S4217 A Man With Intractable Back Pain: A Rare Presentation of Metastatic Esophageal Squamous Cell Carcinoma

Introduction: Esophageal cancer is relatively rare and comprises 1.1% of all new cancer cases in the US population. Esophageal squamous cell carcinoma incidence has declined in the US over the past 20 years while esophageal adenocarcinoma has increased. The 5-year survival for all stages of esophageal cancer combined is around 20%. Esophageal squamous cell carcinoma frequently presents at an advanced stage with the most common metastatic sites being lung, liver, and distant lymph nodes. Bone metastasis is rare but has been identified. Our case report highlights an unusual presentation of sacral metastasis from esophageal squamous cell carcinoma and discusses the management and clinical implications. Case Description/Methods: We present an 82-year-old man with past medical history of gastroesophageal reflux who presented to emergency with long-standing, progressive back pain over the past few months that radiated to the right hip and leg. Patient was admitted for intractable pain and computed tomography L-spine revealed a new finding of 5.3 × 5.1 cm destructive lytic right sacral mass. Patient then underwent IR-guided biopsy of sacral mass which was consistent with squamous cell carcinoma. To further ascertain primary source of squamous cell carcinoma, computed tomography abdomen pelvis was ordered and showed circumferential thickening of distal esophagus with regional adenopathy. Upon further questioning, patient reported a long-standing history of dysphagia to solids and nausea. Upper endoscopy showed a partial obstructing, partially circumferential mass in mid esophagus with stigmata of bleeding with biopsies consistent with squamous cell carcinoma. Patient was seen by oncology and started on 8 rounds of palliative radiation and remained hospitalized through due to intractable pain. Patient opted to transition to comfort care after 8th cycle of radiation and was discharged home with hospice. Discussion: Sacral metastasis from esophageal squamous cell carcinoma, while rare, is a recognized metastatic site of esophageal cancer. Esophageal cancer should be considered as part of the differential for primary site of sacral metastasis when diagnosis is unclear as long-standing gastrointestinal symptoms may be underreported as seen with our patient. Diagnosis is made by endoscopy and confirmed histologically, and management is on a case-by-case basis, but is generally palliative with a focus on systemic therapy and symptom control.