A 65-year-old man comes to the office with dysphagia. For the last 3 months, he has relied on protein shakes and juices for nourishment as he has had difficulty swallowing solid foods. He has also had a diminished appetite and an estimated weight loss of 9.1 kg (20 lb). Medical history includes hyperlipidemia, emphysema, and previous episodes of pancreatitis. Family history includes lung cancer in his mother. The patient smoked a pack of cigarettes daily for 50 years but quit 2 years ago. He has been drinking a fifth (750 mL) of vodka weekly for the last decade. Vital signs are normal. BMI is 19.2 kg/m². Temporal wasting is present but physical examination is otherwise unremarkable. Upper endoscopy reveals a 4-cm mass in the middle third of the esophagus, and several biopsies are taken. Thoracic imaging reveals mediastinal lymphadenopathy. Histologic evaluation of the biopsy specimens will most likely show which of the following in this patient?

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11ec160b_3942_e855_9249_b34f73e8ab76_MD0001_00 This patient with a mid-esophageal mass and mediastinal lymphadenopathy likely has squamous cell carcinoma (SCC) of the esophagus. SCC is characterized by sheets or nests of atypical squamous cells with abundant eosinophilic cytoplasm and may show large, bizarre nuclei with atypical mitoses; keratin formation (keratin pearls) and intercellular bridges are common. Malignant cells are often seen invading the submucosa and surrounding structures. The esophagus can be subdivided (based on anatomy and embryonic formation) into thirds; malignancies occur at different frequencies within each segment. Proximal and middle third: SCC is more common, and occurs at the highest frequency in the middle third. Lymphatics drain to mediastinal nodes; metastatic disease may present with mediastinal lymphadenopathy. Distal third: Adenocarcinoma is more common. Lymphatics drain caudally to the gastric and celiac nodes; metastatic disease may present with abdominal lymphadenopathy. Adenocarcinoma is characterized by invasive patches of dysplastic, mucin-producing cells that form glands. It typically occurs as a consequence of chronic gastroesophageal reflux disease and is preceded by Barrett esophagus (replacement of the normal esophagus with nondysplastic columnar intestinal cells) (Choices A and B). (Choices D and E) Leiomyosarcoma demonstrates myocyte atypia on histology. Gastrointestinal stromal tumors are often composed of uniform spindle cells that overexpress CD117. These malignancies occur more commonly in the stomach and small intestine and are rare in the esophagus. Educational objective: Esophageal squamous cell carcinoma presents mostly in the proximal two-thirds of the esophagus and frequently metastasizes to the mediastinal lymph nodes. Histology characteristically shows sheets of atypical squamous cells with keratin pearls and intercellular bridges.

A 65-Year-Old Man Comes to the Office with Dysphagia