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Case records of the Massachusetts General Hospital. Case 21-2011. A 31-year-old man with ALK-positive adenocarcinoma of the lung.

A 31-year-old man was seen in the outpatient cancer center at this hospital because of dysphagia and a mediastinal mass. The patient had been well until approximately 3 months before this evaluation, when progressive difficulty swallowing (solid foods but not liquids) developed that was occasionally associated with choking and regurgitation. On examination by his primary care physician 6 weeks before this evaluation, the patient’s blood pressure was 140/90 mm Hg, and the remainder of the examination was normal. A course of omeprazole was prescribed. Symptoms persisted, and 4 weeks later, a barium-swallow examination performed at another hospital showed narrowing of the distal third of the esophagus, which was thought to be caused by extrinsic compression. Computed tomography (CT) of the chest, abdomen, and pelvis was performed after the administration of oral and intravenous nonionic contrast medium. The images revealed a heterogeneous soft-tissue mass (4.0 cm in diameter) adjacent to the distal esophagus, gastrohepatic and subcarinal lymphadenopathy (including nodes up to 2.5 cm in diameter), and numerous nodules (<1 cm in diameter) in the right lung. The patient was referred to the cancer center at this hospital. At presentation, the patient reported that the dysphagia had not worsened, and he was not aware of having lost weight. He also reported a morning cough (but no persistent coughing or difficulty breathing) and severe anxiety about his current medical problem. There was no odynophagia, nausea, vomiting, diarrhea, anorexia, or fatigue. He had had a history of intermittent heartburn for several years, asthma in childhood, and three episodes of palpitations of unknown cause. His only medication was zolpidem, and he had no known allergies. He lived with his wife and child, worked in a technical field, and was physically active, participating in sports and working out regularly. He drank alcohol, had a history of smoking (10 pack-years) but had stopped 2 years earlier, and did not use illicit drugs. A maternal aunt had an unknown type of cancer. On examination, the patient was anxious and pacing but in no acute distress; the weight was 82.7 kg and the height 175 cm; the vital signs, oxygen saturation, and Case 21-2011: A 31-Year-Old Man with ALK-Positive Adenocarcinoma of the Lung