Esophageal cancer, most commonly presents with upper digestive symptoms such as dysphagia, odynophagia. Lymph nodes are among the most common metastatic sites of this cancer. An isolated scalp metastases as a sole signature of an underlying esophageal carcinoma has never been addressed in any surgical literature till to date. In our case report, we have shared our clinical experience of coming across through such a scenario where an orthopedically handicapped gentleman with 44 years of age, presented with isolated scalp mass later on proved to be metastatic squamous cell carcinoma from underlying esophageal cancer is being discussed in brief. It is a rare presentation of esophageal cancer without the upper gastrointestinal symptoms.

TAG:2]Introduction

Esophageal cancer is the fifth leading cause of death in men with cancer worldwide.[1] Men were more affected with 1200 estimated new cases.[2] The median age at diagnosis is 68 years.[3] There are two majors histopathological types of esophageal cancer such as esophageal squamous cell cancer (ESCC) and esophageal adenocarcinoma (EAC). Both are represented in more than 90% of primary esophageal carcinomas. There are numerous identifiable risk factors. Tobacco use and previous radiotherapy for breast cancer are major known risk factors for both EAC and ESCC.[4] ESCC risk is also increased with alcohol consumption, caustic injury to the esophagus, achalasia, tylosis (nonepidermolytic palmoplantar keratoderma), Plummer–Vinson syndrome and a history of head and neck cancer. The known risk factors for EAC are chronic gastroesophageal reflux disease and Barrett's esophagus.[5] Clinical presentation is similar for all types of esophageal cancers. The most common symptoms are dysphagia, and odynophagia.[1] Other less common ones include hoarseness, cough, and dyspnea.[4] More than a third of patients with ESCC present with metastatic disease. The metastases are usually in the lymph nodes, liver, lungs, and bones.[1] The initial investigation includes an upper gastroesophageal endoscopy or a barium swallow exam. To exclude metastasis, a computed tomography (CT) scan of the chest, abdomen, and pelvis should be performed.[4] The stages of esophageal cancer are defined according to the American Joint Committee on Cancer Staging System. Treatment is based on this staging and includes endoscopic mucosal resection, surgery, radiotherapy, and chemotherapy.[5]

Case Report

A 44-year-old orthopedically handicapped gentleman presented with nontender right posterior aspects of scalp mass measuring 5 cm × 6 cm, progressively increasing in size over last 3 months [Figure 1]. The patient also complained of a superficial painless mass in his right axillary skin, measuring 5 cm × 4 cm [Figure 2]. Detailed clinical examination revealed mild pallor, bilateral cervical, and supraclavicular nontender fixed lymphadenopathy and also the above mentioned two swelling in the scalp and right axilla. The patient had mild fever without chill and rigor for last 2 months. The patient reported with no dysphagia to both solid and liquids, icterus, vomiting, odynophagia, neither upper abdominal pain nor abdominal swelling, hematemesis, and malena. Although, the patient had a history of weight loss and anorexia for 3 months. Plain and contrast CT scan of the thorax (December 26, 2014] revealed long segment esophageal luminal thickening suggestive of neoplasia, right supraclavicular nodal lesion. Subsequently the patient was offered esophagogastroduodenoscopy (December 31, 2014) that showed a large polypoidal lesion beginning at 20 cm from incisor, the lesion has involved the whole of the luminal circumference with the partial luminal compromise and endoscope could not negotiate further, multiple biopsies taken [Figure 3]. Endoscopic esophageal biopsy showed the squamous cell carcinoma [Figure 4]. FNAC from both the scalp swelling, right cervical and supraclavicular lymph node showed the cytomorphological features of malignant tumor consistent with the squamous cell carcinoma, metastatic [Figure 5]. We did a feeding jejunostomy and place the patient in the tumor board for discussion regarding the further management of this patient in the form of palliative chemotherapy and radiotherapy. We are fortunate to have this patient in our surgical oncology ward without any complications for further discussion about management.{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}

Discussion

Esophageal squamous cell carcinoma was not our initial hypothesis because of our patient's overall atypical presentation. First, the median age at diagnosis is 68 years with only 12% of patients between 45 and 54 years of age.[3] Our patient was a 44-year-old man. Second, he did not have dysphagia or odynophagia, which are the most common symptoms of esophageal cancer according to the literature.[1] His main complaint were that scalp, axillary, and bilateral supraclavicular swelling. To our knowledge, an initial presentation of esophageal squamous cell carcinoma with scalp and axillary skin mass has not been reported, although there are few reports in the literature presenting some unusual metastatic presentations of esophageal squamous cell carcinoma, such as brain, myocardium, skin, jejunum, orbit, spleen, thyroid, Sister Mary Joseph's nodule, or numb chin syndrome.[6],[7],[8],[9],[10],[11],[12],[13],[14] Finally, Esophageal squamous cell carcinoma is an aggressively invasive tumor.[4] With this large Scalp and axillary mass, our patient was diagnosed with a stage IV ESCC, according to the American Joint Committee on Cancer Staging System, rending surgery was impossible.[1] The best treatment for our patient would have been concomitant radio-chemotherapy, which improves 5-year survival in 25% of patients, whereas no patients survived for 5 years using radiotherapy alone.[15]

Conclusion

To our knowledge, this is the first reported case of esophageal squamous cell carcinoma presenting as the scalp and axillary metastases. In this regard, our experience of a case of esophageal squamous cell carcinoma presenting as the scalp and axillary metastases is really an uncommon one and requires special mention.