S4268 Vocal Cord Paralysis as an Initial Presentation of Metastatic Esophageal Adenocarcinoma

Introduction: Esophageal cancer is a relatively uncommon malignancy, although it carries a high mortality rate and is the eight leading cause of cancer worldwide. The overall 5-year survival rate is approximately 20%. Vocal cord paralysis is a rare complication of esophageal cancer, observed in up to 5% of cases, and can manifest with symptoms such as dyspnea, cough, hoarseness, and dysphonia. We present a unique case of esophageal cancer initially detected due to a patient’s complaint of persistent voice changes. Case Description/Methods: A 63-year-old man with a medical history of hypertension and gastroesophageal reflux disease presented with persistent hoarseness and chest pain following a recent upper respiratory tract infection. The patient was evaluated by otolaryngology which promoted further imaging with a computed tomography scan of the chest. Imaging revealed bilateral pulmonary nodules, esophageal wall thickening, and significant central lymphadenopathy. These results were concerning for metastatic disease. Subsequently, a biopsy of the left cervical lymph node revealed metastatic adenocarcinoma, with immunohistochemical staining positive for CK7 and AE1/AE3. A follow-up esophagogastroduodenoscopy revealed a circumferential, non-bleeding mass in the middle third of the esophagus, causing partial obstruction. A fully covered metallic stent was placed for alleviation of the obstruction. The patient was subsequently initiated on systemic chemotherapy with a combination of leucovorin, fluorouracil, and oxaliplatin (FOLFOX). Discussion: This case underscores the importance of maintaining a broad differential diagnosis when evaluating patients with atypical symptoms such as dyspnea, cough, and dysphonia. Although a rare initial manifestation, vocal cord paralysis can be the initial presenting symptom of esophageal cancer. This may occur due to direct tumor extension or recurrent laryngeal nerve involvement from mediastinal lymphadenopathy. Maintaining a high index of suspicion and early recognition is essential to prompt management.