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INTRODUCTION: Esophageal cancer is the sixth most common cancer worldwide that is associated with a poor prognosis. Clinically, dysphagia and weight loss are the most common presentations. However, non-specific symptoms of distant metastatic disease might be the initial presentation which provides a diagnostic challenge and delay in management. We describe a case of an unusual presentation of esophageal cancer with acute low back pain secondary to vertebral compression fracture without gastrointestinal symptoms. CASE DESCRIPTION/METHODS: A 51-year-old male with tobacco use disorder but otherwise unremarkable medical history, presented to the clinic with acute onset non-traumatic right flank pain and low back pain. Patient had no gastrointestinal symptoms. Physical examination and baseline laboratory data yielded no pertinent findings. Computed Tomography scan of the abdomen showed L2 vertebral body compression deformity. Radiography and Magnetic Resonance Imaging of the lumbar spine were concerning for an acute L2 pathological compression fracture. Therefore, patient had a core biopsy of the L2 vertebral body which revealed metastatic adenocarcinoma favoring an upper gastrointestinal primary tumor. Accordingly, patient underwent an upper endoscopy which revealed a non-lumen occluding distal esophageal mass. Endoscopic Ultrasound revealed a 7 × 8 mm lymph node adjacent to the pancreatic body. Biopsy of the mass and fine needle aspiration of the lymph node were consistent with Stage IV esophageal adenocarcinoma. Patient is currently undergoing palliative chemotherapy and radiation therapy. DISCUSSION: Esophageal cancer is often asymptomatic in early stages and patients present with progressive dysphagia at advanced stages, when the esophageal lumen is less than 13 mm. Initial presentation of esophageal cancer with symptoms of distant metastatic disease without gastrointestinal symptoms have been rarely described in the literature. Our patient’s lack of supportive gastrointestinal symptoms and atypical presentation with low back pain, provided a diagnostic challenge. However, L2 vertebral body biopsy was the key in establishing the diagnosis of esophageal cancer. This case highlights the atypical initial presentation of esophageal cancer as a metastatic disease which can present with myriad of symptoms unrelated to the primary tumor. Therefore, when esophageal malignancy is suspected, histopathological examination of a possible metastasis might be the only window towards diagnosing the primary esophageal cancer.

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