Gastrointestinal · Year 2 · from Gastrointestinal
Case 3: Esophageal Adenocarcinoma
Patient Presentation
Demographics: 68-year-old male
Chief Complaint: Progressive dysphagia and weight loss for 3 months
History of Present Illness: The patient reports difficulty swallowing that started with solid foods and has progressed to include liquids over the past 3 months. He has lost 25 pounds during this time. He reports dull chest discomfort and occasional pain radiating to his back. He has a long history of heartburn that he never formally treated.
Past Medical History: Hypertension, type 2 diabetes, obesity (previous BMI 35, now 29)
Social History: 40 pack-year smoking history (still smoking), moderate alcohol use
Physical Examination
- Vital Signs: BP 132/82 mmHg, HR 84 bpm, BMI 29
- General: Cachectic male appearing older than stated age
- Neck: 2 cm firm, non-tender left supraclavicular lymph node (Virchow's node)
- Abdomen: Soft, no hepatomegaly
Workup and Results
- Upper Endoscopy: Ulcerated, friable mass at 35 cm extending to the GE junction; unable to pass scope
- Biopsies: Invasive adenocarcinoma
- CT Chest/Abdomen/Pelvis: 5 cm esophageal mass with mediastinal lymphadenopathy; liver metastases
- PET-CT: FDG-avid primary tumor, mediastinal nodes, and hepatic lesions
- FNA of Virchow's node: Metastatic adenocarcinoma
Endoscopic image of esophageal adenocarcinoma showing an ulcerated, fungating mass arising in the distal esophagus at the gastroesophageal junction, causing near-complete luminal obstruction.
Image Source: Case courtesy of Radiopaedia.org
Diagnosis
Stage IV Esophageal Adenocarcinoma
Clinical Correlation
Esophageal adenocarcinoma arises from Barrett's esophagus in the distal esophagus, driven by chronic GERD. Risk factors include obesity, GERD, Barrett's esophagus, smoking, and male sex. The progression of dysphagia from solids to liquids indicates worsening mechanical obstruction. Back pain suggests mediastinal invasion. Virchow's node (left supraclavicular) represents metastatic spread via the thoracic duct. Symptoms often present late because the esophagus can accommodate substantial tumor growth before causing obstruction.
Treatment
- Given Stage IV disease: palliative intent
- Esophageal stent placement for dysphagia relief and nutrition maintenance
- Systemic chemotherapy (FOLFOX or fluoropyrimidine-based regimen)
- Immunotherapy if PD-L1 positive or MSI-high
- Radiation therapy for bleeding or local palliation
- Supportive care and nutrition optimization
- Overall 5-year survival <5% for metastatic disease