S4416 Advanced Esophageal Adenocarcinoma Presenting as Dysphagia in a Middle-Aged Man

Introduction: Esophageal adenocarcinomas at the gastroesophageal junction are increasingly prevalent, particularly among patients with chronic gastroesophageal reflux disease, obesity, and metabolic syndrome. Despite surveillance protocols, early disease may elude detection due to its submucosal origin or nonspecific presentation. Timely recognition is essential to impact outcomes in this aggressive cancer subtype. Case Description/Methods: A 54-year-old man with diabetes, obesity, hyperlipidemia, and prior cholecystectomy presented with months of reflux and epigastric discomfort. An outpatient esophagogastroduodenoscopy in December 2024 showed no abnormalities and no malignancy on biopsy. Three months later, he returned with progressive dysphagia. Repeat esophagogastroduodenoscopy revealed a stenotic distal esophagus and a friable, fungating mass extending to the cardia. Biopsies confirmed poorly differentiated adenocarcinoma with lymphatic invasion. Nutritional support via jejunostomy was attempted but was complicated by functional obstruction and severe abdominal pain, requiring surgical revision and decompressive gastrostomy placement. The patient’s clinical status rapidly declined; he developed jaundice, bilateral pleural effusions, and worsening hypoxia. Cytology from thoracentesis confirmed metastatic adenocarcinoma. Contrast enhanced computed tomography imaging demonstrated a new 1.6 cm hepatic lesion and an enlarged pancreatic lymph node measuring 2.6 cm. He expired in April, before he was able to start treatment, less than 4 months after initial negative endoscopy. Discussion: This case illustrates an extraordinarily aggressive progression of esophageal adenocarcinoma, transitioning from normal endoscopy to widespread metastatic disease in under 120 days. Rapid evolution of symptoms despite negative early workup suggests potential sampling limitations or early subepithelial tumor infiltration. Poorly differentiated tumors are associated with early dissemination and limited response to intervention. This case emphasizes the importance of high clinical suspicion, particularly in patients with multiple risk factors and evolving symptoms. Prompt reassessment and multidisciplinary involvement may offer the best chance for early diagnosis and therapeutic intervention in such aggressive cases.