Rare Oncologic Emergency in Esophageal Cancer

Case Report

Ann Hematol Oncol. 2016; 3(10): 1115.

Rare Oncologic Emergency in Esophageal Cancer

Gannamani V¹*, Yegneswaran B¹ and Porcelli M²

¹Department of Internal Medicine, Saint Peter’s University Hospital, USA

²Department of Hematology & Oncology, Saint Peter’s University Hospital, USA

*Corresponding author: Vedavyas Gannamani, Department of Internal Medicine, Saint Peter’s University Hospital, 254 Easton Avenue, CARES building 4th floor, New Brunswick, New Jersey, USA

Received: August 30, 2016; Accepted: October 10, 2016; Published: October 13, 2016

Abstract

Less than 1% of cancer patients develop intramedullary spinal cord metastases (ISCM). They present with rapid progression of neurological symptoms and cause severe disability. With advent of imaging techniques and improved survival of patients, ISCM are increasingly recognized. To the best of our knowledge few cases of ISCM from esophageal cancer were reported from the United States. The patient we present here was diagnosed with adenocarcinoma of distal esophagus in June 2013 and later developed liver, lung and multiple brain metastases. He had stable disease for three months before this hospitalization. The reason for admission was history of multiple falls in three weeks. Examination showed reduced motor strength in both legs, left greater than right. Also absent ankle and knee reflexes bilaterally and reduced position sense in right leg was noted. An initial MRI of brain showed multiple metastatic lesions including left parietal lobe (30 mm in size) and right occipital lobe (23 mm in size). The physical exam findings were difficult to explain by MRI brain. Further evaluation by MRI spine showed focal intramedullary mass at T11 level with surrounding edema. Patient was treated with Decadron® and palliative radiation. At the end of radiotherapy, the improvement in neurological status was only minimal. Three months after the diagnosis, he died on hospice care.

Keywords: Intramedullary tumors; Esophageal cancer; Spinal cord tumors

Abbreviations

ISCM: Intramedullary Spinal Cord Metastases; BUN: Blood Urea Nitrogen; MRI: Magnetic Resonance Imaging; CNS: Central Nervous System

Introduction

Less than 1% of cancer patients develop intramedullary spinal cord metastases (ISCM). These tumors constitute 2-8.5% of all central nervous system metastases and are less than 5% of spine metastases [1,2]. Lung and breast cancers are commonly associated with ISCM [1-3]. Esophageal cancer rarely metastasizes to brain and even less rarely to spinal cord [4]. With improvement in imaging studies, ISCM are being increasingly recognized. Understanding of their management is necessary to reduce the disability. Worldwide, to our knowledge three cases of esophageal cancer with ISCM involving cervical region have been described and reported [4-6]. We here present a case of ISCM with involvement of lower thoracic region from esophageal cancer.

Case Presentation

An 82-year-old male with past medical history of hypertension, hyperlipidemia, tongue cancer, chronic kidney disease, benign prostate hyperplasia and metastatic esophageal cancer was admitted with the history of multiple falls in three weeks. Patient was diagnosed with moderately differentiated adenocarcinoma involving distal third of esophagus in June 2013 and received definitive chemotherapy and radiation. A follow up PET scan in February 2014 showed new metastatic lesion in liver, treated with radiofrequency ablation in May 2014. Therapy was delayed as patient was hospitalized with metastatic disease of brain and had fractionated brain radiation. Follow up imaging revealed metastatic lung disease for which patient received chemotherapy. In early 2015 the disease progressed manifesting as multiple brain metastases and whole brain radiation was given. Patient then had stable disease with Kornafsky’s score of 60-70 until the current admission in July 2015.

At admission patient complained that his legs were “giving away”. His symptoms worsened gradually over three weeks. Initially he was unable to stand which progressed to the need of a wheel chair for ambulation. He had no history of incontinence, back pain or trauma. Patient did not have weakness of upper limbs, speech or swallowing difficulty.

His vital signs on admission included blood pressure of 120/71 mmHg, heart rate of 51/min, regular, temperature of 97.4F, respiratory rate of 16/min. Examination showed motor strength of 2/5 in left leg with no ability to move distal part of left leg and 3/5 strength in right leg; reduced position sensation in right foot, absent knee and ankle reflexes bilaterally. The Babinski’s test was negative bilaterally. Rest of the examination was unremarkable. His admission labs included WBC 7.0x109/L, hemoglobin 100 gm/L, platelets count of 134x109/L, serum sodium 134 mmol/L, potassium 4.5 mmol/L, BUN 17.5 mmol/L, creatinine 162 μmol/L and calcium 2.28 mmol/L. An initial MRI of the brain showed a large 30 mm left parietal metastatic lesion with edema, a 23mm right occipital lesion and multiple small metastases in both hemispheres (Figure 1and 2). His symptoms and physical findings were not completely explained by the MRI findings.