General Surgery · Year 3 · from General Surgery

Case 1: Esophageal Adenocarcinoma

Patient Demographics

  • Age: 62 years
  • Sex: Male
  • Occupation: Accountant

Chief Complaint

"I've been having trouble swallowing solid foods for the past 2 months."

History of Present Illness

The patient presents with progressive dysphagia that began approximately 2 months ago. Initially, he noticed difficulty swallowing large pieces of meat and bread, but now has trouble with softer foods as well. He reports unintentional weight loss of 8 kg over the past 3 months. He has a long history of gastroesophageal reflux disease (GERD) for which he has taken over-the-counter antacids for 20 years. He admits to poor compliance with PPI therapy. He denies odynophagia, hematemesis, or melena.

Past Medical History

  • GERD (20+ years)
  • Barrett's esophagus (diagnosed on EGD 5 years ago, lost to follow-up)
  • Obesity (BMI 32)
  • Hyperlipidemia
  • Type 2 diabetes

Medications

  • Metformin 1000 mg BID
  • Atorvastatin 40 mg daily
  • Occasional OTC antacids

Social History

  • Former smoker (25 pack-years, quit 5 years ago)
  • Social alcohol (2-3 drinks weekly)

Physical Examination

  • Vitals: BP 138/84 mmHg, HR 78 bpm, Weight 88 kg (down from 96 kg)
  • General: Slightly cachectic-appearing male
  • Neck: No cervical lymphadenopathy
  • Abdomen: Soft, non-tender, no hepatomegaly
  • Nutritional status: Moderate malnutrition

Diagnostic Workup

Upper Endoscopy (EGD):

  • Partially obstructing, ulcerated mass in the distal esophagus
  • Located 35-40 cm from incisors (GE junction)
  • Barrett's mucosa proximal to mass
  • Scope unable to pass; tumor dilated for staging EUS

Biopsy Results:

  • Invasive adenocarcinoma, moderately differentiated
  • Arising in background of Barrett's esophagus with high-grade dysplasia

Endoscopic Ultrasound (EUS):

  • Mass involves muscularis propria (T3)
  • Several paraesophageal lymph nodes suspicious for metastasis
  • No celiac axis involvement

CT Chest/Abdomen/Pelvis:

  • Thickening of distal esophagus/GE junction
  • Several periesophageal lymph nodes
  • No distant metastases
  • No liver lesions

PET-CT:

  • FDG-avid mass at GE junction (SUV 12.4)
  • FDG-avid periesophageal and lesser curvature lymph nodes
  • No distant metastatic disease

Staging Laparoscopy:

  • No peritoneal carcinomatosis
  • No liver metastases
  • Peritoneal washings negative for malignancy

Clinical Stage

cT3N1M0 (Stage III)

Multidisciplinary Tumor Board

  • Locally advanced esophageal adenocarcinoma
  • Candidate for curative intent treatment
  • Neoadjuvant chemoradiation (CROSS regimen) followed by surgery

Neoadjuvant Therapy

  • CROSS protocol: Carboplatin/paclitaxel weekly x 5 with concurrent radiation (41.4 Gy)
  • Completed without significant complications
  • Post-treatment PET: Marked decrease in FDG avidity (metabolic response)

Nutritional Optimization

  • Dietary counseling
  • High-protein supplements
  • Weight stabilized during treatment

Operative Procedure

Ivor Lewis esophagectomy performed 6 weeks after chemoradiation:

  • Laparoscopic gastric mobilization and creation of gastric conduit
  • Right thoracotomy with en bloc esophagectomy
  • Two-field lymphadenectomy
  • Intrathoracic esophagogastric anastomosis
  • Feeding jejunostomy placed

Pathology Results

  • Residual adenocarcinoma, 1.2 cm
  • Negative margins (R0 resection)
  • Treatment effect: 40% viable tumor
  • 1/18 lymph nodes positive
  • ypT2N1M0 (pathologic Stage IIIA)

Postoperative Course

  • ICU x 2 days
  • NGT removed POD 5
  • Swallow study POD 7: No anastomotic leak
  • Diet advanced slowly
  • J-tube feeds supplemented
  • Discharged POD 10

Adjuvant Therapy

  • Nivolumab (adjuvant immunotherapy) given residual disease and positive node

Follow-up

  • Quarterly surveillance imaging for 2 years
  • EGD at 6 months: Anastomosis intact, no recurrence
  • Nutritional counseling ongoing

Teaching Points

  1. Barrett's esophagus is the precursor to esophageal adenocarcinoma
  2. GERD surveillance with regular EGD important for Barrett's patients
  3. Dysphagia and weight loss are alarm symptoms requiring urgent evaluation
  4. Multimodality treatment (neoadjuvant chemoradiation + surgery) is standard for locally advanced disease
  5. Complete staging essential before treatment planning
  6. Nutrition support critical throughout treatment

Clinical Image

Image Description: Endoscopic image demonstrating an ulcerated, partially obstructing mass at the gastroesophageal junction consistent with esophageal adenocarcinoma. The irregular, friable mucosa with raised borders is characteristic of malignancy.

Attribution: Image from Wikimedia Commons, Category:Endoscopic images of esophageal cancer. Source: https://commons.wikimedia.org/wiki/Category:Endoscopic_images_of_esophageal_cancer

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