A 63-year-old man comes to the office due to several months of dysphagia, fatigue, occasional chest discomfort, and indigestion. He has a history of hypertension and takes amlodipine. The patient smokes 1 or 2 cigars daily. His blood pressure is 140/80 mm Hg. Physical examination is normal. An endoscopic evaluation with esophageal biopsy is performed. The histopathology of the specimen is shown in the image below. Which of the following is the most likely cause of this patient's dysphagia?

Question

A 63-year-old man comes to the office due to several months of dysphagia, fatigue, occasional chest discomfort, and indigestion.  He has a history of hypertension and takes amlodipine.  The patient smokes 1 or 2 cigars daily.  His blood pressure is 140/80 mm Hg.  Physical examination is normal.  An endoscopic evaluation with esophageal biopsy is performed.  The histopathology of the specimen is shown in the image below.  Which of the following is the most likely cause of this patient's dysphagia?

Quizplus · Accepted Answer

11ec160b_3942_7324_9249_478b42b4d41a_MD0001_00 This patient's biopsy is consistent with esophageal squamous cell carcinoma (SCC). The histopathologic features of this condition include solid nests of neoplastic squamous cells with abundant eosinophilic cytoplasm and distinct borders (compared to normal esophagus). Areas of keratinization are identified (keratin pearls). The presence of intercellular bridges is also characteristic of squamous differentiation. Most cases of esophageal SCC occur in men age >50 with a history of prolonged smoking and alcohol use. Patients typically present with solid food dysphagia as the tumor gradually obstructs the esophageal lumen, which can progress to liquid dysphagia. Retrosternal discomfort/burning and significant weight loss are also common. Chronic gastrointestinal blood loss may result in iron deficiency anemia with fatigue. The prognosis for esophageal cancer is generally poor as many patients present with incurable locally advanced or metastatic disease. (Choice A) Benign tumors of the esophagus (most commonly leiomyomas) are rare and slow growing. On light microscopy, leiomyomas consist of fascicles of spindle cells with variable amounts of fibrosis. (Choices C and E) Reflux esophagitis commonly occurs due to gastroesophageal reflux disease and is characterized histologically by elongation of the papillae, basal cell hyperplasia, and intraepithelial eosinophils. Repeated epithelial injury caused by reflux esophagitis may lead to Barrett esophagus, which is characterized by intestinal metaplasia with goblet cells. Barrett esophagus is a premalignant condition that significantly increases the risk of esophageal adenocarcinoma. (Choice D) Achalasia is an esophageal motility disorder characterized by failed relaxation of the lower esophageal sphincter resulting in food retention, dilation of the esophageal body, and symptoms of solid/liquid dysphagia. Achalasia increases the risk of squamous cell carcinoma of the esophagus. Educational objective: The histopathologic features of esophageal squamous cell carcinoma include solid nests of neoplastic squamous cells with abundant eosinophilic cytoplasm and distinct borders. Areas of keratinization and the presence of intercellular bridges are also characteristic. Patients typically present with progressive solid and eventually liquid dysphagia and weight loss.

A 63-Year-Old Man Comes to the Office Due to Several