INTRODUCTION: Esophageal cancer is one of the least studied and sixth most common cause of cancer death. Most patients present with advanced disease which has a poor prognosis and a 5-year survival rate ranging from < 10% - 14%. In addition to a limited life expectancy, patients may develop many potentially incapacitating complications such as malignant dysphagia, airway stenosis, esophagotracheal fistulation or other impediments related to therapeutic or palliative interventions.
CASE PRESENTATION: A 61 year old female presented to the Emergency Department with one week of worsening dyspnea. She reported a cough of similar duration but denied fever, chills or night sweats. She had a past history of advanced esophageal cancer with placement of a coated, expandable metallic esophageal stent six months prior for dysphagia related to esophageal obstruction. Initial laboratory data showed mild leucocytosis, while the admission chest x-ray showed a small left pleural effusion. The patient became unresponsive 6 hours after admission and was subsequently intubated. Her clinical status did initially improve however she had a prolonged hospital course that was complicated by the development of pulmonary embolism and atrial fibrillation with rapid ventricular response. On day 29 of her hospital course, she developed worsening respiratory distress and the ensuing chest x-ray showed complete opacification of the left hemithorax. The patient was transferred to the medical intensive care unit and a bronchoscopy was performed which revealed fistulation of the esophageal stent at the level of the left main bronchus superorly into the lumen of the trachea. No intervention could be performed at that time so the procedure was terminated. A subsequent CT chest performed revealed complete collapse of the left lung with worsening airspace disease of the right lung. Due to the patient’s grave prognosis, the family opted for comfort care. The patient subsequently expired the following day.
DISCUSSIONS: The majority of patients with esophageal cancer present with dysphagia (74%), odynophagia (17%) and weight loss (57%). Less common presentations which may indicate extensive and unresectable disease include dyspnea, cough, hoarseness and retrosternal, back or right upper abdominal pain. Less than 50% of patients are candidates for surgical resection. For the greater majority of patients, palliation is the treatment of choice. The placement of an esophageal stent is a common palliative modality used in the treatment of dysphagia resulting from esophageal tumor obstruction, particularly in patients with advanced disease and poor functional status, unable to tolerate chemotherapy or radiation therapy, or in whom prior therapeutic interventions failed. Over 90% of patients with dysphagia experience relief after receiving expandable metal stents. Nevertheless, placement of esophageal stents have inherent risks: a) intra-procedural complications comprise those related to conscious sedation, aspiration, stent malposition and esophageal perforation; b) immediate complications include chest pain, bleeding, foreign body sensation, perforation and tracheal compression leading to airway compromise; c) late complications such as in our patient can occur up to 2 years post-insertion and consist of stent migration, esophagotracheal fistulation, pneumomediatinum, bleeding, overgrowth of granulation tissue or tumor, gastroesophageal reflux, aspiration pneumonitis and stent occlusion. It is important to note that placement of these stents decrease the rate of early but not late complications; the latter being higher in patients previously treated with chemotherapy, radiation or both.
CONCLUSION: Expandable metallic stents are effective for the palliation of malignant esophageal obstruction. However, they are associated with a number of late and frequently life-threatening complications. These complications may not be completely unavoidable, nevertheless, early recognition is vital to effectively managing these patients with such a limited life expectancy.
DISCLOSURE: Ahmad Abdel-wahed, No Financial Disclosure Information; No Product/Research Disclosure Information