Rare Presentation of Esophageal Adenocarcinoma: 1778

Introduction: The incidence of esophageal carcinoma has increased dramatically in recent decades. Esophageal cancer is the eighth most common cancer and sixth leading cause of cancer death. Squamous cell cancer is the most common type of esophageal cancer all over the world, but the incidence of esophageal adenocarcinoma has been increasing. Most, if not all, esophageal adenocarcinomas arise from a region of Barrett's metaplasia. The most common location is near the EG junction with an association of endoscopic evidence of Barrett's esophagus. We present a case of young male presented with lower extremity pain and swelling due to metastasis of undiagnosed primary esophageal cancer. Case Description: A 36-year-old male with no medical history presented with complaints of lower extremity pain and swelling. Vital signs were WNL. Lab work showed Alk phos 263, ESR of 28, TSH 7.07, Vit D (25 hydroxy) 8, Hgb A1c 7.0, CRP 102.6. Knee x-ray was highly suspicious for chronic osteomyelitis vs. neoplastic lesion. Doppler US ruled out lower extremity DVT, but showed large complex fluid collection anterior to the knee measuring 8.0 x 5.8 x 18.6 cm with concern for osteomyelitis with overlying abscess vs an aggressive primary bone tumor. MRI showed periostitis with possible differential of osteomyelitis/periostitis and osteosarcoma. CT scan showed aortocaval and left iliac lymphadenopathy concerning for metastasis. Biopsy was consistent with metastatic adenocarcinoma favoring gastrointestinal and pancreaticobiliary tract as the primary source. EGD showed esophageal mass at the GE junction. Chemotherapy and radiation therapy were initiated. Patient developed cardiopulmonary arrest and died prior to discharge. Discussion: Esophageal adenocarcinoma is usually associated with Barrett's esophagus. It is a very aggressive disease associated with diffuse metastasis and high mortality rate. The most common metastatic sites for esophageal cancer are liver brain and lung. Risk factors associated with cancer are smoking, higher body mass index, gastroesophageal reflux disease, and a diet low in fruits and vegetables. Almost half of the cases of adenocarcinoma have no associated reflux disease. The median survival rate of metastatic esophageal cancer is 4-9 months. Physicians should always think of visceral malignancy in cases of biopsy proven adenocarcinoma for better prognosis. Endoscopy should always be done to look for visceral malignancy if cancer is suspected.1778_A Figure 1. EGD finding of esophageal mass1778_B Figure 2. Esophageal mass at the GE junction