When progressive dysphagia could be related to an “old friend” – a case report

Clinical case: Here it is presented the case of a 63 years old female patient, which developed a progressive dysphagia. These are main data about her history: mastectomy (in 1997) and subsequent chemotherapy and radiotherapy for breast cancer; adrenal gland adenoma; nontoxic multinodular goiter; colon polyp (adenoma). Since 2009 she was diagnosed with an unilateral vocal cord palsy of undefined origin (neck MRI, brain MRI: negative). In December 2011 she was referred to the emergency ward due to a marked worsening of a progressive dysphagia in the last few months. She was admitted to Otorinolaringoiatric department where FBS demonstrated bilateral vocal cord hypomobility; a nasogastric sondine was placed. She was then transferred to the Neurology department where she underwent an EMG, consistent with a sensory-motor polyneuropathy; some features were also consistent with a Lambert-Eaton syndrome (Ig i.v. were started without response). She underwent a total body CT scan with contrast which was negative, apart from the yet known adrenal gland adenoma. In the mean time her clinical condition worsened: her nutritional state progressively deteriorated and her respiratory function started to become impaired with the necessity of PEG positioning and tracheostomy procedure. She then was studied with a brain MRI with mean of contrast: pathological tissue with enhancement was showed at the level of right jugular foramen, involving nerve fibers. Subsequently a biopsy was performed: histological exam revealed a localization of a breast adenocarcinoma. After completing restaging (no other sites of neoplastic disease were found), she was referred to the Oncology department were she was treated with radiotherapy (60 Gy in 30 fractions) and Letrozole. She was then discharged from the hospital in stable clinical condition; PEG and tracheostomy still placed and necessary. Conclusion: the peculiarity of this clinical case is the particular metastatic disease found, both for its being the only one metastatic localization developed, both for presenting itself after nearly 15 years of negative oncological follow-up, in absence of metastatic disease before the present one. Even more, diagnosis was quite challenging, since it was quite surprising to discover her symptoms were due to a neoplastic disease that was considered as “cured”.