Case 19-2009 — A 63-Year-Old Woman with Carcinoma of the Gastroesophageal Junction  

Oleh:

Kwak, Eunice L. ; Hong, Theodore S. ; Berger, David L. ; Forcione, David G. ; Uppot, Raul N. ; Lauwers, Gregory Y.

Jenis: Article from Journal - ilmiah internasional
Dalam koleksi: The New England Journal of Medicine (keterangan: ada di Proquest) vol. 360 no. 25 (Jun. 2009), page 2656-2664 .
Topik: adenocarcinoma; gastroesophageal junction

Ketersediaan

Perpustakaan FK Nomor Panggil: N08.K.2009.03 Non-tandon: 1 (dapat dipinjam: 0) Tandon: tidak ada

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Dr. Stephanie Heon (Hematology–Oncology): A 63-year-old woman was seen in the Cancer Center at this hospital for management of adenocarcinoma of the gastroesophageal junction. The patient had been well until approximately 2 months before this evaluation, when chest and epigastric discomfort developed after she ate solid foods, lasting from minutes to an hour. She had no difficulty swallowing liquids. Eighteen days before this evaluation, radiographs of the upper gastrointestinal tract, obtained at another hospital, showed severe erosive changes in the distal esophagus, an eccentric filling defect in the anterolateral portion of the esophagus, and minimal gastroesophageal reflux. Three days later, upper gastrointestinal endoscopy showed a mass in the distal esophagus, 32 cm from the incisors, that extended to the gastroesophageal junction. Pathological examination of a biopsy specimen showed moderately to poorly differentiated adenocarcinoma infiltrating glandular mucosa and lying beneath squamous mucosa, focal intestinal metaplasia in the glandular mucosa consistent with Barrett's esophagus, and changes in the squamous mucosa consistent with reflux esophagitis. Computed tomography (CT) of the chest, abdomen, and pelvis revealed an enlarged lymph node (1.0 cm in diameter) in the gastrohepatic ligament, mild thickening of the distal esophageal wall, cholelithiasis with no intrahepatic or extrahepatic biliary-duct dilatation, bilateral renal cysts, and diverticulosis. There were no pulmonary nodules or enlarged mediastinal lymph nodes. Positron-emission tomographic (PET) scans obtained after the administration of 18F-fluorodeoxyglucose (18F-FDG) showed an area of increased uptake in the distal esophagus and in the gastrohepatic ligament. She was referred to the Cancer Center at this hospital. The patient had had gastroesophageal reflux disease for 3 years. One year earlier, she had had an episode of difficulty swallowing, for which she went to the emergency department of another hospital; medication for anxiety was administered, and the symptoms resolved. She had lost 4.5 kg during the previous 6 months while dieting. She did not have melena, hematemesis, fevers, chills, night sweats, shortness of breath, fatigue, nausea, vomiting, abdominal pain, numbness, or weakness. She had hypertension, mild arthritis, and postpartum urinary incontinence. Previous surgical procedures included bunion surgery, tonsillectomy, and trigger-finger repair. She lived with her husband and worked at home; she was fully active (functional Eastern Cooperative Oncology Group [ECOG] performance status of 0). She drank alcoholic beverages rarely, had smoked cigarettes for 25 years but stopped 20 years earlier, and did not use illicit drugs. Her father died of encephalitis at 54 years of age; her mother died of a myocardial infarct in her 60s; and her brother died of lung cancer at 52 years of age. She had no known allergies. Medications included daily atenolol, pantoprazole, tolterodine tartrate, and a multivitamin, with lorazepam and acetaminophen as needed. On examination, she appeared anxious but well. The temperature was 37.2°C, the pulse 98 beats per minute, the blood pressure 140/80 mm Hg, the weight 82.1 kg, the height 155 cm, and the respiratory rate 18 breaths per minute. The abdomen was soft, with normal bowel sounds and no tenderness, rebound, or distention. The remainder of the examination was normal. Serum levels of CA 19-9, carcinoembryonic antigen, plasma iron, ferritin, and vitamin B12; iron-binding capacity; a complete blood count; levels of electrolytes, calcium, and albumin; and tests of coagulation and renal, hepatic, and thyroid function were normal. Laparoscopy revealed no evidence of intraabdominal metastases. Pathological and cytologic examination of tissue from peritoneal washings revealed no malignant tumor cells. Endoscopic ultrasonography showed a nonobstructing, hypoechoic mass in the distal esophagus (34 to 37 cm from the incisors) that extended to the muscularis propria and focally into the periesophageal fat (stage uT3, according to the tumor–node–metastasis [TNM] classification criteria). A hypoechoic lymph node, 2.1 cm in diameter, was seen in the gastrohepatic area. Fine-needle aspiration of the lymph node was performed. Pathological and cytologic examination showed adenocarcinoma.

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