S4326 A Real Pain in the Neck: A Rare Presentation of Esophageal Adenocarcinoma

Introduction: Esophageal adenocarcinoma (EA) is a relatively rare diagnosis in the United States. Typical symptoms of EA are dysphagia, chest pain, cough, and weight loss. While metastases to liver, lung and lymph nodes can often be the presenting symptoms, metastasis to the spinal column is exceedingly rare with only a few cases documented. Here, we report a case of metastatic cancer that was incidentally discovered during spinal decompression surgery that was due to an undiagnosed EA. Case Description/Methods: A 67-year-old man presented with chief complaint of chest pain and leg weakness. He was found to have pulmonary embolism with incidental osseous metastasis at the level of T3-T4. Follow up imaging demonstrated thoracic cord compression and he was taken for surgery where a fungating mass was found. Surgical pathology revealed a CK7+, CK20-, CDX2+ adenocarcinoma most consistent with upper gastrointestinal or pancreatobiliary primary. Prior to admission, he endorsed some early satiety but denied any other upper gastrointestinal symptoms including dysphagia, reflux, and/or melena. No other sites of metastases were noted. Esophagogastroduodenoscopy showed long segment Barrett’s esophagus in the middle and lower third of the esophagus along with severe mucosal changes characterized by erythema, friability, and nodularity, along with 1 non-bleeding gastric ulcer. Esophageal biopsy revealed Her2-, microsatellite stable, PDL1+ esophageal adenocarcinoma. Discussion: Metastasis from a primary EA is rare, and metastatic disease to the spine is even more rare. In this case and in 3 other reported cases, spinal metastasis is an indicator of poor prognosis. Typical presenting symptoms include dysphagia, early satiety, and odynophagia. Risk factors for development of EA can include long-standing reflux along with Barrett’s esophagus. In this case, the patient did not have complaints of dysphagia. Esophagogastroduodenoscopy can be beneficial for diagnosis of primary EA. If neurological symptoms develop and persist, magnetic resonance imaging with gadolinium should be included. This case highlights both the rarity of metastatic spinal EA and the need for a multidisciplinary approach as well as shared decision making with the patient. EA may present with distant metastases in the absence of classic gastrointestinal symptoms, underscoring the need for a broad differential when evaluating spinal lesions of unknown origin.