A Case of Esophageal Squamous Cell Carcinoma with Pancreatic Metastasis
A 58-year-old male with a 1-month history of abdominal bloating and indigestion visited our hospital for esophagogastroduodenoscopy. This detected a 3×4-cm erythematous lesion with an irregular nodular surface extending between 38 and 41 cm from the incisors in the 9 to 1 o,clock position (). With Iodine staining, it was shown as an iodine-void area with a well-defined boundary. A biopsy revealed squamous cell carcinoma, and he was admitted for further evaluation and management of this esophageal cancer. He was an alcoholic who had been drinking one bottle of Soju daily for the past 30 years and had a 30-pack-year smoking history. He was a hepatitis B carrier without regular follow-up. At admission, the patient's vitals were stable and he was alert mentally. No abnormalities were detected in the physical examination. The peripheral blood tests were normal, with hemoglobin 13.6 g/dL, white blood cell count 7,330/mm3, platelets 238,000/mm3, as were the blood chemistry and electrolytes. Additional studies for hepatitis B showed hepatitis B e antigen (-) and anti-hepatitis B e antibody (+), and no virus was detected with hepatitis B virus real-time polymerase chain reaction. The results for tumor markers were as follows: carcinoembryonic antigen 2.39 ng/mL (reference range, <4.1), CA19-9 2 U/mL (reference range, <37), and alpha-fetoprotein (AFP) 8.58 ng/mL (reference range, <4.0). Abdominal computed tomography (CT) showed a poorly demarcated and poorly enhancing mass at the pancreatic tail (). Magnetic resonance imaging (MRI) showed that the pancreatic mass appeared poorly demarcated and hyperintense on T2-weighted image and hypointense on T1-weighted image. Dynamic enhancing MRI showed that the mass was poorly enhanced without rim enhancement. So we were highly suspicious that the pancreatic mass was a primary adenocarcinoma rather than metastasis, because of tumor character and extremely low incidence of pancreatic metastasis from esophageal cancer. CT and MRI showed 1.2 cm-sized single nodule in the liver (). MRI showed that the hepatic mass was hypointense on T1-weighted image and hyperintense on T2-weighted image, and poorly enhanced on dynamic enhancing study. However, serum AFP was elevated (8.52 ng/mL) and we had to undergo ultrasound-guided liver biopsy. The hepatic mass was confirmed as a primary HCC based on the loss of ductular reaction and CD34 positivity (). The patient underwent surgery for the esophagus and pancreas lesions and radiofrequency ablation for the hepatic cancer. Histologically, the partial esophagectomy and distal pancreatectomy specimens showed squamous cell carcinoma and local lymph node invasion and the patient was diagnosed with stage IV esophageal cancer with pancreatic metastasis (). In the esophagus, the tumor invaded to submucosal layer with lymphatic invasion and metastasis to 3 of 31 regional lymph nodes. In the pancreas, the size was 5×4.5×4 cm with clean resection margins but there was lymphatic invasion involving 2 of 20 regional lymph nodes. The patient had received 5-fluorouracil/cisplatin combination therapy six times for 4 months after the surgery. He has been followed up without any evidence of recurrence on abdomen CT and gastroscopy until this month.