Adam Mylonakis

Summary: Leptomeningeal carcinomatosis (LMC) is a rare but devastating complication of solid tumors. Involvement from esophageal cancer is exceedingly uncommon and poorly characterized, with evidence limited to case reports and small series. PubMed/MEDLINE, Scopus, Embase, Web of Science, and the Cochrane Library were systematically searched by two investigators for LMC originating from esophageal cancer. Thirty-one studies reporting 43 patients were included (93% male; mean age 59.3 years). Esophageal adenocarcinoma was the predominant histology (86%), followed by squamous cell carcinoma (11.6%), most commonly from the distal esophagus or esophagogastric junction. LMC occurred synchronously in 27.9% and metachronously in 72.1%, with a median interval of 11.2 months between primary diagnosis and leptomeningeal disease. At diagnosis, 37.2% had isolated leptomeningeal involvement without extracranial metastases. Presentation was heterogeneous, most frequently including headache or meningeal symptoms (55.8%), vestibulocerebellar manifestations (39.5%), and cranial nerve involvement (37.2%). Cerebrospinal fluid cytology was positive in 81.1% of tested cases, often requiring repeat lumbar punctures. Molecular data were reported for 27.9% of patients; Human Epidermal Growth Factor Receptor 2 (HER2) was positive in 3 of 10 tested cases (30%). Management was individualized: radiotherapy in 37.2%, intrathecal therapy in 20.9%, and supportive care alone in 46.5%. Median survival was 1.1 months, though three patients achieved 12, 14, and 19 months following Central Nervous System (CNS)-directed therapy. LMC from esophageal cancer is rare and clinically aggressive, characterized by heterogeneous presentation, frequent diagnostic delay, and poor prognosis. Early recognition and palliative care are essential, while rare long-term survivors suggest selected patients may benefit from individualized CNS-directed treatment.

Background: Endoluminal vacuum therapy (EndoVAC/EVT) is widely used for managing esophageal anastomotic leaks, with high closure rates and a favorable safety profile compared with stent placement or surgical revision. Serious neurological complications associated with endoVAC treatment appear to be exceptionally rare. Case presentation: We present the case of a 60-year-old patient who underwent open Ivor Lewis esophagectomy for pT2N0 esophageal adenocarcinoma. On postoperative day (POD) 8, fever and leukocytosis developed, and imaging confirmed an intrathoracic anastomotic leak. EVT was initiated on POD 12 with intracavitary sponge placement at − 80 mmHg continuous suction. Seven subsequent exchanges were uneventful, with progressive reduction of the leak cavity. On POD 37, during the eighth exchange using CO₂ insufflation, sudden neurological collapse occurred immediately after sponge removal and irrigation. Brain CT demonstrated extensive intracranial gas within supratentorial and infratentorial compartments, predominantly in the dural venous sinuses, with cerebral edema. The patient died six days later. Discussion: A plausible mechanism was retrograde venous gas embolization via the posterior mediastinum and Batson’s plexus, facilitated by direct endoscopic access to the leak cavity. Preventive strategies include minimizing insufflation pressure, gentle irrigation, and careful reassessment of the need for continued intracavitary therapy. Conclusions: This case of fatal cerebral gas embolism during EVT highlights an exceptionally rare and potentially catastrophic complication and the need for procedural vigilance.

Background/Objectives: Boerhaave’s syndrome (BS) is a rare, life-threatening condition associated with high mortality. This systematic review aimed to summarize the clinical presentation, management, and outcomes of adult patients with BS. Methods: PubMed and Scopus were searched through 12 June 2026 for case reports and case series reporting individual patient-level data. Demographic, clinical, diagnostic, therapeutic, and outcome data were extracted. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist, and factors associated with in-hospital mortality were explored using logistic regression. Results: A total of 427 studies comprising 694 patients were included. Mean age was 57.1 years and 523 patients (80.6%) were male. Vomiting (79.5%) and chest pain (60.7%) were the most common symptoms, while 263 patients (67.6%) met SIRS criteria at diagnosis. The distal esophagus was involved in 83.5% of cases, and computed tomography was the predominant diagnostic modality (55.5%). Surgery was the most common first-line treatment (62.8%). In-hospital and 30-day mortality were 18.2% and 15.4%, respectively. In exploratory analyses, increasing age and SIRS were associated with in-hospital mortality. Risk of bias assessment identified methodological concerns across studies predominantly due to selective and incomplete outcome reporting. Certainty of evidence for in-hospital mortality was very low according to GRADE. Conclusions: BS remains associated with substantial morbidity and mortality. Surgery remains the most frequently applied treatment, while conservative and endoscopic strategies are used in selected patients. Case-based evidence precludes reliable comparative assessment of treatment effectiveness. The association between SIRS and mortality remains hypothesis-generating.

