Via Research Recognition Day 2024 VCOM-Carolinas

Clinical Case-Based Reports

A Case of the Coexistence of Esophageal Squamous Cell Carcinoma and Simultaneous Adenocarcinoma Margaret Munz, OMS III 1 , Dr. Kristin Lombardozzi, MD 1 , Dr. Lorenzo Sampson, MD 2 . 1 Edward Via College of Osteopathic Medicine- Carolinas Campus, Spartanburg SC 2 Aiken Regional Medical Center, Department of Surgery, Aiken SC

Abstract

Discussion

Diagnostic Evaluation

Esophageal malignancy is the eighth most common cancer in the world 1 . Adenocarcinoma is the most common esophageal malignancy in the United States, seeing increasing incidence resulting from GERD and Barrett’s esophagus 2 . While squamous cell carcinoma is the most common globally, especially prevalent in Asian countries, in the “esophageal cancer belt.” 2 Squamous cell carcinoma and adenocarcinoma of the esophagus have clinical, oncologic, and histologic differences and literature suggests this warrants different therapeutic approaches 3 . A case such as this one involving a patient presenting with simultaneous poorly differentiated squamous cell carcinoma as well as high grade adenocarcinoma in the background of tubulovillous- adenoma like change, presents a unique clinical course as well as a possible example of a uniquecollision tumor. Patient Profile: 61-year-old African American male presents to an outpatient surgery clinic for referral from primary physician for anemia. Chief Complaint: The patient admits to a two-week history of post-prandial abdominal burning sensation in the epigastric region. The pain is improved when laying on his left side. Patient admits to occasional dysphagia. Past Medical History: Type 2 Diabetes Mellitus, hypertension, hyperlipidemia, arthritis, GERD, spondylosis Past Surgery/ Procedures: The patient had 4 screening colonoscopies with findings of tubular adenomas. Social History: The patient drinks 1-2 alcoholic beverages per month and is a former smoker. Medications: Fenofibrate, trandolapril, meloxicam, Tylenol, gabapentin, pantoprazole, multivitamin, fish oil ROS : No chest pain, fever, chills, unexpected weight loss, dizziness, or neurologic symptoms. Abdominal pain and burning after meals, improved in left Physical Exam General: Alert, in no acute cardiopulmonary distress. Mental Status: Oriented to person, place and time. Normal affect. Head: Normocephalic. Respiratory: Clear to auscultation and percussion. No wheezing, rales or rhonchi. Cardiovascular: Heart sounds normal. No thrills. Regular rate and rhythm, no murmurs, rubs or gallops. Gastrointestinal: Abdomen soft, non-tender, non-distended. Normal bowel sounds. No pulsatile mass. No hepatosplenomegaly. Pt has no acute TTP over epigastric region, pt does have TTP over RUQ. No peritoneal Signs. Genitourinary: No costovertebral angle tenderness. HR 98, 146/80 Clinical Assessment and plan: The patient's symptoms and clinical exam prompted further endoscopic evaluation. At that time a 8 cm mass (33cm- 41 cm from the central incisors) was found in the distal esophagus and several biopsies were retrieved for histologic evaluation. lateral recumbent position. Physical Exam (Focused): Case Description

The final diagnosis showed both squamous cell carcinoma (SCC) and adenocarcinoma within a single gross 8 cm tumor located in the distal esophagus. The patient was referred to oncology for radiation and chemotherapy treatments. The patient was recommended to receive FOLFOX (5-FU and Oxaliplatin and leucovorin) and OPDIVO (Nivolumab a PD-L1 analog). The patient is due to undergo an additional PET scan at the termination of his next chemotherapy cycle to evaluate if he is a surgical candidate. The pathologist reported that due to the fact the several biopsies were taken and placed in the same container further grading was not possible at this time. The pathologist states he does not believe this tumor is "adenosquamous" as that represents a different disease pathology. In his opinion, without resection of the entire tumor or thorough examination, the tumor likely arose secondary to Barrett's esophagus while a simultaneous squamous cell carcinoma originated adjacent to it, the tumors appeared as one mass, or a collision tumor. It was impossible to tell if the original origin was in the distal esophagus or gastric cardia and or in reference to the Z-line. It is possible this patient's smoking history and meloxicam use contributed to his GERD and secondary Barrett's esophagus, it is now more widely recognized in literature that SCC and adenocarcinoma have concurrent risk factors 3 . Collision tumors result in a unique and rare presentation that may warrant specific treatment 2 . Traditionally SCC is associated with lower socioeconomic status, nicotine, and alcohol while adenocarcinoma is associated with high socioeconomic status, obesity, and cardiovascular risk factors 16 . Additionally, surgical approach differs based on tumor morphology and location. SCC is typically located in the proximal third of the esophagus and surgery usually requires a subtotal esophagectomy with cervical anastomosis, while adenocarcinoma in the distal third of the esophagus can be resected with an intrathoracic anastomosis (Ivor-Lewis procedure) 16 .

Image 1-12 . The patient underwent an EGD for the evaluation of symptomatic dysphagia

Conclusion

Final Diagnosis: Biopsy obtained via EGD showed a mass in the distal esophagus extending from 33cm to 41 cm from the central incisors. The biopsy showed Invasive squamous cell carcinoma of the distal esophagus along with invasive high-grade adenocarcinoma of the distal esophagus with mucinous features and mild signet-ring features, extending into the proximal stomach. Suspected case of collision tumor. goblet cells in the lower third of the esophagus and the gastric cardia. PET Scan: Focal Intense radiotracer activity in the distal esophagus. Local regional metastasis to subcarinal lymph node. Distant metastatic diffuse activity in the central mesentery with ascites. CT Scan: Mesenteric thickening of the greater omentum. Circumferential thickening of the distal esophagus and gastric cardia Pathology and Further Imaging Pathology report :Biopsy showed Invasive poorly differentiated squamous cell carcinoma with focal spindled feature and Invasive high-grade adenocarcinoma with mucinous features and mild signet ring features arising in the background of tubulovillous adenoma-like change with high-grade dysplasia and scattered

With over half a million deaths related to esophageal cancer in 2020, there is no question that this malignancy is a significant threat to general health of the population 11 . While SCC is the most common (90% of global esophageal malignancies), adenocarcinoma is seeing increased incidence in developed countries 8 . The global incidence of esophageal cancer is set to increase by 50% by 2040 11 . Both forms of malignancy most commonly presents as severe, stage IV disease 17 . This case presents a rare account of simultaneous esophageal malignancies and the importance of better understanding disease progression, given the poor prognosis of these cases.

I would like to thank Dr. Sampson and his staff for helping me study this case, obtain all necessary documents and information, as well as patient consent. I would like to thank Dr. Lombardozzi for her assistance preparing the case for presentation. Patient informed consent obtained from written document received via mail. No disclosures or conflicts of interests to report. Acknowledgements & References

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2024 Research Recognition Day