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Bone lesions simulating multiple myeloma: Unusual presentation of esophageal cancer
European Journal of Internal Medicine 20 (2009) e14 www.elsevier.com/locate/ejim
Letter to the Editor Bone lesions simulating multiple myeloma: Unusual presentation of esophageal cancer
Keywords: Bone lesions; Multiple myeloma; Esophageal cancer
To the Editor, A 59 year-old Caucasian and smoker man with past history of chronic bronchitis, was admitted to the hospital because of abrupt onset cervical pain, leading to limit neck active mobilisation, with no other remarkable findings on physical examination. Neck X-ray showed third cervical vertebra fracture in the setting of osteolytic lesion. Magnetic resonance imaging did not show spinal cord compression. Other bone osteolytic lesions were found in dorso-lumbar vertebrae, left humerus, ribs and right femoral neck. A bone scan showed multiple osteoblastic lesions. Serum electrophoresis did not reveal monoclonal peak, Bence Jones protein in urine was negative and no significant percentage of plasma cells appeared in bone marrow. Therefore, multiple myeloma was excluded fairly. Osteolytic metastases from melanoma, renal, gastric, colorectal hepatocellular, thyroid and oat-cell carcinoma, were kept in mind. All of them could be ruled out respectively because of no visible skin lesions, negative urine cytology, no iron-deficiency anemia, dysphagia, dyspepsia or bowel function disorders, normal serum CEA, alpha-fetoprotein and thyroglobulin, as well as absence of findings in CT scan. On the other hand, osteoblastic metastases could appear from prostate and pancreas, but serum PSA and CA 19.9 were normal and no findings were seen in CT scan. No fever was detected, intervertebral disc was no damaged and tuberculin skin testing was non-reactive. Therefore, bone infectious diseases were not considered. A pathological review of bone marrow biopsy led to show it infiltrated by malignant cells consistent with adenocarcinoma. Despite the patient had no dysphagia, a gastroscopy was performed. A nonstenosing and ulcerating lesion in the middle and lower third of the esophagus disclosed an adenocarcinoma. Four weeks later, patient died because of respiratory failure due to chronic bronchitis exacerbation.
Esophageal adenocarcinoma arises in the presence of gastric metaplasia (Barrett's esophagus) in the distal esophagus. A deep infiltration can appear without swallowing disturbances, spreading to adjacent lymph nodes, liver, lungs and pleura. Cases of isolated bone metastases due to esophageal cancer have been reported [1,2]. In the same way, other malignancies can mimic multiple myeloma, like hepatocellular carcinoma. To our knowledge, this is the first case report about osteoblastic and osteolytic lesions, in the setting of wide-spread bone metastases from esophageal adenocarcinoma, simulating multiple myeloma. Management focuses on symptom control, since chemotherapy and radiation therapy have not improved survival. References [1] Singh HK, Silverman JF, Balance WA, et al. Unusual small bone metastases from epithelial malignancies: diagnosis by fine-needle aspiration cytology with histologic confirmation. Diagn Cytopathol 1995;13(3):192–5. [2] Sánchez-Jiménez J, Acebal-Blanco F, Arévalo-Arévalo RE, et al. Metastasic tumours in upper maxillary bone of esophageal adenocarcinoma. A case report. Med Oral Patol Oral Cir Bucal 2005;10(3):252–7.
