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A 56 year old man with a history of progressive dysphagia was referred, having had three subsequent endoscopies reporting a tight stricture in the lower oesophagus and dilatation of the proximal oesophagus. Repeated biopsies had failed to prove malignancy. At this stage a computerised tomogram (CT) scan suggested a bulky tumour of the distal oesophagus with left gastric nodal enlargement. Examination was unremarkable apart from multiple cutaneous dermatofibromas and evidence of weight loss.
Repeated endoscopic biopsies again failed to confirm any neoplastic process. Narrowing of the lower oesophagus and gastro-oesophageal junction from a submucosal eccentric mass was shown at barium swallow; the dilated thick walled oesophagus had features compatible with achalasia. Oesophageal manometry failed to assess the lower oesophageal sphincter but showed absent peristalsis. CT scan was repeated and endoscopic ultrasonography (EUS) was also performed (fig 1).
What is the diagnosis based on the CT and EUS images? What is the next step forward?
See page 1292 for answer
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