Is it cancer? Another case study

As I wrote in my previous post, sometimes other diseases may masquerade as cancer. Tay CW et al. reports another such case published in the International Journal of Surgery Case Reports.

They reported a case of a 33 year old female patient who presented with difficulty in swallowing, technically termed as dysphagia. There were no other symptoms. She was a non-smoker and there were no significant previous medical conditions. Chest X-ray and routine blood examination was normal. Physical examination did not reveal much.

Now the differential diagnosis of dysphagia is pretty long, involving the mouth, pharynx and the esophagus. Whether the symptom of dysphagia is progressive or not have to be considered. Progressive dysphagia suggests a malignant lesion. The type of  food which is difficult to swallow is also significant. Dysphagia which was initially to solids and gradually progresses to liquids indicates a malignant lesion. Dysphagia to liquids from the onset indicates a motility disorder of the esophagus. Dysphagia particularly aggravated on eating acidic food indicates an ulcerative lesion of the esophagus. In this case, the dysphagia was progressive for two weeks.

During the course of further investigation an upper gastrointestinal endoscopy was done. Upper gastrointestinal endoscopy is done to directly visualize the esophagus to look for any abnormal mass, ulceration or stricture that may cause dysphagia. A large submucosal esophageal mass was found, 25 cm from the incisor teeth. In the esophagus, any position is denoted by its length from the incisor teeth. The end of the esophagus is at about 40 cm from the incisor teeth. The mass was soft and covered by normal esophageal mucosa. Subsequently, a CT scan was done which showed a mid-esophageal mass, 4X2 cm in size. It was suggested to be an esophageal carcinoma and the patient was advised to undergo surgery.

Smoking and alcohol consumption are high risk factors for the development of esophageal carcinoma. They were absent in the patient. Dysphagia was the only complaint of the woman without any associated symptoms of cough, weight loss, fever, and hemetemesis (vomiting of blood). Squamous cell carcinoma is the commonest type esophageal carcinoma; adenocarcinoma is the second commonest. Other types are rare.

Sub carinal space. Modified screenshot from Google body browser.

At this stage the patient was referred to the authors for a second opinion. They arranged for an endoscopic ultrasound (EUS) and surprise! EUS detected a heterogeneous mass, 46 mm X 23 mm in size in the subcarinal window (subcarinal space is the space in front of the esophagus below the bifurcation of the trachea which is called the carina). It was suggested to be a lymph node which has enlarged and compressed the esophagus, causing the symptom of dysphagia. Fine needle aspiration was done endoscopically and cytological examination of the aspirate revealed an epithelioid granuloma, typically seen in tuberculosis. Molecular analysis of the aspirate was positive for Mycobacterium tuberculosis.

This finding changed the picture radically. Instead of surgery, the patient underwent medical treatment for tuberculosis with antitubercular drugs. EUS was the pivotal diagnostic study.

What is intriguing is that the lungs of the patient were completely clear. I would have thought of the presence of a primary lung lesion. In fact I double checked the article to see if I had missed it. The chest X-ray and CT scan of the lungs were clear. No esophageal lesions were present either. It appears to be a case of primary  mediastinal lymph node tuberculosis. At least it is better than esophageal cancer considering the poor prognosis of esophageal cancer.

Happy new year!

Tay, C., Deans, D., Khor, J., Seet, J., & So, B. (2010). Suspected oesophageal cancer in a 33 year old lady International Journal of Surgery Case Reports DOI: 10.1016/j.ijscr.2010.10.002