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Massive Cervical Mass Being the First Sign of Esophageal Carcinoma.

To the Editor: Neck masses are common signs and complaints in otolaryngology practice. Although most of the masses in the neck region are caused by inflammation, in the absence of inflammation, a neoplastic expression must be considered. Although the metastasis of cervical lymph nodes primarily expresses head and neck carcinomas, distant metastasis from other origins must also be considered. In the current article, we present a unique case of cervical lymph node metastasis of esophageal squamous cell carcinoma (SCC) in which the first sign of the esophageal cancer is massive cervical mass without any other complaints. A 57-year-old woman presented with 7-month history of a growing swelling on the right neck region. Despite a week of antibiotherapy prescribed by other physicians, the volume of the mass had continued growing. Physical examination of the neck revealed a painless, solid, nontender, huge mass in the right supraclavicular region. Computerized tomography of the neck with contrast revealed a mass in the right supraclavicular region (6 8 cm) that displaced thyroid gland to the left and invaded soft tissues of the anterior neck region (Fig. 1). The fine needle aspiration biopsy was performed. After fine needle aspiration biopsy, a diffuse hyperemia was occurred at the biopsy region. Because the result of fine needle aspiration biopsy was nondiagnostic, an open incisional biopsy was performed. After incisional biopsy, the mass began growing rapidly, invaded subcutaneous layer and caused hyperemia and necrosis on skin in 3 weeks (Fig. 1). The histopathologic examination of the biopsy material was metastasis of malign epithelial tumor. To evaluate the primary tumor, fluorodeoxyglucose (FDG) positron emission tomography was performed. In FDG-positron emission tomography scan, an unexpected FDG uptake was reported at the gastric cardia region. Upper gastrointestinal endoscopy revealed nodular lesions at the distal part of esophagus and protruding mass located at the gastric cardia region. Upon endoscopic biopsy of both the lesions, histologic examination of the biopsy was SCC of esophagus that had spread to the gastric cardia region and metastased to the cervical lymph node. The patient was accepted as inoperable and referred to medical oncology clinic for chemotherapy because of distant metastasis. Esophageal cancer is the eighth most common cancers worldwide. Because of its extremely aggressive nature and poor survival rate, it is the sixth most frequent causes of death caused by cancer worldwide. The lymphatic metastases of SCC of esophagus may occur at the cervical region, mediastinum, or abdomen. A majority of the lymphatic metastasis from the upper two thirds of the esophagus tends to spread to the cervical region, and the cancer from the lower third of the esophagus spreads relatively toward abdomen. The symptoms of the disease depend on the functional disorders, local invasion, and distant metastases. The most important and frequent symptom is dysphagia. At advance stages of the cancer, odynophagia and weight loss can occur. Hematemesis, tracheoesophageal fistula, hemoptysis, and hoarseness caused by paralysis of recurrent laryngeal nerve are other symptoms of the disease. Cervical lymph node metastases are common diseases in otolaryngology practice. Generally, the primary tumor originates from nearby organs. In our case, the cervical lymph node metastasis originated from esophageal SCC. In this unique case, the massive cervical mass was the first sign of the esophageal cancer without any other complaints. When an unexpected aggressive nature was observed at a cervical metastatic mass, the esophageal SCC must also be kept in mind in the evaluation of primary tumor.