tissue destruction. Most preliminary studies assessing cryoablation in esophageal cancer have demonstrated symptomatic improvement in esophageal adenocarcinoma. Few studies have assessed the use of cryoablation in ESCC. A prospective study conducted in China demonstrated cryoablation’s ability to achieve complete remission in patients with moderate to high grade ESC neoplasm. Here we present a case utilizing endoscopic liquid nitrogen cryoablation as palliative therapy in a symptomatic patient with metastatic ESCC. Case Description/Methods: 82-year-old male former smoker with daily alcohol use presented with dysphagia and weight loss. CT scan of the chest revealed a mid-esophageal mass concerning for malignancy. Upper endoscopy demonstrated a large, fungating esophageal mass with partial obstruction (Figure A). Pathology revealed invasive poorly-differentiated ESCC. PET scan confirmed metastatic disease involving the right lung and paraesophageal, mediastinal, supraclavicular and right thoracic inlet lymph nodes. A multidisciplinary team offered palliative chemotherapy and radiation, which he declined. Due to worsening dysphagia and a 35lbs weight loss, he agreed to cryoablation (Figure B). He underwent an additional three sessions at two-months, three-months, and five-months for small areas of mucosal abnormalities (Figure C). He is four months out from treatment with improved dysphagia and stable weight. Discussion: This case report provides further evidence for the use of cryoablation alone as a minimally invasive, palliative intervention in patients with ESCC. Previous studies have highlighted the effectiveness of cryoablation in improving dysphagia and quality of life in symptomatic patients. This case report provides endoscopic evidence of cryoablation’s ability to reduce tumor burden and achieve complete remission in ESCC. Cryoablation alone appears to be a safe and well tolerated palliative treatment for patients with metastatic ESCC.Figure 1.: Upper endoscopic liquid nitrogen cryoablation of esophageal neoplasm. A) Initial upper endoscopy demonstrating large fungating mass in mid-esophagus with partial obstruction. B) Following completion of cryoablation treatment. C) Following three additional cryoablation sessions for treatment of residual disease.

An Unusual Cause of Esophagitis

An Unusual Cause of Esophagitis

Esophageal carcinosarcoma comprising undifferentiated pleomorphic sarcoma and squamous cell carcinoma: a case report

BackgroundEsophageal carcinosarcoma (ECS) is a rare malignant tumor that often presents as an intraluminal polypoid lesion in the esophageal lumen. The pathogenesis of esophageal carcinosarcoma is not clear and its etiology is still being discussed.Case presentationWe report the case of a 68-year-old male who had dysphagia for approximately three months. Contrast-enhanced computed tomography showed an irregular enhancing mass in the lower esophagus. Endoscopy showed a gray-white mass with a smooth surface that almost filled the esophageal lumen at a location 28 cm from the incisor tooth. Considering the location of the tumor, we opted for Ivor-Lewis esophagectomy with intrathoracic anastomosis through a 5-port laparoscope and uniport video-assisted thoracic surgery (VATS). Pathological analysis showed that the mass comprised carcinoma in situ and pleomorphic sarcoma, without lymphatic metastasis. The postoperative pathological stage was T1bN0M0, stage I (Japanese Classification of Esophageal Cancer 11th Edition). The latest follow-up of the patient was 14 months after the surgery, and no signs of recurrence or metastasis were found.ConclusionThis case demonstrates a rare esophageal malignancy with a peculiar histological composition. Successful VATS esophagectomy with intrathoracic anastomosis was conducted without recurrence or metastasis at the 14-month follow-up.

Histiocytic Sarcoma: Clinical Features and Outcomes of Patients Treated at a Tertiary Cancer Care Center

Histiocytic sarcoma (HS) is an extremely rare histiocytic disorder of unknown etiology. It is not a true sarcoma and is named so, due to the pathological resemblance to mature histiocytes. The clinical presentation of HS is diverse and is related to the involved organs. Due to its aggressive nature, with poor prognosis and lack of a standard treatment regimen of choice, its diagnosis and management pose a challenge to the clinician. Limited literature is available on the management of this entity. Here, we report four patients with HS, diagnosed over 15 years in a tertiary cancer center, with varied clinical presentation, management, and outcomes. The first patient presented with a localized unresectable esophageal mass. He was treated with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) combination chemotherapy and attained complete remission. The second patient had a painless mass of the hand, treated with wide excision and adjuvant Radiotherapy. She is disease-free for the past 12 years. The third patient had presented with an anterior mediastinal mass. He had progressive disease on chemotherapy. The fourth patient had multifocal disease with generalized lymphadenopathy. She was treated with CHOP chemotherapy and is now disease-free at 13 months. To summarize, the patients with the localized resectable disease did well, with surgical excision and adjuvant radiotherapy, while patients with the multifocal disease did well on CHOP chemotherapy. The take-home message from this case series is - CHOP off whenever you can and if not give CHOP to chop off the disease.

