Progressive Dysphagia and Weight Loss in an African American Woman

Over the past 6 months, a 76-year-old African American woman has had increasingdifficulty in swallowing solid food and has lost 40 lb. She can now tolerateonly liquids and foods with a pudding-like consistency. Ingestion of moresolid food produces the sensation that it is "sticking in her chest," and shesubsequently regurgitates it undigested. She denies heartburn, reflux, nausea,hematemesis, abdominal pain, and melena.HISTORYThe patient is taking amlodipine for hypertension. The results of a colonoscopy1 year earlier to investigate heme-positive stool were negative. She isa retired textile worker who had smoked heavily until 4 years ago and whoused alcohol in moderation when she was younger. She has lived in the innercity her entire life.PHYSICAL EXAMINATIONThis thin woman appears chronically ill. Blood pressure is 140/70 mm Hg.Temporal wasting is evident, and mucous membranes are slightly dry; scleraeare anicteric. Heart and lungs are normal. Abdomen is soft and nontender,without organomegaly; no abnormal masses. Stool is heme-negative. There isno clubbing or edema of the extremities.LABORATORY AND IMAGING RESULTSHemoglobin level is 9.8 g/dL, and albumin level is 2.7 g/dL. Electrolyteand liver enzyme levels are normal. Chest radiograph is consistent with chronicobstructive pulmonary disease but reveals no adenopathy or masses.What is the most appropriate next step to determine the cause of thispatient's dysphagia?A. Barium swallow.
B. Upper endoscopy.
C. CT scan of the thorax.
D. Urease breath testing for Helicobacter pylori and a 4-week trial of aproton pump inhibitor.
E. Measurement of carcinoembryonic antigen (CEA) and carbohydrateantigen (CA) 19-9.CORRECT ANSWER: B
The patient's progressive dysphagia and weight lossstrongly suggest malignancy, and her symptoms are relatedto the upper GI tract. Thus, upper endoscopy (choiceB) is the most useful test here. It permits both direct visualizationof the upper GI tract and tissue biopsy of anypathology encountered.A barium swallow (choice A) can reveal a mass orstricture but not more subtle lesions or mucosal abnormalities.Moreover, even if pathology is detected on a bariumswallow, endoscopy is still required for biopsy.CT (choice C) reveals anatomic information superiorto that provided by a barium swallow (and will be indicatedlater for stagingpurposes);however, it is notthe first-choiceinitial study because--as witha barium swallow--it has tobe followed byendoscopy fortissue biopsy ifthere are anypositive or suspiciousfindings.CEA andCA 19-9 (choiceE) are nonspecificmarkers that are used to follow the course of colon andpancreatic cancers, respectively--after diagnosis. Neitheris of any use in the diagnosis of suspected esophagealcancer.The patient has no history of heartburn or other reflux-related symptoms typical of peptic ulcer disease orBarrett esophagus. Moreover, her dysphagia and considerableweight loss are not typical of either entity. Thus,testing for and empiric treatment of suspected H pyloriinfection (choice D) are not the optimal strategy at thispoint.Esophageal cancer: epidemiology and risk factors.Esophageal cancer is the ninth most common malignancyin the world. However, its incidence varies widely amongregions. An "esophageal cancer belt" stretches fromnortheast China to the Middle East; however, in the UnitedStates, esophageal cancer accounts for only 1.5% of allmalignancies.¹In the United States, the epidemiology of squamouscell carcinoma (SCC) is quite different from that of adenocarcinoma(AC). AC is seen mainly in white men andis strongly linked to Barrett esophagus and chronic reflux.It has also been associated with cigarette smokingand obesity.SCC is most prevalent in urban areas, among AfricanAmericans, and among patients with lower socioeconomicstatus. In addition, tobacco and alcohol use arewell-known risk factors for SCC.¹ All of these risk factorsfor SCC are present here.Outcome of this case. Upper endoscopy revealed alarge circumferential mass in the mid esophagus that suggestedmalignancy. Biopsy revealed SCC of the esophagus.A staging CT scan of the chest, abdomen, and pelvisshowed a 9-mm mass that involved the esophageal wallbut did not extend into the adventitia. There was no evidenceof lymph node metastasis. The patient's tumor wasstaged as T2N0M0.Because of her age and other comorbidities, the patientrefused surgical consultation for resection. She receivedconcurrent chemotherapy (with 5-fluorouracil andcisplatin) and radiotherapy. Her course was complicatedby chemotherapy-related fatigue and anemia, which weretreated with growth factors. Four months after diagnosis,her condition has improved and she is able to eat solidfood.

References:

REFERENCE:

1.

Esophageal cancer. Clinical Practice Guidelines in Oncology.

Journal of theNational Comprehensive Cancer Network.

2003:1.

FOR MORE INFORMATION:

• Lerut T, Coosemans W, De Leyn P, et al. Treatment of esophageal carcinoma.Chest. 1991;116:463-479.

• Spechler SJ. Barrett’s esophagus. N Engl J Med. 2002;346:836-842.