Presentation
Esophageal cancer with enlarging painful left thigh mass
Patient Data
No bony abnormality.
Well defined heterogeneous hypervascular intramuscular mass abutting the femoral cortex.
No bony destruction.
Extensive edema involving the left quadriceps muscle with sparing of the rectus femoris. Edema is also reaching up to and surrounding the femoral vessels at the level of the lesser trochanter.
Two focal inhomogeneously, peripherally enhancing mass lesions within the lateral aspect of the vastus intermedius (4.5 x 3.2 x 5 cm) and in the vastus medialis/vastus intermedius 1.8 cm in all dimensions. The larger lesion is in contact with the periosteum of the lateral aspect of the midshaft of the femur, but no radiological evidence of invasion.
No evidence of bone marrow edema or focal bone lesion within the visualized bones.
Case Discussion
Ultrasound guided biopsy of the thigh mass was undertaken.
Histology
Macroscopic: Two cores up to 14 mm in length. Microscopic: The needle core biopsies show extensive infiltration by an invasive, moderately differentiated adenocarcinoma. There are some cytoplasmic vacuoles but no true clear cell changes present. There is no associated microcalcification. Immunohistochemistry shows diffuse strong positive staining with cytokeratin 7. Cytokeratin 20 shows focal and weak positive staining only. CEA, CD10 and TTF-1 are all negative. The morphological appearances and immunohistochemical profile indicate metastatic adenocarcinoma. The most likely primary sites of origin would include the pancreas, hepatobiliary tract and upper gastrointestinal tract, including the esophagus. The recent endoscopic examination results are noted: Two separate biopsy samples both show features of columnar lined esophagus (Barrett esophagus) with high-grade glandular dysplasia features suspicious of invasive neoplasia.
Diagnosis: metastatic adenocarcinoma.
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