Acute gastrointestinal bleeding in Egyptian elderly patients: real-life experience

BackgroundElderly people are a vulnerable group of patients subjected to multiple health problems. Upper gastrointestinal bleeding (UGIB) in older adults is a frequent cause of hospital admissions. The presence of multiple comorbidities and greater medication use influence the clinical outcome.AimThe aim of our work was to analyze the etiology, precipitating factors, management, and outcome of the elderly Egyptian patients (> 65 years old) presenting with acute UGIB.MethodsThree hundred thirty-two patients presenting with acute UGIB. The patients were classified into two groups according to age (elderly, above 65 years old, and young, below 65 years old). Clinical assessment, laboratory tests, and upper endoscopy were done for all patients. They were followed for 1 month.ResultsElderly females showed higher incidence of acute UGIB (45.8% versus 28.9%) with significant P-value (0.001). The incidence of esophageal varices was high in young patients than in the elderly (46.4% vs 35.5%) with P-value (0.045), while the elderly patients showed a higher incidence of esophageal ulcers and gastric mass than the young patients (7.8% vs 2.4%), (6% vs 0%) with P-value (0.025 and 0.013) respectively. Also, there was a higher incidence of peptic ulcer in elderly than young patients but does not reach a significant value with P-value (0.067), while there was no difference between both groups as regards presence of (fundal varix, erosive gastritis, moniliasis, portal hypertensive gastropathy, antral gastritis, bulb duodenitis, post band ulcer, dieulafoy, gastric polyp, and angiodysplasia). Rockall score, duration of hospital stay, and mortality incidence (33.1% vs 15.7%) were high in the elderly than young patients with P-value (< 0.001).ConclusionThe elderly are vulnerable groups who are at high risk of adverse outcome and mortality following acute upper gastrointestinal bleeding.

Correction: Endoscopic resection of a large tongue-like esophageal mass: a rare case of esophageal striated muscle tumor.

Correction: Endoscopic resection of a large tongue-like esophageal mass: a rare case of esophageal striated muscle tumor.

Leiomyoma of the esophagus: A case report and review of the literature.

IntroductionBenign tumors represent less than 1% of esophageal neoplasms. Esophageal leiomyoma is a very rare tumor that arises from mesenchymal tissue.We present here a case of leiomyoma of the esophagus which was revealed by dysphagia and vomiting that was treated by surgical enucleation.Presentation of caseThis report illustrates the case of a female who presented with dysphagia and vomiting. Imageology demonstrated an esophageal mass which was treated with surgical enucleation. Histopathology confirmed the diagnosis of leiomyoma.Clinical discussionBenign esophageal tumors are rare. Leiomyoma commonly presents as a single lesion in the middle or lower third of the esophagus. Leiomyomas located in the proximal and middle third of the esophagus can be operated on by right thoracotomy. Surgical treatment varies from enucleation to esophageal resection depending on the size and location of the mass. In our case, the tumor was enucleated by a right posterolateral thoracotomy.ConclusionEsophageal leiomyoma is a benign and generally asymptomatic tumor. Surgery is the pillar of treatment. Enucleation should be performed whenever possible to avoid esophagectomy and thus decrease morbidity and mortality.

A Rare Esophageal Mass

Question: A 57-year-old woman was found to have an elongated submucosal mass on upper esophagus by gastroscopy done because of discomfort while swallowing. The tumor seems to extend from the esophageal introitus to the upper esophagus with a smooth surface and yellowish color measuring 1.0 × 4.5-cm (Figure A). Endoscopic ultrasound examination revealed a hyperechoic mass protruding into the esophageal cavity with an obscure origin (Figure B). A computed tomography scan showed a well-defined and low-density mass in the cervical esophagus (white arrow, computed tomography value –79.9 Hounsfield units) (Figure C, D).

