A 59-year-old man was referred to the general surgery department of our hospital for a one-month history of progressive dysphagia for solids, which was not associated with malnutrition or significant weight loss.
The patient had recently undergone esophagogastroduodenoscopy in another hospital, which revealed a bleeding, ulcerative lesion in the middle third of the esophagus, but no biopsy had been collected.
The medical past history included COPD diagnosed in 1999 and a myocardial infarction in 2002.
The patient had smoked approximately 25 cigarettes per day for several years.
Physical examination was unremarkable.
Computed tomography (CT) of the chest and abdomen revealed stenosis involving a 5-cm segment of the middle third of the esophagus with no other lesions in the thoracic or abdominal organs.
Barium studies disclosed a swelling in the esophageal wall 7 cm above the cardia with an ulcerative pattern, which reduced the diameter of the lumen to 5 mm.
An endoscopic biopsy of the oesophageal mass demonstrated poorly differentiated (G3) squamous cell carcinoma.
Mid-distal esophagectomy was performed with oesophagogastric anastomosis and gastric tube reconstruction.
Pathological examination of the surgical specimen confirmed the biopsy diagnosis of poorly differentiated (G3) SCC.
The tumor, which measured 3 cm of length, had infiltrated the oesophageal wall and the surrounding paraesophageal fat.
Surgical margins were tumor-free, as the seven perigastric limph-nodes dissected (pT3 N0).
The postoperative period was quite unremarkable, and a contrast enhanced x-ray obtained on the 9th POD showed normal esophageal and gastric transit.
On the 14th POD, the patient was discharged with an oncology referral for routine medical follow-up.
Nine months after the operation, CT and esophagogastroduodenoscopy were repeated.
The imaging study revealed mild splenomegaly with multiple nonspecific nodules within the organ (Figure ​1).
The patient was virtually asymptomatic with the exception of a vague sensation of mild discomfort in the left upper quadrant of the abdomen.
FNAC of the spleen revealed a pattern of numerous inflammatory cells admixed with large cells displaying immunohistochemical positivity for several cytokeratins (Figure 2).
The specimen was Gram stain-negative.
A bone-marrow biopsy was negative for metastatic involvement.
The diagnosis was isolated metastases of the spleen with inflammatory and necrotic alterations.
The patient was referred to our centre for splenectomy, which was performed as a routine procedure to role out, also, a spontaneous rupture of the spleen.
On 12th December 2007, the patient had transabdominal total splenectomy with splenic and celiac artery lymph node dissection.
The postoperative course was uneventful.
On the 7th postoperative day, Doppler ultrasonography revealed portal-tree patency with no signs of thrombosis.
Ten days later, the patient was discharged with a stable platelet count (780,000/mm3), Hb 10.9 g/dL, and a WBC count of 16,500/mm3.
Pathological examination of the spleen described multiple nodules containing medium to large-sized cells, some of which were keratinized.
The nodules were mostly solid with areas of central necrosis (Figure ​3).
The findings were consistent with metastases of SCC.
Thereafter, the patient was referred to the oncology department of our hospital, where he received two 3-day cycles (separated by a 3-week interval) of systemic chemotherapy based on 5-fluorouracil (800 mg/day IV) and cisplatin (20 mg/day).
Three months after the splenectomy, multiple liver metastases were seen on the CT scan, and cutaneous metastases were also present.
The patient died 9 months later.