Indian J Gastroenterol DOI 10.1007/s12664-014-0480-0
LETTER
Four cases of adenocarcinoma of esophagus with co-existing hydatid cyst of liver which caused delayed management of carcinoma esophagus Jayant Kumar Ghosh & Sundeep Kumar Goyal & Vinod Kumar Dixit & A. K. Jain
# Indian Society of Gastroenterology 2014
Sir, Hydatid disease is a significant health problem where animal husbandry is common. Common sites of involvement in man are the liver (75 %) and lungs (15 %). Other uncommon and rare sites are the peritoneum, spleen, ovary, and adnexa [1, 2]. Carcinoma of esophagus is also one of the most common gastrointestinal tract malignancies in India. From our large experience with managing liver hydatid cysts, we are reporting four cases of liver hydatid cyst in patients with carcinoma of esophagus. In December 2011, July 2012, and February 2013, three males aged 57, 60, and 65 years respectively, came with progressive dysphagia, and upper gastrointestinal endoscopy (UGIE) in all the cases revealed lower esophageal ulceroproliferative lesion, and biopsy showed adenocarcinoma. Computed tomography (CT) scan showed metastatic esophageal diseases along with liver space occupying lesions (SOLs) (4 cm×4 cm, 1.5cm×2 cm, and 1cm×2 cm), respectively in the above three cases, which were considered as liver metastases (Fig. 1). A self-expanding metallic stent (SEMS) was placed across the esophageal lesion in all the three. Patients were followed up with the diagnosis of esophageal cancer with distant metastasis and prognosticated accordingly. However, the liver SOL enlarged during follow up and turned out to be a hydatid cyst (8cm×8 cm, 5cm×6 cm, and 7cm×6 cm) in the right lobe of liver in each case. Percutaneous aspiration, hypertonic saline injection into the liver hydatid cyst followed by J. K. Ghosh (*) : S. K. Goyal : V. K. Dixit : A. K. Jain Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India e-mail: [email protected]
re-aspiration (PAIR) was done in all the cases. Ultrasonography (USG) abdomen was done 1 and 2 months later in the follow up, and they showed resolving hydatid cyst of liver. Cancer management was re-planned. In November 2013, a 59-year-old male presented with vague right upper quadrant pain for last 5 months and was diagnosed by USG abdomen as hydatid cyst of the right lobe of liver (5 cm×6 cm). Cystic fluid serology was positive for Echinococcus. PAIR was done for liver hydatid cyst. One month later, the patient again came, but with the complaints of dysphagia. UGIE showed lower esophageal infiltrative lesion which turned out to be adenocarcinoma in the histologic examination. CT scan showed local invasion. Patient was treated with chemotherapy followed by surgery and remains well on follow up. A typical hydatid cyst has three layers. The graycolored outer layer (pericyst) consists of fibrous tissue which blends with the liver. USG classification of hydatid cysts is the following: (1) type I, univesicular fluid-filled cysts; (2) type II, univesicular cysts with a floating membrane (the water lily sign); (3) type III, multivesicular cysts with a prominent fluid component (the honeycomb image); (4) type IV, pseudotumoral lesions with a prominent solid component; and (5) type V, solid, calcified lesions. USG and CT are both excellent imaging modalities for the detection of hydatid cysts. However, in the early stages, sometimes it may be difficult to diagnose radiologically and may be confused with liver cancer or liver metastasis. CT has high sensitivity and specificity for calcified hydatid cysts. Magnetic resonance is the best imaging procedure to demonstrate a cystic component and to show a biliary tree involvement. In our first three cases,
Indian J Gastroenterol
the initial CT scan missed the diagnosis of liver hydatid cyst, and the patient was given a false impression of liver metastases which caused delay in appropriate management of esophageal carcinoma. Our observation is unique that liver hydatid cyst was never reported earlier in any patient with carcinoma of esophagus. Hydatid cysts were earlier reported in association with ovarian and adnexal malignancies [3, 4]. Primary abdominal hydatid cyst presenting as an appendicular mass has also been reported in the literature [5]. Another important finding in this report was that all the four had adenocarcinoma. This could be an incidental finding or some unknown association between the two conditions.
References
Fig. 1 CT scan showing metastatic esophageal diseases along with liver space-occupying lesions considered as liver metastases
1. Babu KS, Goel D, Prayaga A, Rao IS, Kumar A. Intraabdominal hydatid cyst: a case report. Acta Cytol. 2008;52:464–6. 2. Singh RK. A case of disseminated abdominal hydatidosis. J Assoc Physicians India. 2008;56:55. 3. Mehra BR, Thawait AP, Gupta DO, Narang RR. Giant abdominal hydatid cyst masquerading as ovarian malignancy. Singap Med J. 2007;48:e284–6. 4. Sharma A, Sengupta P, Mondal S, Raychaudhuri G. Hydatid cyst of ovary mimicking ovarian neoplasm with its imprint cytology. Am J Case Rep. 2012;13:276–8. 5. De U. Primary abdominal hydatid cyst presenting in emergency as appendicular mass: a case report. World J Emerg Surg. 2009;4:13.
