Lower Extremity Pain and Swelling as an Unusual Presentation of Metastatic Esophageal Adenocarcinoma

Introduction: The incidence of adenocarcinoma of the esophagus has increased dramatically in the past three decades. Esophageal cancer is the eighth most common cancer and sixth leading cause of cancer death. Squamous cell cancer is the most common type of esophageal cancer all over the world, but the incidence of esophageal adenocarcinoma has been increasing. Most, if not all, esophageal adenocarcinomas arise from a region of Barrett\u27s metaplasia. The most common location is near the EG junction with an association of endoscopic evidence of Barrett\u27s esophagus. We present a case of young male presented with lower extremity pain and swelling due to metastasis of undiagnosed primary esophageal cancer. Case Presentation: A 36-year-old male with no significant medical history presented with complaints of lower extremity pain and swelling. Patient denied any other symptoms. On admission, vital signs were temp. 97.8, BP 145/87 mmhg, HR 75 bpm, RR was 18. Labs work showed Na 141, K 3.7, BUN 17, Cr 0.70, Alkaline phosphatase 263, AST 14, ALT 9, CHOL 202, HDL 27, Triglyc 285, Hgb 12.4, Plt 244, Wbc 9.6, ESR 28, TSH 7.07, Vit D (25 hydroxy) 8, Hgb A1c 7.0, CRP 102.6. Knee x-ray was highly suspicious for chronic osteomyelitis vs. neoplastic lesion. Doppler US of lower extremity ruled out DVT, but showed large complex fluid collection anterior to the knee and proximal leg measuring 8.0 x 5.8 x 18.6 cm with concern for osteomyelitis with overlying abscess vs an aggressive primary bone tumor. Patient was started on antibiotics and had a MRI that showed periostitis with possible differential of osteomyelitis/periostitis and osteosarcoma. CT scan of chest, abdomen and pelvis showed aortocaval and left iliac lymphadenopathy concerning for metastasis. Blood cultures were negative but biopsy was consistent with metastatic adenocarcinoma favoring gastrointestinal and pancreaticobiliary tract as the primary source. Patient had an upper endoscopy that showed esophageal mass extended from the GE junction up about 7cm. Chemotherapy and radiation therapy were initiated. HER-2 gene was ordered. Patient developed cardiopulmonary arrest and died prior to discharge. Discussion: Adenocarcinoma of the esophagus is usually associated with Barrett\u27s esophagus that involves the lower third of esophagus. It is a very aggressive disease associated with diffuse metastasis and high mortality rate. The most common metastatic sites for esophageal cancer are liver brain and lung. Risk factors associated with cancer are smoking, higher body mass index, gastroesophageal reflux disease, and a diet low in fruits and vegetables. Almost half of the cases of adenocarcinoma have no associated reflux disease. The median survival rate of metastatic esophageal cancer is 4-9 months. Physicians should always think of visceral malignancy in cases of biopsy proven adenocarcinoma for better prognosis. Endoscopy should always be done to look for visceral malignancy if cancer is suspected