Microsatellite unstable esophageal adenocarcinoma masquerading as a conventional esophageal primary

Abstract Introduction/Objective Patients with microsatellite instability (MSI) are susceptible to developing epithelial malignancies in multiple organs and systems, especially along the gastrointestinal tract. It’s important to know that MSI-tumors may present with an intriguing non-classical, “non-MSI-appearing”, histomorphology that deviates from the well-known MSI or Lynch syndrome spectrum. Pathologists should thus be prepared for unusual histopathological presentations in order to detect MSI and related therapeutic and prognostic targets. Ultimately, a timely and accurate classification is a crucial step in guiding clinical course. Methods/Case Report An 80-year-old male presented to an outside facility due to worsening dysphagia. Imaging and endoscopy studies confirmed a near-obstructing distal esophageal mass. Subsequently, an esophagogastrostomy was performed, which removed a moderately differentiated adenocarcinoma (pT3N1). The patient was managed with conventional chemotherapy after the surgery; however, due to progressive metastasis involving the liver, he was referred to our cancer center. Results (if a Case Study enter NA) Upon review of outside pathology materials, the tumor displayed irregularly arranged bizarre glands with eosinophilic cytoplasm and unusually large nuclei within the abundant fibrotic stroma. No intra-tumoral lymphocytes or “Crohn’s-like” pushing borders were identified. However, ancillary tests performed on acquired outside material showed loss of MLH1 and PMS2 with retained MSH2 and MSH6 in the tumor. Subsequent mutational analysis revealed additional MSI-related carcinogenic mutations. Accordingly, the previous regimen was switched to immunotherapy-based management. The patient remains disease-free 10-months later. Conclusion This unusual MSI esophageal adenocarcinoma exemplifies that such tumors may present with non- MSI/non-lynch histomorphology and that ancillary analyses should be carried out without reservation to evaluate microsatellite status. Thus, optimizing patient management and outcome.

A case of esophageal squamous cell carcinoma metastasized to the colonic anastomotic site of right hemicolectomy

Abstract Introduction/Objective Although squamous cell carcinoma of the esophagus rarely metastasizes to the uncommon sites, colonic metastasis from squamous cell carcinoma of the esophagus is extremely rare. There has been no case report of colonic metastasis from squamous cell carcinoma of the esophagus to an anastomotic site of the colon. Methods/Case Report A 73-year-old female with a history of right hemicolectomy for advanced ascending colon cancer in 2006 was referred to our facility for a two-month history of solid food dysphagia. The patient has been followed up in the survivorship clinic for surveillance with no evidence of recurrence for 13 years to date. An esophagogastroduodenoscopy revealed a 7 cm fungating and ulcerated mass in the middle to lower esophagus. The biopsy from the esophageal mass showed a moderately to poorly differentiated squamous cell carcinoma. A colonoscopy showed an end-to-end ileocolonic anastomosis with a 7 mm ulceration in the transverse colon. The biopsy from the ulceration at the anastomotic site showed a moderately to poorly differentiated squamous cell carcinoma. Immunostains performed on both esophageal and colonic biopsies demonstrate that the tumor cells in both esophageal and colonic biopsies are positive for p40, p63, p16, and negative for CK7, CK20, and CDX2. The diagnosis of metastatic esophageal squamous cell carcinoma to the colonic anastomotic site of previous right hemicolectomy was rendered based on the morphology and immunoprofile. A subsequent computed tomography (CT) and positron emission tomography (PET) demonstrated no other distant metastases. Chemotherapy with 5-FU and oxaliplatin has been started. A metastasis to the anastomotic site is extremely rare. Although the anastomotic site might be a good niche for cancer cells to metastasize to, the pathogenesis of a metastasis to the anastomotic site remains unknown. Our case is very intriguing because a metastasis occurred at the anastomosis site, and no other metastasis was found. Results (if a Case Study enter NA) N/A Conclusion We have reported the first case of metastatic esophageal squamous cell carcinoma to the colonic anastomotic site of previous right hemicolectomy in a 73-year-old female. Although the pathogenesis of a metastasis to the anastomotic site remains unknown, the possibility of contribution of surgical trauma to metastasis formation at the ileocolonic anastomosis cannot be completely ruled out.