An oesophageal stricture

This 50 year old lady presents with dysphagia and a distal oesophageal stricture is confirmed.  Intubation is a little tricky due to a pharyngeal pouch but we managed to intubate the oesophagus after the successful passage of a guidewire.  After you have obtained a set of samples (last photo), the patient asks what will happen next.
WHAT IS YOUR REPLY?

■ Too early to tell, we will await analysis of the samples first

It's not too early to tell - the signs are there!

■ Whilst we await histology, I will request at CT

Good man! And organise a cancer MDT discussion!

■ The analysis will probably be reassuring and in all likelihood a dilatation is next

Sadly, this is unlikely !

■ The pouch is more likely to be the main problem than the stricture

No, that's not it!

explanation

The stricture doesn't look quite right does it?  Somewhat 'nobbly' and without associated reflux oesophagitis. This stricture looks malignant !  There is one more concerning feature which you may have missed...

The vocal cord on the left-hand side is weaker than the right! On direct questioning, the patient confirmed that her voice had recently changed and become more hoarse!  This patient had an advanced oesophageal cancer with metastases to the high lymphnodes on the left causing a recurrent laryngeal nerve paralysis!  Out of the four options, organising a staging CT and referral to the UGI cancer MDT is the correct course of action!