Successful triple therapy for advanced synchronous multiple primary esophageal carcinoma with metal stenting, photodynamic and comprehensive systemic therapies-shining light on hope: a case report and literature review

Abstract

Synchronous multiple primary esophageal cancer (SMPEC) is a rare and aggressive condition often accompanied by obstructive dysphagia, significantly impacting patients' quality of life. Current treatments, including chemotherapy, radiotherapy, immunotherapy, and targeted therapy, are limited in providing immediate symptom relief. This case report describes a 64-year-old female with SMPEC and metastases to thoracic lymph nodes, the lesser curvature of the stomach, and the right adrenal gland, presenting with severe dysphagia (score 4 on the Japanese Dysphagia Severity Scale). To rapidly alleviate symptoms, she underwent simultaneous metal stent implantation and photodynamic therapy (PDT). She started a liquid diet on the second day after treatment and resumed a normal diet one week later. Subsequently, she underwent systemic chemotherapy, targeted therapy, and immunotherapy. By the third treatment cycle, primary and metastatic lesions significantly decreased, achieving a partial response (PR) with stable disease and progression-free survival (PFS) exceeded 12 months. This triple therapy approach-combining stent implantation, PDT, and systemic treatments-proved effective and safe for advanced SMPEC, not only providing immediate dysphagia relief and selective tumor destruction but also delaying disease progression and improving patient outcomes.

Keywords: chemotherapy; immunotherapy; metal stent implantation; photodynamic therapy; synchronous multiple primary esophageal cancer; targeted therapy.

Figure 1

Gastroscopy images, Contrast-enhanced CT images and HE staining images at initial diagnosis. (A) Lesion in the upper segment of the esophagus and metastatic lymph nodes. (B) Lesion in the middle segment of the esophagus. (C) Lesion in the lower segment of the esophagus. (D) Metastatic lesion in the right adrenal gland. (E) Metastatic lesion on the lesser curvature side of the stomach.(F) Endoscopic findings revealed the first lesion located approximately 17-19 centimeters from the incisors. (G) Endoscopic findings revealed the second lesion located approximately 26-32 cm from the incisors. (H) Endoscopic findings revealed the third lesion located approximately 34-37 cm from the incisors. (I, J) Represent the HE staining results at 10x and 20x magnification, respectively.

Figure 2

Endoscopic images, contrast-enhanced CT images and critical laboratory parameters before and after treatment. (A) Middle esophageal lesion prior to treatment. (B) Metal stent implantation and the first PDT to relieve obstruction at the middle segment lesion, intraoperative X-ray shows the stent is elongated in the middle, indicating that the stent is in place. (C–E) The second, third, and fourth PDT for the middle segment lesion of the esophageal cancer, respectively, and the mucosal tissue of the tumor gradually turns white and necrotic. (F–J) After one week, two months, five months, nine months and twelve months of treatment, lesion mucosa appeared white, necrotic, and detached, while partial esophageal mucosal roughness is observed. Post-treatment, the lumen remains patent. (K, L) Contrast-enhanced computed tomography demonstrated significant reduction in the size of the primary esophageal lesion and metastatic lesions after treatment. P1-P3 represent the primary lesions in the upper, middle, and lower segments of the esophagus, respectively. M1 indicates the metastatic lesion on the lesser curvature side of the stomach, and M2 indicates the metastatic lesion in the right adrenal gland. C3-C9 represent the re-examination every two cycles. MLN indicates the metastatic lymph nodes. (M–O) The changes in WBC, Hb, and PLT in the complete blood count during each treatment cycle. (P–R) The changes in ALT, AST, and ALB during each treatment cycle.

Figure 3

Overview of the patient’s treatment course reported in this study and brief mechanism of anti-tumor. (A) The treatment course. (B) Metal stents rapidly alleviate obstruction, PDT can exert local tumor-killing effects while generating “abscopal effects” and enhancing the therapeutic efficacy of systemic treatment.