What is the best course of action to evaluate and manage unintended weight loss and CT findings in a 73-year-old male with esophageal diverticulum, history of prostatectomy, and a sacral lesion?

Management of Esophageal Diverticulum with Unintended Weight Loss in a 73-Year-Old Male

Urgent endoscopy is strongly recommended as the first step in evaluation due to the high risk of esophageal malignancy associated with the 5.6 cm mid-to-distal esophageal diverticulum and unintended weight loss. 1

Diagnostic Approach

Initial Evaluation

• Endoscopy with biopsy: Must be performed promptly to rule out malignancy within the diverticulum
  • At least 6 biopsies should be taken for histological confirmation 1
  • Document exact location, size, and any mucosal abnormalities

Comprehensive Staging (if malignancy is found)

1. CT scan: Already performed, shows 5.6 cm esophageal diverticulum
2. Endoscopic ultrasound (EUS): Essential for accurate T and N staging if malignancy is suspected 1
   • Superior to CT for local staging (sensitivity 81-92%, specificity 94-97%)
   • Can assess depth of invasion and regional lymph nodes
3. PET-CT: Should be performed if patient is a surgical candidate to identify occult metastases 1
   • Can detect otherwise unidentified distant metastases in approximately 15% of patients

Risk Assessment

The patient has several concerning features:

• Unintended weight loss: Cardinal symptom requiring thorough investigation
• Large diverticulum size (5.6 cm): Larger diverticula carry higher risk of malignancy 2
• Advanced age (73 years): Risk factor for malignancy in diverticula 2
• Male gender: Another risk factor for malignancy in diverticula 2

Management Algorithm

If Malignancy is Confirmed:

1. Staging according to AJCC/UICC TNM system 1
2. Treatment based on stage:
   • Early cancer (Tis-T1a N0): Endoscopic resection or surgery 1
   • Localized disease without lymph node involvement (T1-2 N0M0): Surgical resection 1
   • Locally advanced disease: Preoperative therapy followed by surgery 1

If No Malignancy is Found:

1. For symptomatic diverticulum:

   • Surgical intervention is recommended even with minimal symptoms due to:
     • Risk of aspiration (45% of cases) 3
     • Potential for life-threatening pulmonary complications (15%) 3
     • Risk of malignant degeneration (0.6-1.8% for mid-esophageal/epiphrenic diverticula) 2

2. Surgical options:

   • Diverticulectomy with myotomy (if motility disorder present) 4, 5
   • Minimally invasive approaches when feasible 1, 5
   • In cases with structural stenosis, esophagectomy may be required 6

Nutritional Management

• Assess nutritional status and provide support according to ESPEN guidelines 1
• Consider enteral feeding if severe malnutrition is present
• Monitor weight closely during evaluation and treatment

Follow-up Recommendations

• If diverticulum is not resected, regular endoscopic surveillance is necessary due to the risk of malignant transformation 2
• Even after resection, follow-up is advisable as carcinoma may develop in treated diverticula 2

Important Caveats

• The sacral lesion should be monitored on follow-up imaging as recommended in the CT report, but addressing the esophageal pathology takes priority due to the risk of malignancy and the patient's weight loss
• The history of prostatectomy should be noted but appears stable based on CT findings
• Diagnostic delay in esophageal malignancy significantly worsens prognosis, with mortality of esophageal perforation ranging between 10-20% 1