Gastrointestinal

Gastrointest Radiol 1,249 - 251 (1976)

Radiology {~'~by Springer-Verlag 1976

Metastasis to the Esophagus Mary Stuart Fisher Philadelphia General Hospital, Philadelphia, Pennsylvania, U.S.A.

Abstract. Tumor metastatic .to the esophagus is a rare

lesion. Two cases, primary in pancreas and rectum, are described. There are no distinguishing radiologic features. Key words: E s o p h a g u s Rectum.

Metastasis -

Pancreas -

Metastatic tumor to the esophagus is very rare, occurring in 3.2% of autopsies on patients with carcinoma in one series [1]. Probably the incidence of true metastases, in contradistinction to local invasion from contiguous organs, is closer to 1%. Primary tumors of stomach, breast, larynx, hypopharynx, pancreas, testis, eye, tongue, bronchus, prostate, tibia, liver and pleura have been reported to produce esophageal metastases [2, 3]. There has been very little reference to esophageal metastases in the radiological literature. It is the purpose of this paper to present two such cases.

C a s e Reports Case 1. A 17-year-old boy complained of dysphagia and profound weight loss for 2 months, with some lower abdominal pain. A G.I. series showed a constriction of the lower end of the esophagus, with slight irregularity suggesting that a mass might be present (Fig. 1). There was no anemia or blood in the stool. The esophagoscopist saw no abnormality except for mild inflammatory changes. In spite of a negative mecholyl test and class IV cells in the gastric washings, a presumptive diagnosis of achalasia was entertained. Bouginage and reassurance failed Io relieve the dysphagia or arrest the loss of weight. Constipation appeared, a new complaink and a lower abdominal mass was felt. Proctoscopy revealed a polypoid lesion: and on barium enema, there was annuAddress rel,'hTt requests to." Mary Stuart Fisher, M.D., Professor of Radiology, Temple University Hospital, Dept. of Radiology, 3401 North Broad Street, Philadelphia, PA 19140, U.S.A.

lar constriction at the rectosigmoid (Fig. 2). Esophageal obstruction became complete, with smoothly tapering margins. At laparotomy there was diffuse peritoneal carcinomatosis, ascites, a right lower quadrant mass in contiguity with the rectum, and masses surrounding the gastroesophageal junction. Biopsy diagnosis was ~'poorly differentiated carcinoma". The patient died, and autopsy was not permitted. Although the primary site was not unequivocally established, the dominant mass was clearly in the area of the rectum. Case 2. A 66-year-old man complained of anorexia, weight loss, and generalized aches for 18 months. There was no dysphagia. A large mass was present in the left upper quadrant of the abdomen. On G.I. series, the stomach was draped over a huge mass in the area of the body and tail of the pancreas, without evidence of intrinsic mucosal abnormality. In the mid-esophagus, there was a short segment of narrowing and irregularity, with apparent mucosal destruction (Fig. 3), which on esophagoscopy was described as a friable necrotic lesion. Surgery and, shortly thereafter, autopsy revealed an undifferentiated spindle cell carcinoma of the pancreas, involving the muscularis of the posterior stomach wall, and an ulcerated metastatic nodule in the esophagus. The pathologist felt confident that the primary lesion was pancreatic, because of the cell type, the relative size of the masses, and the fact that there was relatively little involvement of the esophageal mucosa, the bulk of the tumor being in the wall.

Discussion

Secondary tumor involvement of the esophagus may be of three types: direct invasion, involvement by tumor-containing mediastinal nodes, and blood-borne metastasis. Of these, the first type is the most common. Neoplasm of the thyroid, pharynx, larynx, lung, and stomach may extend into the esophagus. Although the x-ray appearance at times may be indistinguishable from a primary esophageal neoplasm, the primary site is usually obvious. Constriction of the esophagus by mediastinal lymph nodes is next in frequency, with lung and breast primaries [2, 4] figuring prominently among these reports. Langton and Laws [5], Pygott [1], and Ward [6] report on esophageal presentations of pancreatic

250

M.S. Fisher: Esophageal Metastasis

Fig. 1. Case 1. Constriction of abdominal esophagus with a slight shelving defect inferiorly

Fig. 3. Case 2. Short irregular constriction of mid-esophagus, with a destroyed mucosa

Fig. 2.

Case 1.

Annular constriction of rectosigmoid

t u m o r s that are p r o b a b l y o f this type. The appearance of s m o o t h constriction or localized extrinsic i n d e n t a tion is usually the clue to the non-esophageal origin o f the mass, a l t h o u g h an adherent node m a y present as an intramural mass, and occasional frank mucosal invasion m a y occur. Third, and rarest, is a true b l o o d - b o r n e metastatic focus. D y s p h a g i a is apparently not usual. Gross and F r e e d m a n [7] described the first case, and Toreson [8] f o u n d dysphagia in only 50% o f his 26 cases. Holyoke [4] reported on 10 cases with dysphagia, but f o u n d 24 additional cases of a s y m p t o m a t i c esophageal metastasis ( a m o n g 280 w o m e n dying of breast cancer). The x-ray appearances are variable. S m o o t h intramural mass, s m o o t h l y tapering "stricture" [2], and an achalasia-like picture [5] have all been reported. Rarely the appearance is indistinguishable f r o m a prim a r y esophageal carcinoma, as was said to be the

M.S. Fisher: Esophageal Metastasis

case with a prostatic metastasis described by Gross and Freedman [7] and one of Ward [6]. Of the two cases presented here, one was a blood-borne metastasis indistinguishable radiographically from primary esophageal carcinoma, and the other the result of lymph node involvement with a picture suggestive of achalasia.

References l. Pygott F: Radiologic appearances in pancreatic cancer. Brit J Radiol 23.'656--666, 1950 2. Atkins JA: Metastatic carcinoma to the esophagus. Ann Otol 75:356 367, 1966

251 3. Valdes-Dapena AM, Stein GN: Morphologic Pathology oJ the Alimentary Canal. Philadelphia: W.B. Saunders 1970 4. Holyoke ED, et al.: Esophageal metastasis and dysphagia in patients with carcinoma of the breast. J Surg Oncol 1:97-107, 1969 5. Langton L, Laws JW : Dysphagia in carcinoma of the esophagus. J Fac Radiol (London) 6: 134-138, 1954 6. Ward P: Pulmonary and oesophageal presentations of pancreatic carcinoma. Brit J Radiol 37.'27-34, 1964 7. Gross P, Freemand, L J: Obstructing secondary carcinoma of the esophagus. Arch Path 33.'361 364, 1942 8. Toreson WE: Secondary carcinoma of the esophagus as a cause of dysphagia. Arch Path 38.'92 84, 1944

Receit'ed: August 9, 1976," accepted." September 29, 1976

Metastasis to the esophagus.

Tumor metastatic to the esophagus is a rare lesion. Two cases, primary in pancreas and rectum, are described. There are no distinguishing radiologic f...
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