INTRODUCTION: Malignant Tracheoesophageal Fistulas(TEF) accounts for over 50% of acquired TEFs. This is a devastating complication most often associated with esophageal and bronchogenic carcinomas. We report a case in which a patient had a esophageal-bronchial fistula at the time of her esophageal carcinoma diagnosis. Palliative stenting initially improved her quality of life, but she went on to develop multiple esophago-pulmonary fistulas that cross the mediastinum and led to pulmonary sepsis. Three-dimensional CT imaging assisted in guiding the bronchoscopic diagnosis of her anomalous fistula communications.
CASE PRESENTATION: A 43-year-old Caucasian woman presented in May 2005 with increasing dysphagia and dyspnea with weight loss and oxygen dependent hypoxemia. Upper endoscopy revealed a 6 cm mid-esophageal squamous cell carcinoma. Bronchoscopy revealed unresectable disease with left mainstem endoluminal invasion and obstruction of left mainstem. She had an extensive oncological history including squamous cell carcinoma of the tongue requiring excision, Hodgkin's disease 12 years prior, vulvar carcinoma and glioblastoma multiforme. Prior mantle radiation given for Hodgkins precluded additional radiotherapy. In June 2005 we performed interventional bronchoscopy with laser debridement of endobronchial tumor, balloon bronchoscopy and placement of a self-expanding Nitinol stent. Follow-up bronchoscopy in September 2005 showed good airway patency. During the 6 months following stent replacement, patient's breathing improved and she was off oxygen. Symptoms recurred in February 2006 with fever, chills and increasing productive cough with sputum cultures positive for Pseudomonas and Enterococcus Faecalis. A CT scan showed multi-lobar consolidation with a new 5.7 × 5.9 cavitary lesion air fluid level extending across the posterior mediastinum with communication to the left mainstem bronchus still covered by an intact stent. 3D reconstruction and analysis of imaging revealed communication of fistula to abscess cavity to right lower lobe RB6 and RB7 segments. Video-optic bronchoscopy after patient swallowing of methylene blue marker confirms fistula drainage at the proximal left mainstem around the edge of the stent, and retrograde drainage of dye and mucopurulent material from RB6 lower lobe superior segment bronchioles into the central airways. Attempt to block drainage from the fistulous airway segments were made by placement of vascular coils within the airways. However the drainage from multiple fistulous sites could not be stemmed and the patient succumbed to overwhelming pulmonary sepsis and ARDS.
DISCUSSIONS: Untreated TEF leads to continued tracheobronchial soilage and rapidly progresses to pulmonary sepsis, with a median survival from time of diagnosis between 1 and 6 weeks. Endoscopic esophageal stenting is currently the most widely used palliative treatment modality. In our patient, bronchial stenting prolonged her survival and provided her with a reasonable quality of life. A follow up bronchoscopy done 3 months after placing the stent showed no evidence of new fistulisation. However, given the highly aggressive local growth and unpredictable natural history of esophageal cancers, the patient developed multiple esophago-pulmonary fistuls and a lung abscesses that eventually lead to pulmonary soilage, sepsis, ARDS and death. The esophago-pulmonary fistula was unusual because it crossed the posterior mediastinum, extending from the left bronchus to the cavity in right lower lobe. Use of 3D image reconstruction using high-resolution CT scan assisted in the assessment of fistula-abscess drainage pattern and can be useful in planning interventions to control unwanted drainage.
CONCLUSION: Esophageal cancers grow aggressively with local extension and frequently lead to esophageal-bronchial fistulas. Flagrant disregard for anatomical boundaries may occur, leading to unusual patterns of spread. Simple stenting is inadequate in this circumstance and novel management is sought. There is no consensus regarding optimal follow-up with imaging and/or bronchoscopy and needs to be tailored to each patient's situation.
DISCLOSURE: Johann Brandes, None.