LETTER
Four cases of adenocarcinoma of esophagus with co-existing hydatid cyst of liver which caused delayed management of carcinoma esophagus Jayant Kumar Ghosh & Sundeep Kumar Goyal & Vinod Kumar Dixit & A. K. Jain
# Indian Society of Gastroenterology 2014
Sir, Hydatid disease is a significant health problem where animal husbandry is common. Common sites of involvement in man are the liver (75 %) and lungs (15 %). Other uncommon and rare sites are the peritoneum, spleen, ovary, and adnexa [1, 2]. Carcinoma of esophagus is also one of the most common gastrointestinal tract malignancies in India. From our large experience with managing liver hydatid cysts, we are reporting four cases of liver hydatid cyst in patients with carcinoma of esophagus. In December 2011, July 2012, and February 2013, three males aged 57, 60, and 65 years respectively, came with progressive dysphagia, and upper gastrointestinal endoscopy (UGIE) in all the cases revealed lower esophageal ulceroproliferative lesion, and biopsy showed adenocarcinoma. Computed tomography (CT) scan showed metastatic esophageal diseases along with liver space occupying lesions (SOLs) (4 cm×4 cm, 1.5cm×2 cm, and 1cm×2 cm), respectively in the above three cases, which were considered as liver metastases (Fig. 1). A self-expanding metallic stent (SEMS) was placed across the esophageal lesion in all the three. Patients were followed up with the diagnosis of esophageal cancer with distant metastasis and prognosticated accordingly. However, the liver SOL enlarged during follow up and turned out to be a hydatid cyst (8cm×8 cm, 5cm×6 cm, and 7cm×6 cm) in the right lobe of liver in each case. Percutaneous aspiration, hypertonic saline injection into the liver hydatid cyst followed by J. K. Ghosh (*) : S. K. Goyal : V. K. Dixit : A. K. Jain Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India e-mail: [email protected]
re-aspiration (PAIR) was done in all the cases. Ultrasonography (USG) abdomen was done 1 and 2 months later in the follow up, and they showed resolving hydatid cyst of liver. Cancer management was re-planned. In November 2013, a 59-year-old male presented with vague right upper quadrant pain for last 5 months and was diagnosed by USG abdomen as hydatid cyst of the right lobe of liver (5 cm×6 cm). Cystic fluid serology was positive for Echinococcus. PAIR was done for liver hydatid cyst. One month later, the patient again came, but with the complaints of dysphagia. UGIE showed lower esophageal infiltrative lesion which turned out to be adenocarcinoma in the histologic examination. CT scan showed local invasion. Patient was treated with chemotherapy followed by surgery and remains well on follow up. A typical hydatid cyst has three layers. The graycolored outer layer (pericyst) consists of fibrous tissue which blends with the liver. USG classification of hydatid cysts is the following: (1) type I, univesicular fluid-filled cysts; (2) type II, univesicular cysts with a floating membrane (the water lily sign); (3) type III, multivesicular cysts with a prominent fluid component (the honeycomb image); (4) type IV, pseudotumoral lesions with a prominent solid component; and (5) type V, solid, calcified lesions. USG and CT are both excellent imaging modalities for the detection of hydatid cysts. However, in the early stages, sometimes it may be difficult to diagnose radiologically and may be confused with liver cancer or liver metastasis. CT has high sensitivity and specificity for calcified hydatid cysts. Magnetic resonance is the best imaging procedure to demonstrate a cystic component and to show a biliary tree involvement. In our first three cases,
Indian J Gastroenterol
the initial CT scan missed the diagnosis of liver hydatid cyst, and the patient was given a false impression of liver metastases which caused delay in appropriate management of esophageal carcinoma. Our observation is unique that liver hydatid cyst was never reported earlier in any patient with carcinoma of esophagus. Hydatid cysts were earlier reported in association with ovarian and adnexal malignancies [3, 4]. Primary abdominal hydatid cyst presenting as an appendicular mass has also been reported in the literature [5]. Another important finding in this report was that all the four had adenocarcinoma. This could be an incidental finding or some unknown association between the two conditions.
References
Fig. 1 CT scan showing metastatic esophageal diseases along with liver space-occupying lesions considered as liver metastases
1. Babu KS, Goel D, Prayaga A, Rao IS, Kumar A. Intraabdominal hydatid cyst: a case report. Acta Cytol. 2008;52:464–6. 2. Singh RK. A case of disseminated abdominal hydatidosis. J Assoc Physicians India. 2008;56:55. 3. Mehra BR, Thawait AP, Gupta DO, Narang RR. Giant abdominal hydatid cyst masquerading as ovarian malignancy. Singap Med J. 2007;48:e284–6. 4. Sharma A, Sengupta P, Mondal S, Raychaudhuri G. Hydatid cyst of ovary mimicking ovarian neoplasm with its imprint cytology. Am J Case Rep. 2012;13:276–8. 5. De U. Primary abdominal hydatid cyst presenting in emergency as appendicular mass: a case report. World J Emerg Surg. 2009;4:13.
