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When Occam's Razor Meets Hickam's Dictum
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Bilal Hameed, Uma Mahadevan, and Kay Washington, Section Editors
When Occam’s Razor Meets Hickam’s Dictum Rochelle E. Wong,1 Baldeep S. Pabla,2 and Anthony M. Gamboa2 1 Vanderbilt University School of Medicine, Nashville, Tennessee; 2Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
Question: A 59-year-old woman presented to our hospital with a 4-month history of progressive dysphagia. Her past medical history included a history of laryngeal squamous cell carcinoma for which she underwent radiation therapy in 2013 and cigarette smoking (40 pack-year history, recently quit 6 months ago). On physical examination, the patient’s neck was noted to have chronic radiation changes. A computed tomography scan of the neck demonstrated an 18 19 22-mm irregular enhancing mass-like lesion that seemed to arise from the anterior esophagus with abutment into the posterior wall of the trachea (Figure, A, B). Airway narrowing and upper mediastinal adenopathy was noted, as well as a new 11-mm spiculated nodule in the right upper lung lobe not seen on prior imaging. Endobronchial ultrasound examination was first pursued given concern for airway compromise and showed impending airway invasion by a mass along the posterior tracheal wall with transbronchial fine needle aspiration (FNA) of the mass, mediastinal lymph nodes, and the lung nodule notable for atypical squamous epithelium, negative lymph nodes, and nondiagnostic tissue from the lung nodule. Subsequent upper endoscopy showed a large food impaction with a cervical stricture at 19 cm. The stricture seemed to be benign and was dilated to 39F (Figure C, D). There was no evidence of an intraluminal mass or malignant features, and there seemed to be extrinsic bulbous compression of the lumen proximal to the stricture. Biopsies of the stricture were obtained and demonstrated normal squamous epithelium. Subsequent endoscopic ultrasound examination was performed and revealed a 17.7 24.2-mm mass in the pretracheal space between the esophagus and the trachea at 19 cm from the incisors without involvement of the esophageal mucosa (Figure E). A diagnostic FNA of the mass was obtained.
Gastroenterology 2019;157:e1–e3
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2019 by the AGA Institute 0016-5085/$36.00 https://doi.org/10.1053/j.gastro.2019.05.049
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ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to: Image 1: Squamous Cell Carcinoma of Unknown Primary FNA of the paraesophageal mass revealed squamous cell carcinoma (SCC) of unknown primary (Figure F). Her course was complicated by persistent dysphagia and a percutaneous endoscopic gastrostomy tube was placed after discussions with oncology and thoracic surgery. A positron emission tomography-computed tomography scan was ultimately performed to further investigate an etiology of the primary malignancy and demonstrated intense fludeoxyglucose (FDG) activity consistent with the known paraesophageal mass in the upper esophagus, mild FDG activity of the spiculated right upper lobe nodule suspicious for a primary lung malignancy, and mild FDG uptake of mediastinal lymph nodes raising the possibility of metastatic disease. Although it remains unclear what the exact origin of her obstructing lesion is, it seems most likely that it is a metastatic lesion from either a new lung SCC or an undiagnosed head and neck second primary SCC. This case exemplifies the competing forces of diagnostic parsimony as expressed by Occam’s razor and the complexity possible in an individual patient as expressed by Dr Hickam. Cigarette smoking leads to a field cancerization effect, inducing malignancy-associated changes in the upper aerodigestive tract mucosa. In fact, the leading cause of mortality in patients with primary head and neck cancer (HNC) is the development of a second primary malignancy with approximately one-third of HNC deaths attributed to second primary malignancy.1 Although surgery is preferred for the treatment of recurrent or second primary HNC in a previously irradiated field, operations can be challenging and are associated with an overall failure rate of 67%.2 As management strategies of recurrent or second primary HNC evolve with new emerging data, nutritional management with percutaneous endoscopic gastrostomy tube placement is often needed and, in more contemporary studies in patients with esophageal cancer, has been shown to not interfere with surgical outcomes.3
References 1. 2. 3.
Morris LGT, Sikora AG, Patel SG, et al. Second primary cancers after an index head and neck cancer: subsite-specific trends in the era of human papillomavirus-associated oropharyngeal cancer. J Clin Oncol 2011;29:739–746. Wong SJ, Heron DE, Stenson K, et al. Locoregional recurrent or second primary head and neck cancer: management strategies and challenges. Am Soc Clin Oncol Educ B 2016:e284–e292. Wright GP, Foster SM, Chung MH. Midwest Surgical Association Esophagectomy in patients with prior percutaneous endoscopic gastrostomy tube placement. Am J Surg 2014;207:361–365.
