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November 11, 2019

Image challenge: When Occam’s razor meets Hickam’s dictum

What caused an irregular enhancing mass-like lesion that seemed to arise from the anterior esophagus in a 59-year-old patient?
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Gastroenterology clinical image challenge: A 59-year-old woman presented to our hospital with a four-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 six 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. 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. 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). A diagnostic FNA of the mass was obtained.

What is the diagnosis?

To find out the diagnosis, read the full case in Gastroenterology.

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