Esophageal cancer in esophageal diverticula associated with achalasia

Abstract

The simultaneous occurrence of achalasia and esophageal diverticula is rare. Here, we report the case of a 68-year-old man with multiple esophageal diverticula associated with achalasia who was later diagnosed with early esophageal cancer. He initially presented with dysphagia and dyspepsia, and injection of botulinum toxin to the lower esophageal sphincter relieved his symptoms. Five years later, however, the patient presented with worsening of symptoms, and esophagogastroduodenoscopy (EGD) was performed. The endoscopic findings showed multifocal lugol-voiding lesions identified as moderate dysplasia. We decided to use photodynamic therapy to treat the multifocal dysplastic lesions. At follow-up EGD 2 months after photodynamic therapy, more lugol-voiding lesions representing a squamous cell carcinoma in situ were found. The patient ultimately underwent surgery for the treatment of recurrent esophageal multifocal neoplasia. After a follow-up period of 3 years, the patient showed a good outcome without symptoms. To manage premalignant lesions such as achalasia with esophageal diverticula, clinicians should be cautious, but have an aggressive approach regarding endoscopic surveillance.

Keywords: Diverticulum; Esophageal; Esophageal achalasia; Neoplasms.

Conflict of interest statement

The authors have no financial conflicts of interest.

Figures

Fig. 1

Barium esophagography. View of a barium esophagogram showing multiple esophageal diverticula and a bird-beak appearance at the esophagogastric junction.

Fig. 2

Esophageal manometry. An esophageal manometric view shows the absence of peristalsis in the esophageal body and simultaneous contractions.

Fig. 3

Esophagogastroduodenography. Endoscopic view at 5 years after botulinum toxin injection therapy. A lugol-voiding lesion is seen at one of the multiple esophageal diverticula.

Fig. 4

Esophagogastroduodenoscopy after photodynamic therapy. Endoscopic view 2 months after photodynamic therapy. Another lugol-voiding lesion can be seen. Subsequently, a biopsy was performed.

Fig. 5

Histologic findings. A biopsy specimen, from the lesion observed 2 months after photodynamic therapy, shown in Fig. 3 reveals a high-grade epithelial dysplasia and focal squamous cell carcinoma in situ (H&E stain, ×200).