An unusual cause of odynophagia

A 45-year-old man presented with odynophagia, felt in the region of the upper chest. Upper GI endoscopy was normal and proton pump inhibitor therapy ineffective. Oesophageal function tests showed no reflux on 24 h pH monitoring; manometry revealed ineffective oesophageal motility (low-amplitude peristalsis) thought to explain his symptoms. He re-presented 6 years later with worsening odynophagia; repeat endoscopy showed a 1 cm nodule in the proximal oesophagus at 24 cm from the incisor teeth. Endoscopic biopsies showed features of low-grade adenocarcinoma of mucinous/tubular type. He was referred to the network upper GI cancer multidisciplinary team and a decision was made for further endoscopic assessment, after staging CT and positron emission tomography scans did not identify the tumour or any metastases; endoscopic ultrasound (EUS) was not performed. Figures 1 and 2 show the appearances at endoscopy and with narrow band imaging. How would you proceed and what is the...