Unprecedented non-luminal esophageal adenocarcinoma invading the spine

Background: Upper endoscopy with biopsy is the gold standard for diagnosing esophageal cancer. However, esophageal tumors can rarely escape endoscopic detection by growing in atypical patterns, such as entirely outside the esophageal lumen.

Case: We report a unique case of primary esophageal adenocarcinoma that presented with spinal cord compression due to local invasion of the T5 vertebral body, despite an initially normal upper endoscopy. A 68-year-old man developed progressive paraparesis and sensory loss due to a T5 pathological fracture. He had classic symptoms of esophageal cancer (dysphagia and weight loss), yet endoscopic evaluation one month prior showed no intraluminal tumor. Imaging revealed a posterior mediastinal mass contiguous with the esophagus and invading the T4–T6 vertebrae. Surgical resection of the epidural tumor confirmed poorly differentiated adenocarcinoma consistent with an esophageal primary. The patient declined chemoradiation and succumbed one month later.

Conclusions: This unprecedented pattern of esophageal adenocarcinoma—growing extraluminally with isolated posterior extension to the spine—highlights the potential for esophageal cancer to present with no mucosal lesion on endoscopy. Clinicians should remain vigilant for malignancy in patients with high suspicion, even if initial endoscopic findings are benign.