PMC7196963_01
Dynamic endoscopic changes of esophageal mucosa seen on serial endoscopies. (a) From April 2016 demonstrates scattered moderate and severe mucosal changes with white plaques, congestion, erythema, and friability throughout the entire esophagus. Pathology demonstrated squamous mucosa with acute inflammation and Candida esophagitis. (b) From June 2016 noted keratinization in the upper and middle thirds of the esophagus and diffuse inflammation with congestion, erythema, friability, and plaques in the middle and lower thirds of the esophagus. Pathology in both areas showed squamous mucosa with focal erosion with bacterial colonies. (c) From September 2016 noting diffuse severe mucosal changes with congestion, friability, inflammation, fungation, and altered texture in the lower third of esophagus from 30 cm to 40 cm. Pathology from endoscopic mucosal resection was suspicious but not diagnostic of esophageal carcinoma cuniculatum as described in the text.
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She had 3 prior upper endoscopies over the previous 4 years and the dynamic changes are shown (Figures 1(a)-1(c)). She underwent endoscopy and had diffused severe mucosal changes with congestion, friability, inflammation, fungation, and altered texture in the lower third of the esophagus from 30 to 40 cm (Figure 1(c)).
Findings pretreatment. (a) Shows endoscopic views of large, friable, exophytic, and ulcerating mass covered with white exudates in the lower third of the esophagus, gastroesophageal junction, and cardia. (b) Shows pathologic features including (1) a hollow "burrow" with a deep pushing pattern (200x) (2) cyst-like squamous nest filled with keratin and acute inflammatory cells (200x) and (3) keratin pearl in a nest of invasive squamous epithelium. (c) PET/CT shows a large mass in the distal esophagus and proximal stomach without evidence of surrounding adenopathy with mild dilation and likely partial disruption of the distal esophagus.
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Repeat endoscopy one month later redemonstrated the mass, and endoscopic mucosal resection demonstrated invasive carcinoma with focal "burrowing channels" characteristic of carcinoma cuniculatum (Figures 2(a)-2(b)). The mass measured 8.2 x 5.1 x 0.8 cm on PET/CT, and there was no hypermetabolic adenopathy or distant disease (Figure 2(c)).
Cone-beam CT (CBCT) changes during treatment. Red outline represents gross tumor volume (GTV). (a) Diagnostic scan pretreatment and CBCT from day 1. (b) CBCT showing treatment changes from weeks 1-3, left to right. Treatment response noted as early as week 2. (c) CBCT for weeks 3-6 after the patient was resimulated for new volumes given marked treatment response. (d) Boost volume based on residual PET-activity.
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Cone-beam CT (CBCT) changes throughout treatment are shown demonstrating this rapid response (Figure 3).
Findings during treatment. (a) PET/CT minimal residual mass with minimal distal esophageal and proximal stomach thickening. (b) Demonstrates postradiation mucosal changes without obvious residual mass and biopsies were negative for residual disease.
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PET/CT and endoscopy was performed to assess disease status for surgical evaluation (Figure 4). PET/CT noted an excellent response to treatment with minimal residual mass.
Findings posttreatment. (a) PET/CT noting persistent hypermetabolism and wall thickening in the distal esophagus. (b) Endoscopic finding of severe stenosis in the distal esophagus. (c) H&E stains demonstrating an invasive squamous cell carcinoma (200x and 400x, respectively). This is a higher grade than seen on initial biopsy and may represent a hybrid verrucous carcinoma. There is evidence of radiation treatment effect in the invasive nests.
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At 3 months posttreatment, PET/CT noted persistent hypermetabolism and wall thickening in the distal esophagus (Figure 5(a)). She had persistent dysphagia and underwent endoscopy that noted an area of nontraversable stenosis in the lower third of the esophagus (Figure 5(b)). Biopsy at this site was consistent with invasive squamous cell carcinoma (Figure 5(c)).