Dysphagia in a Patient With Recurrent Small-Cell Lung Cancer

Question: A 67-yearold woman with a neuroendocrine small-cell lung cancer (SCLC), recurrent after chemotherapy and radiation therapy, complained of recent-onset dysphagia. She has noticed regurgitation of liquids and some solid-food dysphagia. She has lost 20 pounds in the past 2 months. She has no past history of gastroesophageal reflux symptoms or esophagitis. Physical examination reveals no significant abnormalities, but she had had a peripheral sensory neuropathy that improved with treatment of her SCLC. Laboratory tests are unremarkable except for a positive Hu immunoglobulin (Ig)G serum anti-neuronal nuclear antibody test, an antibody that is associated with SCLC. On serial computed tomography chest examinations, the esophagus had appeared normal (November, 2010; Figure A, arrow). Two months later, the esophagus was slightly dilated and contained contrast (Figure B; computed tomography). On examinations 5 and 7 months later, the esophagus had become even more dilated and was fluid or gas filled (Figure C, D). At esophagogastroduodenoscopy, the esophagus was diffusely dilated, without contraction, and with retained food and secretions. The endoscope passed into the stomach without much resistance, and no lesion was seen on forward view or retroflexion at the gastroesophageal junction. What is the diagnosis? Look on page 252 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.