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+Our patient was a 68-year-old woman with chronic obstructive pulmonary disease.
+She had no history of gastroesophageal reflux disease or esophageal disorders but was found to have a progressive solitary pulmonary nodule (1×1.3cm).
+A right lower wedge resection was performed in December 2011 and the University of Iowa pathology department identified the tumor as a LCNEC.
+Approximately six months after her operation, our patient started having slowly progressing dysphagia for both solids and liquids.
+A positron emission tomography (PET) scan performed in 2012, one year post surgery, was unremarkable for recurrence or metastasis.
+Repeat computed tomography (CT) in June 2013 (18 months post surgery) did not show any recurrence (Figure 1).
+Our patient had an esophagogastroduodenoscopy (EGD) and barium swallow that revealed no stricture of her esophagus but failure of primary and secondary peristaltic waves and reflux.
+In July 2013, esophageal manometry found failure of the lower esophageal sphincter to relax, with a residual pressure of 32mmHg.
+Our patient was treated with calcium channel blockers with partial relief.
+Thus far, up to 18 months post resection, our patient had been able to maintain her weight and her basic laboratory parameters, including hemoglobin, albumin and cholesterol levels.
+However, in January 2014, she reported worsening dysphagia and weight loss of 10lbs over a period of one month.
+She was referred to our center for further treatment of her achalasia.
+A repeat esophageal manometry showed an elevated lower esophageal sphincter pressure of 50mmHg as well non-propagative, non-peristaltic contractions throughout her esophageal musculature (Figure 2).
+A repeat EGD with an intention to perform therapeutic pneumatic dilation showed a nearly circumferential ulcerated, fungating mass from approximately 36cm that extended to her gastroesophageal junction at 39cm.
+Biopsies revealed a LCNEC with similar features to the primary tumor resected in 2011, and was concluded to be a metastasis.
+Subsequently, a repeat CT scan revealed progressive diffuse metastatic disease.
+Our patient underwent two courses of chemotherapy but died from the disease after six months.