A Role for Esophagectomy in Patients with Definitively Treated Solitary Oligometastasis and Worsening Dysphagia: A Case Series

Awe AM, BS, Maloney JD
2021 Japanese Journal of Gastroenterology and Hepatology  
The incidence of esophageal adenocarcinoma and its oligometastatic dissemination to non-conventional sites is increasing. We report three patient cases of stage IV esophageal adenocarcinoma where oligometastatic disease was identified following neoadjuvant chemoradiation. In one patient, worsening dysphagia and complete excision of a cutaneous oligometastasis warranted esophagectomy for a stage IV adenocarcinoma. Historically, evidence of metastatic disease precludes surgical resection,
more » ... we suggest a potential role of resection in patients with persistent or worsening dysphagia and aggressively treated oligometastatic disease of skin and soft tissues. Introduction Esophageal carcinoma exists in two primary histopathologic types: Esophageal Adenocarcinoma (EAC) and Esophageal Squamous Cell Carcinoma (ESCC). Incidence of esophageal carcinoma is decreasing largely due to a decline in ESCC, but EAC incidence is steadily increasing, particularly in Western societies [1]. From 2004 -2015 the incidence of EAC was 3.2 per 100,000 with metastatic stage IV EAC predominating (37%) stage at diagnosis [2]. Common sites of EAC metastases include lung, liver, adrenal glands, and brain. It is less common for EAC metastases to disseminate to soft tissues with roughly 3.5% of non-conventional metastases occurring in cutaneous tissues and skeletal muscles [3]. However, there is an increasing body of literature that describes metastatic EAC to soft tissue sites [4-6]. We report three cases of biopsy-proven oligometastatic disease in patients previously diagnosed with EAC. Case Reports In the last year, patients with previously diagnosed EAC and evidence of oligometastatic disease presented to or were identified at our institution. Case 1 Patient 1 is a 54-year-old male with history of soft-solid food dysphagia at time of presentation who was diagnosed with a cT3 cN1 cM0 (stage III) distal EAC who underwent neoadjuvant chemoradiation with carboplatin and paclitaxel and 50.4 Gray (Gy). Re-staging positron emission tomography/computed tomography (PET/CT) detected a new (18) F-fluorodeoxyglucose (FDG)-avid lesion in the left vastus medialis consistent with oligometastatic EAC on ultrasound-guided fine needle aspiration (Figure 1A). Evidence of metastatic disease advanced staging to stage IV b. The patient had improved dysphagia at time of restaging PET. Operative intervention was not pursued and salvage chemotherapy with FOLFOX and bevacizumab followed by paclitaxel and ramucirumab was initiated. Case 2 Patient 2 is a 68-year-old male with history of hard-solid food dysphagia with previously diagnosed cT3 cN0 cM0 (stage II) distal EAC. This patient underwent neoadjuvant chemoradiation with
doi:10.47829/jjgh.2021.6603 fatcat:dyzyt44u3zcvzd67dufyplrqbm