Purpose: Ocular metastasis from esophageal cancer is a very rare clinical entity, typically only described in isolated case reports. This systematic review describes the clinical features, diagnostic strategies, treatment modalities, and outcomes of this uncommon manifestation. Methods: A systematic search of the literature in the PubMed/Medline and Scopus databases was conducted from database inception to January 25, 2026, focusing on adult ocular metastasis from esophageal cancer. Results: Forty-one cases were identified (mean age 58.7 ± 10.5 years; male-to-female ratio 5.8:1). The most common presenting symptom was blurred vision (46.3%), followed by eye pain (26.8%), diplopia and ptosis (each, 14.6%), and floaters (9.8%). Impaired visual acuity was documented in 85.3% of the cases reported. The choroid was the most frequently involved site (43.8%), followed by the iris (31.3%) and then the retina (12.5%). Ocular metastasis was synchronous in 63.4% of cases and was the presenting manifestation in 29.3%. Additional systemic metastases were present in 80.5% of cases. External beam radiotherapy was the most common local treatment (68.3%), achieving visual improvement in approximately two-thirds of treated patients. Median overall survival was 6 months. Conclusions: Ocular metastasis from esophageal cancer is indicative of advanced systemic disease. Early recognition and prompt local therapy may preserve visual function and quality of life despite poor overall prognosis.

Background: Self-expanding esophageal stents (SEMS) are widely used in the management of malignant dysphagia and a variety of benign esophageal conditions. Although stent migration is a well-recognized complication, late migration -defined as occurring ≥4 weeks after stent placement- is less well characterized and may result in severe, life-threatening emergencies. These events are frequently underrecognized and not consistently addressed within current surveillance practice. Methods: A systematic review was conducted in PubMed/MEDLINE, Embase, and Scopus databases focusing on acute clinical presentations following late esophageal stent migration. Results: Out of 343 unique articles, 53 studies were included, involving 53 patients with a median time to presentation of 3 months after stent placement, and 12.5% of cases occurring more than one year later. The gastrointestinal tract was the most frequent site of migration (64.2%), followed by airway/respiratory (15%), thoracic (13.2%), and vascular structures (5.7%). Clinical presentations included small bowel obstruction (30.2%), gastrointestinal or thoracic perforation, respiratory failure, sepsis, and catastrophic hemorrhage. Surgical intervention was required in most cases. Overall mortality was 28.3%, with especially poor outcomes in cases complicated by vascular or airway involvement. Conclusions: Late esophageal stent migration represents a clinically significant but underrecognized cause of acute surgical emergencies. Risk-adapted surveillance, prompt diagnostic imaging, and early multidisciplinary management are essential to improve outcomes and enhance the long-term safety of esophageal stent therapy.

Esophageal cancer remains a global challenge, with poor overall survival despite advances in multimodal therapy. Surgical resection continues to be the main curative treatment, yet esophagectomy is among the most technically challenging oncological procedures due to the esophagus’s location within the densely packed mediastinal corridor. Critical vascular, neural, and lymphatic structures surround the esophagus, and their frequent anatomical variations pose significant risks during mobilization, lymphadenectomy, and reconstruction. This review synthesizes current evidence on the anatomical variability in the vessels, nerves, lymphatics, and fascial compartments relevant to esophageal surgery. Particular emphasis is placed on aberrant arterial and venous patterns, recurrent and non-recurrent laryngeal nerve pathways, thoracic duct variants and atypical courses, and the fascial planes that are used to define surgical boundaries. By shifting the surgical paradigm from standardized anatomical assumptions to patient-specific structural mapping, we highlight how understanding these variations is driving the field of personalized surgical medicine. By integrating these anatomical insights with surgical approaches—including right and left transthoracic, transhiatal, and transcervical techniques—we highlight the implications of variations for intraoperative safety and postoperative outcomes. A thorough understanding of these relationships is essential for surgical planning, minimizing morbidity, and achieving oncological outcomes. Ultimately, a thorough understanding of these relationships is essential for patient-tailored surgical planning.

