REFERENCES

1. Oyelese Y, Kueck AS, Barter JF, et al. Asymptomatic postmenopausal simple

ovarian cyst. Obstet Gynecol Surv 2002;57:803–809.2. Stany MP, Hamilton CA. Benign disorders of the ovary. Obstet Gynecol

Clin North Am 2008;35:271–284.3. Hartge P, Hayes R, Reding D, et al. Complex ovarian cysts in postmeno-

pausal women are not associated with ovarian cancer risk factors: Prelimin-

ary data from the prostate, lung, colon, and ovarian cancer screening trial.

Am J Obstet Gynecol 2000;183:1232–1237.4. Reimer T, Gerber B, Muller H, et al. Differential diagnosis of peri- and

postmenopausal ovarian cysts. Maturitas 1999;31:123–132.5. Dikensoy E, Balat O, Ugur MG, et al. Serum CA-125 is a good predictor of

benign disease in patients with postmenopausal ovarian cysts. Eur J Gynae-

col Oncol 2007;28:45–47.

EARLY ESOPHAGEAL SQUAMOUS CELLCARCINOMA IN A 100-YEAR-OLD WOMAN

To the Editor: A 100-year-old woman was seen in anoncology outpatient clinic with a chief complaint of dys-phagia for 6 months and recent intake of only liquid diet.She denied any systemic disease and any habitual history ofdrinking, smoking, or betel quid chewing. Thirty centime-ters below her incisor, endoscopy disclosed an esophagealmass, 1.5 cm in length and causing luminal stenosis. Endo-scopic biopsy proved a moderately differentiated squamouscell carcinoma of the esophagus. Multidetector computed

tomography (MDCT) of the chest revealed an esophagealcancer at initial staging status: cT2N0M0 (T: primarytumor; N: regional lymph nodes; M: distant metastasis)belonging to clinical Stage I (Figure 1A, B). Despite earlyesophageal carcinoma, the oncologist decided to administerradiotherapy (RT) alone for symptomatic control becauseof her advanced age and her Eastern Cooperative OncologyGroup Performance Status Scale score of 2. Palliative RTwith 4,800 cGy in 30 fractions and 880 cGy in 4 fractionswas then consecutively delivered to the esophageal cancerwithin 6 months. Positron emission tomography computedtomography (PET-CT) showed multiple metastases in thelungs and mediastinal and abdominal metastatic lymphade-nopathies, so the clinical stage of esophageal cancer pro-gressed to Stage IV (Figure 1C). Because of aggravation ofher general conditions with poor appetite, general weak-ness, and loss of more than 10% of body weight within 6months, she eventually received a peripherally inserted cen-tral catheter for nutrition support.

DISCUSSION

Esophageal cancer is the fifth and eighth leading cause ofcancer deaths in men and women, respectively, worldwideand the fourth most common cancer in developingcountries according to the global statistics based on

A

B

C

Figure 1. Multidetector computed tomography with an axial image (A) and a reformatted coronal image (B) of a 100-year-oldwoman complaining of progressive dysphagia for 6 months showed a biopsy-proven small esophageal squamous cell carcinoma(ESCC) (small white arrows) located at the wall of the middle to lower one-third of the esophagus with luminal stenosis and theinitial staging status: T2N0M0 (Stage I), a focal pleuropulmonary fibrosis (small white arrowheads) at bilateral apical lungregions, cardiomegaly, and degenerative change of the thoracic spine. After failure of palliative radiotherapy delivered to theESCC in a fractional dose for 6 months, positron emission tomography (C) showed multifocal intense fluorodeoxyglucose traceruptakes at the primary ESCC (long black arrows), multiple metastases at both lungs (black arrowheads) and multiple mediastinaland para-aortic metastatic lymphadenopathies (black short arrows). Hence, the status of ESCC had progressed to Stage IV.

1172 LETTERS TO THE EDITOR JUNE 2012–VOL. 60, NO. 6 JAGS

GLOBOCAN 2008, the standard set of worldwide cancerestimates of cancer incidence and mortality produced bythe International Agency for Research of Cancer (IARC)for 2008.1 The prevalence of esophageal adenocarcinomain the lower one-third of the esophagus and the esophagog-astric junction is increasing in North American and someWestern countries, whereas esophageal squamous cell car-cinoma (ESCC) in the middle or upper one-third of theesophagus is still the major histological type of esophagealcancer in the high-risk areas extending from Iran to Asia(the esophageal cancer belt), including Taiwan.1–3 ESCCusually has a poor prognosis owing to its late clinical pre-sentation and rapid progression.4,5 A series of studies andthe IARC have identified that the major risk factors forESCC are poor nutritional status, low intake of fruits andvegetables, low education, intake of hot foods, drinkinghigh-temperature beverages or hot salted tea, smoking, andbetel nut chewing.1,2,6 In Taiwan, some studies reveal asynergistic carcinogenetic effect of betel nut chewing,smoking, and alcohol drinking in the development of ESCCthat may be the main cause of the rapid increase in the inci-dence of ESCC in the past 2 decades.6,7 A recent studydemonstrated that the genotypes ALDH2*2 and MTHFR677TT independently and synergistically increase the riskof ESCC in China.8

