Acute Hematemesis Leading to the Incidental Diagnosis of Esophageal Squamous Cell Carcinoma in an Adolescent: First Case Report From Pakistan.
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Esophageal squamous cell carcinoma (ESCC) is exceptionally rare in children and adolescents and typically presents with progressive dysphagia and weight loss. Its occurrence without conventional risk factors may pose a diagnostic challenge. A 16-year-old boy presented with acute hematemesis and no history of dysphagia, odynophagia, or recognized esophageal cancer risk factors. He was undernourished, with a BMI of 17 kg/m2 and progressive unquantified weight loss. Upper gastrointestinal endoscopy revealed a deep proximal esophageal ulcer, distal esophageal ulcers, a Mallory-Weiss tear, and gastritis. The latter lesions offered potential explanations for the bleeding, but the atypical proximal ulcer raised suspicion for malignancy, prompting biopsy. Histopathology confirmed moderately differentiated ESCC with high-grade dysplasia. Contrast-enhanced CT showed localized upper thoracic esophageal wall thickening without regional lymphadenopathy or distant metastases, and the disease was staged as T2N0M0. The patient completed three cycles of neoadjuvant carboplatin-paclitaxel-based chemotherapy followed by radiotherapy. A repeat endoscopy showed a circumferential raw mucosal area with a superficial erosion in the distal esophagus, while the upper and middle thirds of the esophagus appeared normal; however, esophagectomy was recommended as part of the planned definitive management. This case highlights the incidental discovery of ESCC during evaluation of acute hematemesis in an adolescent without conventional risk factors. Hematemesis with low BMI or unexplained weight loss should prompt careful evaluation for underlying esophageal pathology, even when an apparent benign bleeding source is identified. Early biopsy, appropriate staging, and multidisciplinary management are essential for timely diagnosis and treatment.