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When Occam’s Razor Meets Hickam’s Dictum Rochelle E. Wong,1 Baldeep S. Pabla,2 and Anthony M. Gamboa2 1 Vanderbilt University School of Medicine, Nashville, Tennessee; 2Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
Question: A 59-year-old woman presented to our hospital with a 4-month history of progressive dysphagia. Her past medical history included a history of laryngeal squamous cell carcinoma for which she underwent radiation therapy in 2013 and cigarette smoking (40 pack-year history, recently quit 6 months ago). On physical examination, the patient’s neck was noted to have chronic radiation changes. A computed tomography scan of the neck demonstrated an 18 19 22-mm irregular enhancing mass-like lesion that seemed to arise from the anterior esophagus with abutment into the posterior wall of the trachea (Figure, A, B). Airway narrowing and upper mediastinal adenopathy was noted, as well as a new 11-mm spiculated nodule in the right upper lung lobe not seen on prior imaging. Endobronchial ultrasound examination was first pursued given concern for airway compromise and showed impending airway invasion by a mass along the posterior tracheal wall with transbronchial fine needle aspiration (FNA) of the mass, mediastinal lymph nodes, and the lung nodule notable for atypical squamous epithelium, negative lymph nodes, and nondiagnostic tissue from the lung nodule. Subsequent upper endoscopy showed a large food impaction with a cervical stricture at 19 cm. The stricture seemed to be benign and was dilated to 39F (Figure C, D). There was no evidence of an intraluminal mass or malignant features, and there seemed to be extrinsic bulbous compression of the lumen proximal to the stricture. Biopsies of the stricture were obtained and demonstrated normal squamous epithelium. Subsequent endoscopic ultrasound examination was performed and revealed a 17.7 24.2-mm mass in the pretracheal space between the esophagus and the trachea at 19 cm from the incisors without involvement of the esophageal mucosa (Figure E). A diagnostic FNA of the mass was obtained.
Gastroenterology 2019;157:e1–e3
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2019 by the AGA Institute 0016-5085/$36.00 https://doi.org/10.1053/j.gastro.2019.05.049
e2
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to: Image 1: Squamous Cell Carcinoma of Unknown Primary FNA of the paraesophageal mass revealed squamous cell carcinoma (SCC) of unknown primary (Figure F). Her course was complicated by persistent dysphagia and a percutaneous endoscopic gastrostomy tube was placed after discussions with oncology and thoracic surgery. A positron emission tomography-computed tomography scan was ultimately performed to further investigate an etiology of the primary malignancy and demonstrated intense fludeoxyglucose (FDG) activity consistent with the known paraesophageal mass in the upper esophagus, mild FDG activity of the spiculated right upper lobe nodule suspicious for a primary lung malignancy, and mild FDG uptake of mediastinal lymph nodes raising the possibility of metastatic disease. Although it remains unclear what the exact origin of her obstructing lesion is, it seems most likely that it is a metastatic lesion from either a new lung SCC or an undiagnosed head and neck second primary SCC. This case exemplifies the competing forces of diagnostic parsimony as expressed by Occam’s razor and the complexity possible in an individual patient as expressed by Dr Hickam. Cigarette smoking leads to a field cancerization effect, inducing malignancy-associated changes in the upper aerodigestive tract mucosa. In fact, the leading cause of mortality in patients with primary head and neck cancer (HNC) is the development of a second primary malignancy with approximately one-third of HNC deaths attributed to second primary malignancy.1 Although surgery is preferred for the treatment of recurrent or second primary HNC in a previously irradiated field, operations can be challenging and are associated with an overall failure rate of 67%.2 As management strategies of recurrent or second primary HNC evolve with new emerging data, nutritional management with percutaneous endoscopic gastrostomy tube placement is often needed and, in more contemporary studies in patients with esophageal cancer, has been shown to not interfere with surgical outcomes.3
References 1. 2. 3.
Morris LGT, Sikora AG, Patel SG, et al. Second primary cancers after an index head and neck cancer: subsite-specific trends in the era of human papillomavirus-associated oropharyngeal cancer. J Clin Oncol 2011;29:739–746. Wong SJ, Heron DE, Stenson K, et al. Locoregional recurrent or second primary head and neck cancer: management strategies and challenges. Am Soc Clin Oncol Educ B 2016:e284–e292. Wright GP, Foster SM, Chung MH. Midwest Surgical Association Esophagectomy in patients with prior percutaneous endoscopic gastrostomy tube placement. Am J Surg 2014;207:361–365.
e3