To avoid delayed diagnosis, esophageal cancer shouldbe suspected in elderly adults (� 80) complaining ofprogressive dysphagia.9 Most of the studies on age-inducedchange of pharyngeal and esophageal function have hadinconclusive results because of a lack of prospective meth-ods, including an observation group and a control groupwithout any concomitant diseases and medications.9 Forelderly adults, the clinical problem of dysphagia is commonand is easily neglected, so its serious investigation isrequired to distinguish between underlying functional andstructural disease.9 Multiple causes of dysphagia in elderlyadults can be practically divided into two main groups withsubgroups. Oropharyngeal dysphagia includes centralnervous system disease such as cerebrovascular accident(partially with brainstem involvement), pseudobulbar palsy,parkinsonism, and neoplasm; neuromuscular disorders,such as myasthenia gravis; and local structural lesions suchas oropharyngeal tumor and vertebral osteophytosis. Esoph-ageal dysphagia includes motility disorders such as achala-sia, diffuse esophageal spasm, and diabetes mellitus andmechanical obstruction such as neoplasms, peptic strictures,ring and webs, and vascular lesions (aortic dysphagia). Acareful history taking and detail physical and neurologicalexamination may be helpful in differentiating the causes ofdysphagia.9 If esophageal dysphagia is suspected, endoscopyand endoscopic biopsy are required to clarify and confirmthe diagnosis of esophageal neoplasm, and the endoscopicnarrow-beam imaging technique is useful in detection andcharacterization of superficial ESCC.3,9 MDCT is conductedfor initial tumor staging of esophageal cancer. PET-CT isthe most-reliable noninvasive modality for staging of esoph-ageal cancer. For adults aged 80 and older with good East-ern Cooperative Oncology Group performance status,surgical resection is promising for Stage I ESCC.9,10 Forthose with poor performance status, RT alone may result ina successful treatment outcome comparable with that of sur-gery for Stage I ESCC.11

Wing-Keung Cheung, MDYuk-Ming Tsang, MD

Division of Medical Imaging, Department of RadiologyFar Eastern Memorial Hospital, New Taipei City, Taiwan

and Oriental Institute of Technology, New Taipei CityTaiwan

Pei-Wei Shueng, MDDivision of Radiation Oncology, Department of

Radiology, Far Eastern Memorial Hospital, New TaipeiCity, Taiwan and

Department of Radiation Oncology, National DefenceMedical Center, Taipei City, Taiwan

Min-Po Ho, MDDepartment of Emergency Medicine, Far Eastern

Memorial Hospital, New Taipei City, Taiwan

ACKNOWLEDGMENTS

Conflict of Interest: The editor in chief has reviewed theconflict of interest checklist provided by the authors andhas determined that the authors have no financial or anyother kind of personal conflicts with this paper.

Author Contributions: Concept and design: Wing-Keung Cheung. Acquisition of subjects and data: Wing-Keung Cheung, Min-Po Ho. Analysis and interpretation ofdata: Wing-Keung Cheung, Min-Po Ho, Pei-Wei Shueng,and Yuk-Ming Tsang. Preparation of manuscript: Wing-Keung Cheung. Critical review and approval: all authors.

Sponsor’s Role: None.

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Cancer Causes Control 2010;21:1427–1435.8. Li QD, Li H, Wang MS, et al. Multi-susceptibility genes associated with

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Feicheng County. BMC Gastroenterol 2011;11:74–81.9. Lock G. Physiology and pathology of the oesophagus in the elderly patient.

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over 80 years with esophageal cancer. Hepatogastroenterology 2008;

55:453–456.11. Ishikawa H, Sakurai H, Tamaki Y, et al. Radiation therapy alone for stage I

(UICC T1N0M0) squamous cell carcinoma of the esophagus: Indications for

surgery or combined chemoradiotherapy. J Gastroenterol Hepatol 2006;

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