Response assessment in colorectal cancer (CRC) still relies largely on anatomic imaging, which does not capture dynamic immune or stromal adaptation. Techniques like cytometry by time-of-flight (CyTOF) and imaging mass cytometry (IMC) enable high-dimensional single-cell proteomic and spatial profiling, thereby enhancing our understanding of therapeutic responses in CRC. This narrative review summarizes current evidence from human, preclinical, and organoid studies describing how CyTOF and IMC have been applied to characterize therapeutic response in CRC. Relevant publications applying suspension CyTOF or IMC to CRC tissue, blood, or model systems were identified through PubMed and major oncology journals. Studies linking single-cell features to treatment response or pharmacodynamics were prioritized and organized by biological theme and clinical applicability. Spatial analyses have identified macrophage-T-cell niches enriched for CD68⁺CD74⁺ and C1QC⁺ resident-tissue macrophages that predict benefit from PD-1 blockade more accurately than bulk T-cell density. Conversely, cancer-associated fibroblast (CAF)-dense matrices and granulocytic proximity associate with resistance. Systemic CyTOF studies have demonstrated peri-operative lymphopenia, persistent HLA-DR^low monocytes, and chemotherapy-induced depletion of mature CD56^dimCD16⁺ natural killer (NK) cells on a STAT5-biased background. Organoid and phospho-signaling studies show that cellular differentiation states determine oncogenic ERK activation and therapy tolerance. Collectively, these datasets outline pharmacodynamic and predictive biomarkers relevant to immunotherapy and chemotherapy. CyTOF and IMC provide actionable biomarkers - including C1QC⁺ macrophage-T-cell proximity, HLA-DR^low monocytes, and NK-cell maturation profiles - that refine response assessment beyond imaging criteria. Harmonization of antibody panels, prospective validation, and integration into clinical workflows are required to apply these findings in clinical practice.

Extra-uterine endometrial stromal sarcoma (EESS) is a rare mesenchymal tumour, and primary gastric involvement represents an exceptionally unusual presentation. Because such tumours present as ulcerated submucosal masses, they are easily misdiagnosed as gastrointestinal stromal tumours (GIST), making accurate, timely recognition critical for appropriate management. A 53-year-old woman presented with a five-day history of epigastric pain, low-grade fever, and malaise. Computed tomography (CT) imaging revealed an 11 cm vascular mass on the greater curvature of the stomach with splenic-hilum and transverse-colon contact, without evidence of local invasion. Upper gastrointestinal endoscopy revealed a friable ulcerated lesion, and biopsies suggested a spindle-cell neoplasm favouring GIST. At laparotomy, the tumour was found to infiltrate the stomach, splenic hilum, colon serosa, and omentum. An en bloc partial gastrectomy, splenectomy, segmental colectomy, cholecystectomy, and omentectomy were performed; final pathology showed microscopic involvement of the gastric radial soft-tissue margin. Histology demonstrated a primary gastric low-grade ESS with a vascular pattern and low mitotic index, while immunohistochemistry showed diffuse CD10/ER/PR positivity and absence of c-KIT, DOG-1, desmin, S100, SOX10, and STAT6, excluding GIST, leiomyosarcoma, PEComa, solitary fibrous tumour, and schwannoma. Targeted RNA-based sequencing identified a canonical JAZF1::SUZ12 fusion, confirming low-grade EESS. Given the tumour’s low-grade, hormone-receptor-positive biology and microscopic radial margin involvement, adjuvant endocrine therapy with letrozole (2.5 mg daily) was initiated. At the six-month follow-up, the patient remained asymptomatic with no radiological evidence of recurrence. Primary gastric ESSS remains an exceptional finding and is easily mistaken for GIST. Accurate diagnosis and optimal management depend on comprehensive histology and immunohistochemistry, supported by fusion-gene testing, to guide individualised surgical and adjuvant management. Given the tumour’s potential for very late relapse, prolonged surveillance is warranted despite the favourable short-term outcome.