Hortensia Álvarez Díaz Department of Internal Medicine, Hospital Arquitecto Marcide-Profesor Novoa Santos, Ferrol, A Coruña, Spain Corresponding author. E-mail address: [email protected]. Mar Used Aznar Department of Pathology, Hospital Arquitecto Marcide-Profesor Novoa Santos, Ferrol, A Coruña, Spain Francisco Javier Afonso Afonso Department of Oncology, Hospital Arquitecto Marcide-Profesor Novoa Santos, Ferrol, A Coruña, Spain
0953-6205/$ - see front matter © 2008 European Federation of Internal Medicine. Published by Elsevier B.V. doi:10.1016/j.ejim.2008.07.010
22 February 2008
Letter to the Editor Bone lesions simulating multiple myeloma: Unusual presentation of esophageal cancer
Keywords: Bone lesions; Multiple myeloma; Esophageal cancer
To the Editor, A 59 year-old Caucasian and smoker man with past history of chronic bronchitis, was admitted to the hospital because of abrupt onset cervical pain, leading to limit neck active mobilisation, with no other remarkable findings on physical examination. Neck X-ray showed third cervical vertebra fracture in the setting of osteolytic lesion. Magnetic resonance imaging did not show spinal cord compression. Other bone osteolytic lesions were found in dorso-lumbar vertebrae, left humerus, ribs and right femoral neck. A bone scan showed multiple osteoblastic lesions. Serum electrophoresis did not reveal monoclonal peak, Bence Jones protein in urine was negative and no significant percentage of plasma cells appeared in bone marrow. Therefore, multiple myeloma was excluded fairly. Osteolytic metastases from melanoma, renal, gastric, colorectal hepatocellular, thyroid and oat-cell carcinoma, were kept in mind. All of them could be ruled out respectively because of no visible skin lesions, negative urine cytology, no iron-deficiency anemia, dysphagia, dyspepsia or bowel function disorders, normal serum CEA, alpha-fetoprotein and thyroglobulin, as well as absence of findings in CT scan. On the other hand, osteoblastic metastases could appear from prostate and pancreas, but serum PSA and CA 19.9 were normal and no findings were seen in CT scan. No fever was detected, intervertebral disc was no damaged and tuberculin skin testing was non-reactive. Therefore, bone infectious diseases were not considered. A pathological review of bone marrow biopsy led to show it infiltrated by malignant cells consistent with adenocarcinoma. Despite the patient had no dysphagia, a gastroscopy was performed. A nonstenosing and ulcerating lesion in the middle and lower third of the esophagus disclosed an adenocarcinoma. Four weeks later, patient died because of respiratory failure due to chronic bronchitis exacerbation.
Esophageal adenocarcinoma arises in the presence of gastric metaplasia (Barrett's esophagus) in the distal esophagus. A deep infiltration can appear without swallowing disturbances, spreading to adjacent lymph nodes, liver, lungs and pleura. Cases of isolated bone metastases due to esophageal cancer have been reported [1,2]. In the same way, other malignancies can mimic multiple myeloma, like hepatocellular carcinoma. To our knowledge, this is the first case report about osteoblastic and osteolytic lesions, in the setting of wide-spread bone metastases from esophageal adenocarcinoma, simulating multiple myeloma. Management focuses on symptom control, since chemotherapy and radiation therapy have not improved survival. References [1] Singh HK, Silverman JF, Balance WA, et al. Unusual small bone metastases from epithelial malignancies: diagnosis by fine-needle aspiration cytology with histologic confirmation. Diagn Cytopathol 1995;13(3):192–5. [2] Sánchez-Jiménez J, Acebal-Blanco F, Arévalo-Arévalo RE, et al. Metastasic tumours in upper maxillary bone of esophageal adenocarcinoma. A case report. Med Oral Patol Oral Cir Bucal 2005;10(3):252–7.
Hortensia Álvarez Díaz Department of Internal Medicine, Hospital Arquitecto Marcide-Profesor Novoa Santos, Ferrol, A Coruña, Spain Corresponding author. E-mail address: [email protected]. Mar Used Aznar Department of Pathology, Hospital Arquitecto Marcide-Profesor Novoa Santos, Ferrol, A Coruña, Spain Francisco Javier Afonso Afonso Department of Oncology, Hospital Arquitecto Marcide-Profesor Novoa Santos, Ferrol, A Coruña, Spain
0953-6205/$ - see front matter © 2008 European Federation of Internal Medicine. Published by Elsevier B.V. doi:10.1016/j.ejim.2008.07.010
22 February 2008