Esophagogastric Junction Outflow Obstruction Secondary to Metastatic Squamous Cell Carcinoma: A Diagnostic Challenge and Review of the Literature

Esophagogastric junction outflow obstruction (EGJOO) is a heterogeneous esophageal motility disorder defined by impaired relaxation of the lower esophageal sphincter (LES) with preserved peristalsis. While most cases are functional or benign, a subset stems from secondary pathologies, such as malignancy. We report a rare case of EGJOO secondary to metastatic cutaneous squamous cell carcinoma (SCC) mimicking a primary motility disorder. A 63-year-old male with two renal transplants on long-term immunosuppression presented with 2 months of progressive dysphagia and a 20-lb weight loss. Upper endoscopy revealed a tightly constricted LES without intraluminal lesions. High-resolution esophageal manometry showed an elevated integrated relaxation pressure of 31 mmHg with preserved peristalsis, confirming EGJOO. Computed tomography imaging identified an 8-cm mass at the gastroesophageal junction and a pulmonary lesion. Biopsy confirmed metastatic SCC consistent with recurrence of previous cutaneous disease. Despite chemoradiation, the patient later developed progressive tumoral encasement of the aorta and succumbed to probable aortic rupture. This case illustrates EGJOO as a rare presentation of metastatic SCC and highlights the diagnostic challenge of differentiating secondary malignant causes from idiopathic motility disorders. The Chicago Classification version 4.0 emphasizes the need for symptom-correlated testing and cross-sectional imaging when clinical suspicion for malignancy exists, particularly in patients with a cancer history or immunosuppression. Early identification of secondary EGJOO guides appropriate palliative management and avoids unnecessary invasive procedures. EGJOO secondary to metastatic SCC is exceptionally uncommon but clinically important. Comprehensive evaluation, including imaging, is essential to exclude malignancy in atypical or high-risk cases.