Atypical presentation of an oesophageal carcinoma with metastases to the left buttock: a case report

Soft-tissue metastasis in esophageal cancer managed by dose escalation radiation therapy: a clinical case and review of literature

Soft tissue metastasis in esophageal cancer is a very rare entity. A 76-year-old man was referred for a week's history of dysphagia. Upper gastrointestinal endoscopy was performed, and biopsies were consistent with an adenocarcinoma of the lower esophagus. The patient was free of metastasis on 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT). The patient was treated with pre-operative chemoradiation, followed by surgery. Intravenous carboplatin [area under the curve of 2 mg/mL/min (AUC2)] and intravenous paclitaxel 50 mg/m2 with concurrent radiotherapy (RT) (45 Gy delivered in 25 fractions of 1.8 Gy per fraction) were introduced from May 31st, 2021, to July 2nd, 2021. Lewis-Santy subtotal esophagectomy was performed, and pathology revealed a ypT3 ypN0 (0/26) L0 V1 Pn1 G3 R0. Adjuvant nivolumab was introduced for a total of 12 months. After five months of nivolumab, the patient complained of a painful left shoulder subcutaneous tumefaction in routine evaluation. Biopsy of the deltoid muscle demonstrated a poorly differentiated adenocarcinoma consistent with esophageal metastasis. Additional skeletal muscle (one) and bone metastases (two) were revealed on 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT). After multidisciplinary team approach, palliative radiation therapy to all metastases, denosumab and FOLFOX were introduced. Despite initial excellent clinical outcomes, patient presented avascular necrosis of left femoral head managed by surgery but died after post-operative complications. To the best of our knowledge, it is the first reported case with rare soft-tissue metastasis occurring during adjuvant nivolumab in esophageal cancer.

Subcutaneous soft tissue metastases from esophageal squamous cell carcinoma with neuroendocrine differentiation: Case report and literature review

Background

Esophageal squamous cell carcinoma is the predominant subtype of esophageal cancer in China and so differs from presentations in Western countries. Common metastatic locations of esophageal cancer include the liver, lung, bone, and brain. In contrast, metastases in subcutaneous soft tissue are exceedingly rare.

Case presentation

We present the experience of a 57-year-old man with a complaint of hand and leg dysfunction on the right side. He had a past medical history of esophageal squamous cell carcinoma. Further imaging workup revealed a solitary brain metastasis, thickening of the esophageal wall, swollen lymph nodes in the mediastinum, and right adrenal gland metastasis. Gamma knife radiosurgery of the brain metastasis and intensity-modulated radiotherapy of the esophagus and lymph nodes were administered. After 1.5 months, he was admitted to our hospital again, and nodules were identified in the anterior abdominal wall and left posterior chest wall. Ultrasound, CT, and radical excision of the abdominal wall mass were undertaken and revealed metastatic squamous cell carcinoma with neuroendocrine differentiation. We administered immunotherapy followed by targeted therapy. A PET/CT scan was performed to identify other organ metastases; the scan revealed multiple areas of fluorodeoxyglucose uptake and foci in the esophagus, lung, liver, bone, and right adrenal gland; and in various lymph nodes. In addition, an intensely hypermetabolic lesion was localized in the left posterior thorax.

Conclusion

This case highlights the diagnosis and treatment of uncommon metastases of esophageal squamous cell carcinoma. We hope that our clinical experience provides insights into these uncommon metastases.

Persistent cough: An unexpected diagnosis

Esophageal cancer is the eighth most common cancer and the sixth most common cause of cancer death globally. Esophageal squamous cell carcinoma (ESCC) accounts for 70%-90% of esophageal cancers worldwide, 5% are adenocarcinoma, and 5% represent rare malignancies and metastases from other organs. We present a case where a 54-year-old lady, with multiple readmissions for persistent dry cough and respiratory symptoms, turns out to be an esophageal malignancy. CECT thorax revealed an enhancing wall thickening of the esophagus with paraoesophageal fat stranding, mediastinal lymphadenopathy, and subsegmental right lobe atelectasis, suggestive of a probable esophageal malignancy. An upper gastrointestinal endoscopy showed a circumferential esophageal growth which on biopsy and histopathological examination turned out to be a moderately differentiated squamous cell carcinoma of esophagus.

Soft-Tissue Metastases From Esophageal Cancer

BACKGROUND

Metastatic carcinoma to skeletal muscle and/or subcutaneous fat is a rare event. Only 27 cases of esophageal cancer to soft tissue have been described in the English-language literature.

PURPOSE

Our goal was to describe the prevalence and clinical characteristics of soft-tissue metastasis among patients with primary esophageal cancer at a single institution.

METHODS

We performed a retrospective review of all patients with primary esophageal cancer. Data points analyzed included histologic subtype, anatomic location, metastasis pattern, treatment, and survival. Kaplan-Meier curves were used to estimate survival time, and log-rank tests were used for comparisons. For all analyses, P < 0.05 was considered significant.

RESULTS

Of 1341 patients with primary esophageal cancer, 25 (1.9%) had metastases to soft tissue. Soft-tissue metastases were diagnosed at a median age of 64 years, a median 9.6 months after esophageal cancer diagnosis. Adenocarcinoma was the predominant histopathological type, and soft-tissue metastasis was most common in the lower extremity. Local intervention was used for 10 symptomatic patients with favorable prognoses. Chemotherapy was the only treatment modality in 18 patients. Median survival time after diagnosis of soft-tissue metastasis was 8.9 months and was longer in patients with metastasis in soft tissue only (24.6 months, P = 0.007) and in those who received local intervention (11.1 months vs those who did not, P = 0.020).

CONCLUSION

We estimate the prevalence of soft-tissue metastasis to be 1.9% among patients with esophageal cancer. Local intervention may be beneficial for patients in otherwise good health with symptomatic soft-tissue lesions.