Diffusely infiltrative squamous cell carcinoma of the esophagus resembling scirrhous gastric cancer: a case report

Abstract

Diffusely infiltrative squamous cell carcinoma of the esophagus is rare and difficult to diagnose.

Case presentation: The patient was a 75-year-old woman whose chief complaints were dysphagia and upper abdominal pain. Esophagogastroduodenoscopy and biopsy revealed squamous cell carcinoma at the abdominal esophagus. After neoadjuvant chemotherapy, esophagogastroduodenoscopy showed diffuse thickening and poor distensibility of the stomach wall. We suspected scirrhous gastric cancer and performed multiple biopsies, which revealed no evidence of malignancy. We then performed staging laparoscopy. There were no apparent changes in the serous membrane of the stomach, but peritoneal lavage cytology revealed squamous cell carcinoma. Thus, we made a diagnosis of squamous cell carcinoma of the esophagus with diffuse invasion of the stomach. Intraoperative pathological diagnosis revealed that there was greater diffuse submucosal invasion of the oral esophagus than we expected, and we had to resect the esophagus at the level of the middle thoracic esophagus. Despite multidisciplinary treatment (surgery, chemotherapy, and radiotherapy), the patient died 20 months after the initial diagnosis.

Clinical discussion: In this case, although biopsy did not lead to a diagnosis, peritoneal lavage cytology led to the correct diagnosis. Moreover, it was impossible to preoperatively predict the exact extent of the expansion because of diffuse submucosal invasion.

Conclusion: When diffusely infiltrative squamous cell carcinoma of the esophagus is suspected, peritoneal lavage cytology may be useful for confirming the diagnosis; however, it should be assumed that accurate preoperative evaluation of the range of diffusely infiltrative squamous cell carcinoma is difficult.

Keywords: case report; diffusely infiltrative squamous cell carcinoma; esophagus; peritoneal lavage cytology; scirrhous gastric cancer.

Figure 1

(A) Esophagogastroduodenoscopy before neoadjuvant chemotherapy. (A1) Irregular ulcer at the abdominal esophagus. The biopsy revealed squamous cell carcinoma. (A2, A3) Mild chronic gastritis in the stomach. (B) Esophagogastroduodenoscopy after neoadjuvant chemotherapy. (B1) Partial response of the primary lesion. (B2, B3) Diffuse thickening and poor distensibility of the stomach wall. Multiple biopsies, including boring biopsy, revealed no evidence of malignancy.

Figure 2

(A) Enhanced computed tomography showed diffuse enhancement of the stomach wall after neoadjuvant chemotherapy. (B) Positron emission tomography showed extensive uptake in the stomach [maximum standardized uptake value (SUVmax)=4.79] after neoadjuvant chemotherapy. (C) In staging laparoscopy, there were no apparent changes in the serous membrane of the stomach, but peritoneal lavage cytology revealed squamous cell carcinoma.

Figure 3

Pathological findings. (A) The tumor was 115×85 mm. Areas of importance are indicated as follows: primary lesion (Ο); range of the tumor (⇔); and the surgical margin (→), which was positive twice. (b) Squamous cell carcinoma showed diffuse submucosal invasion in the stomach (→) and (C), while the mucosa of the stomach was almost normal (D). Scale bars: 500 μm in (B) and 250 μm in (C) and (D) (hematoxylin and eosin).