Presentation
Non-smoker with progressive hoarseness of voice and difficulty in swallowing for the last 5 months. Laryngoscopy (FOL) showed left vocal cord paralysis.
Patient Data
No active cardiopulmonary abnormality is seen. A well-defined soft tissue density indenting the left lateral wall of the trachea is seen at the level of the aortic arch (this can be easily overlooked, if not carefully interpreted, and correlated with the patient's clinical history). This finding was not seen on the previous chest radiograph (five years ago), which has been given as a reference.
CT features of left vocal cord paralysis are noted. No significant cervical lymphadenopathy is seen. There is a diffuse circumferential mucosal thickening of the mid and lower esophagus. No obvious abnormality is appreciable at the gastroesophageal junction. No obvious esophageal dilatation is seen. A necrotic lymph node measuring approximately 18 x 19 mm is seen in the tracheoesophageal groove at the level of the aortic arch, which is likely compressing the left recurrent laryngeal nerve, leading to the left vocal cord paralysis. A few other mediastinal lymph nodes (lower right para-tracheal & subcarinal) and small right supraclavicular lymph nodes are also seen.
Well-aerated lungs with mild bilateral apical pleural thickening. No suspicious pulmonary mass/nodularity is seen. Gross morphology of the visualized liver, spleen, pancreas, and adrenal glands is within normal limits. A 7 mm radiopaque calculus, and a 15 x 17 mm simple cortical cyst are seen in the partially visualized upper left kidney.
The patient lost to follow up after initial workup and presented again 6 months later with worsening symptoms of dysphagia and dysphonia, associated with anorexia, and weight loss. CT chest was done again which showed an interval increase in the size of tracheoesophageal groove necrotic nodal mass which is now invading the trachea.
FINDINGS: Intensely increased uptake (maximum SUV=23.9) is seen in the mid esophagus. Intensely increased uptake (maximum SUV=17.4) is seen in 3 x 4 cm upper mediastinal (tracheoesophageal) nodal mass. The right supraclavicular, right lower paratracheal, and subcarinal lymph nodes also demonstrate intensely increased uptake (maximum SUV=11.1). No other significant abnormality is seen.
CONCLUSION: Intensely hypermetabolic mid esophageal mass, consistent with biopsy-proven malignancy. Intensely hypermetabolic left upper paratracheal, right lower para-tracheal, subcarinal, and right supraclavicular lymph nodes, suspicious of metastases.
Esophagogastroduodenoscopy: Esophageal mass lesion occupying 1/3rd of its circumference is seen at 28-35 cm from the incisors (GE junction is at 43 cm). The mass has everted edges, is ulcerated at mid and lower ends, and bleeds easily.
Case Discussion
Esophagogastroduodenoscopy (done after initial CT chest): Esophageal mass.
Diagnosis: Non-keratinizing moderately differentiated, grade II, squamous cell carcinoma of the esophagus.
Bronchoscopy (done after 2nd CT chest): Tracheal lesion/invasion.
Bronchoscopic tracheal lesion biopsy: Non-keratinizing, moderately differentiated squamous cell carcinoma, consistent with the prior diagnosis of esophageal malignancy.
Finally, the case was discussed in the tumor board meeting, and the patient was referred to the medical/radiation oncologist for chemoradiotherapy. He required a gastrostomy tube (by an interventional radiologist) during his treatment and tolerated chemoradiotherapy well. Follow-up CT chest and PET scans showed a complete resolution of the disease.