Case report Spontaneousexpulsionofamediastinallymphnodeincarcinomaoftheesophagus R. Basu, N. R. Datta Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India SUMMARY. A case of spontaneous expulsion of a mediastinal lymph node, which developed during the follow up ofapatientwithcarcinomaoftheesophagusispresented.Tothebestofourknowledge,nosuchinstanceofnatural extrusion of mediastinal lymph node has been reported in the literature. INTRODUCTION Spontaneous expulsion of objects through the tra- cheo-bronchial route is one of the rare mechanisms of expulsion of foreign bodies like pins, needles, nose studs, etc. 1–3 Mediastinal lymph node, a common site of metastasis from carcinoma of the esophagus has never been reported to be extruded through the respiratory passage. We present a unique case of mediastinal node expulsion in a patient on follow up after surgery and postoperative radiotherapy in carcinoma of the esophagus. CASE REPORT A 50-year-old lady presented in May 2001 with grade I dysphagia of 5 months’ duration. She was of thin build with average nutritional status and had a Karnofsky performance status of 80. Barium swallow demonstrated a stricture in the middle third of esophagus with mucosal irregularity. Upper gastro- intestinal endoscopy revealed a ulceroproliferative growth at 28 cm from the incisors, with esophageal narrowing causing difficulty in negotiating the scope past the stricture. A contrast-enhanced computed tomography (CECT) of the thorax showed a 6.5-cm- long lesion in the middle third of the esophagus, which was compromising, and the area of contact with the aorta was around 90°. No significant mediastinal lymphadenopathy could be seen using CECT. Patient underwent transhiatal esophagectomy with feeding jejunostomy in July 2001. Peroperatively, there was a bulky growth in the mid-thoracic region, below the carina. No other loco-regional spread could be documented. The cut section revealed a transmural spread with a single 1 cm · 1 cm perieso- phageal lymph node. Histopathology of the specimen was reported as squamous cell carcinoma with tumor infiltration into the muscularis mucosa and reaching up to the adventia. There was no vascular or neural invasion and all lymph nodes were free of tumor metastasis. The postoperative period was uneventful and she received postoperative radiotherapy to the tumor bed and mediastinum in August 2001, to a total dose of 54 Gy in 27 fractions over 5.5 weeks. Thereafter, she was on regular follow up. In January 2002, the patient presented with complaints of dry cough, difficulty in breathing and hoarseness of voice. Clinically, the patient was in stridor and cyanosed. The rest of the general physical and systemic examination was largely unremarkable. A chest radiograph revealed a round soft tissue opacity in the superior mediastinum compressing the trachea (Fig. 1a). A computerized CECT scan of the neck and thorax showed a lobulated lymph node mass measuring 4.5 cm · 4.5 cm · 5 cm in the pos- terior part of superior mediastinum, extending from the first dorsal vertebra to the fifth dorsal vertebra and ending approximately 1 cm above the carina. The mass had areas of heterogeneous contrast enhancement and necrosis with ill-defined planes between the esophagus and trachea. The lumen of trachea was markedly narrowed to just a slit. There was evidence of circumferential mural thickening of the esophagus above and below the mass. The rest of Address correspondence to: Dr N. R. Datta, MD, DNB, Additional Professor, Department of Radiotherapy, Sanjay Gan- dhi Postgraduate Institute of Medical Sciences, Rae Barelli Road, Lucknow 226014, Uttar Pradesh, India. Tel: (+91) 522 2668004 (to 8) ⁄ 2668700; Fax: (+91) 522 2668017 ⁄ 2668078; E-mail: nrdatta@sgpgi.ac.in 44 Diseases of the Esophagus (2003) 16, 44–46 Ó 2003 ISDE/Blackwell Publishing Asia