esophageal cancer is the fifth leading cause of death in men from cancer worldwide . in 2009 in canada , there were 1,600 estimated new cases of esophageal cancer , representing less than 1% of the 2008 anticipated incidence of cancer . men were more affected with 1,200 estimated new cases . the median age at diagnosis is 68 years . there are two majors types of esophageal cancer : esophageal squamous cell cancer ( escc ) and esophageal adenocarcinoma ( eac ) . tobacco use and previous radiotherapy for breast cancer are major know risk factors for both eac and escc . escc risk is also increased with alcohol consumption , caustic injury to the esophagus , achalasia , tylosis ( nonepidermolytic palmoplantar keratoderma ) , plummer - vinson syndrome and a history of head and neck cancer . the known risk factors for eac are chronic gastroesophageal reflux disease and barrett 's esophagus . the initial investigation includes an upper endoscopy or a barium - swallow exam . to exclude metastasis , a computed tomography ( ct ) scan of the chest the stages of esophageal cancer are defined according to the american joint committee on cancer staging system . treatment is based on this staging and includes endoscopic mucosal resection , surgery , radiotherapy and chemotherapy . a 53-year - old caucasian man sought medical attention for a 4-week history of upper abdominal pain . he had no medical history besides chronic drinking for 35 years and active smoking of 25 packs per year . he denied having dysphagia or odynophagia . over a period of 3 months , he developed anorexia with an aversion to food , drinking only liquids . he lost 40 pounds , which represented 21% of his total weight . on physical examination , abdominal examination revealed present bowel sounds and an epigastric mass that was firm , fixed and non - pulsatile . u / l ( normal 0100 u / l ) and lipase 201 u / l ( normal 060 u / l ) . tumor markers were within normal ranges , including carcinogenic embryonic antigen and carbohydrate antigen 19 - 9 . a ct scan revealed a heterogeneous lesion with necrotic tissue localized beneath the pancreatic gland , at the mesenteric root ( fig . the mass was pushing the pancreas forward and was invading vascular structures of the celiac trunk and the superior mesenteric artery . the rest of the ct was within normal limits , including the renal and urinary systems . it was impossible for the radiologists to determine the exact origin of this tumor on imaging . considering the retropancreatic localization of the mass , an upper endoscopic ultrasound ( eus ) was performed to obtain tissue samples for histology . it demonstrated extrinsic compression of the stomach along the lesser curvature by this heterogeneous mass , which measured more than 6 cm ( fig . it was invading the celiac trunk and the superior mesenteric artery , as described on the ct . biopsies were performed by eus - guided transgastric fine - needle aspiration ( 19-gauge echotip ultra - endoscopic ultrasound needle , wilson - cook medical inc . the specimen was analyzed by a gastrointestinal specialized pathologist and was in keeping with the diagnosis of escc . the histology was confirmed by an immunohistochemical study with cd117 , cd34 , cd45 , be 12 , ker7 , ker20 , ker8 - 18 and 34 markers . with these findings , an upper gastrointestinal endoscopy was performed . it revealed a non - ulcerated suspicious lesion at the mid third of the esophagus , without stenosis ( fig . the diagnosis of infiltrative and moderately differentiated squamous cell carcinoma was confirmed by histology , special colorations ( mowried and mucicarmin ) and immunohistochemical markers ( p63 , ck56 ) . first , the median age at diagnosis is 68 years with only 12% of patients between 45 and 54 years of age . second , he did not have dysphagia or odynophagia , which are the most common symptoms of esophageal cancer according to the literature . his main symptom was abdominal pain that was also associated with postprandial abdominal fullness and vomiting . these were most likely due to extrinsic compression of the stomach by the abdominal mass . when pain is present in escc , it is usually thoracic or radiating to the back , but can occur less often in the upper abdomen . when patients with esophageal cancer seek medical assistance , the majority experience anorexia and weight loss . the retropancreatic mass is also an uncommon site of metastasis in esophageal cancer . with the rich esophageal lymphovascular supply , , the abdominal mass was not described as an adenopathy , but rather as a mass with heterogeneous necrotic tissue of unascertained origin . an initial presentation of escc with an abdominal mass has not been reported , although there are few reports in the literature presenting some unusual metastatic presentations of escc , such as brain , myocardium , skin , jejunum , orbit , spleen , thyroid , sister mary joseph 's nodule or numb chin syndrome [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 ] . to establish the correct diagnosis of any abdominal mass , histology is indispensable in our opinion , especially if the patient does not present specific symptoms . tissue sampling may be obtained by linear eus   or by percutaneous needle biopsy under fluoroscopic , sonographic or ct guidance . eus provides both tissue sampling and an accurate evaluation of mass relationship with adjacent abdominal structures . since another important issue is that the esophageal lesion had not been identified at eus . in our hospital , this procedure uses the linear scanning method that provides a limited wedge - shaped scanning plane . therefore , it is possible to miss lesions if they are not in the scanning plane . hence , a gastroscopy was essential in the diagnosis of our patient 's esophageal cancer , since it provides a proper evaluation of the esophagus . our patient was diagnosed with a stage iv escc , according to the american joint committee on cancer staging system , rending surgery impossible . the best treatment for our patient would have been concomitant radio - chemotherapy , which improves 5-year survival in 25% of patients , whereas no patients survived 5 years using radiotherapy alone . our patient refused chemotherapy because of the possible side effects , but he accepted palliative radiotherapy to alleviate his abdominal pain . to our knowledge , this is the first reported case of escc presenting as a large abdominal mass that was not an adenopathy . this case highlights that when a malignancy is suspected , it is important to establish a cytohistologic diagnosis . this can be safely achieved by eus that will also evaluate extension of an upper abdominal mass . however , this technique does not replace gastroscopy to accurately identify esophageal cancer .
esophageal cancer most commonly presents with upper digestive symptoms such as dysphagia . 
 lymph nodes are among the most common metastatic sites of this type of cancer . 
 we report the case of a 53-year - old man presenting with unusual sole presenting features of esophageal cancer . 
 the patient sought medical attention for abdominal pain without dysphagia , which was first investigated with an abdominal computed tomography scan . 
 a large abdominal mass was discovered on imaging . 
 biopsies of this mass were in keeping with esophageal squamous cell cancer . with this finding 
 , gastroscopy was performed , confirming the presence of primary esophageal cancer . 
 this is a rare presentation of esophageal cancer without upper gastrointestinal symptoms . 
 this case reinforces the value of biopsy for any neoplastic mass , especially in a context of unusual symptoms .