Lung Pathology |

Invasive Tracheal Metastasis: Fatal Complication of Stereotactic Body Radiation Therapy FREE TO VIEW

Nataliya Kozodoy, MD; Anthony Boulos, MD; Abdulmonam Ali, MD; Fadi Safi, MD
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University of Toledo Medical Center, Toledo, OH

Chest. 2015;148(4_MeetingAbstracts):608A. doi:10.1378/chest.2262635
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SESSION TITLE: Lung Pathology Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Renal cell carcinoma (RCC) is an important and increasing public health threat in the developed world. In the US 17 % of patients diagnosed with de novo RCC present with metastatic disease most often to lung (50-60%), bone (30-40%), liver (20%) and brain (5-11%). No treatment is effective for majority of patients with systemic disease; median survival time of those with metastatic disease is 6-12 months with a 2-year survival rate of 10-20% 1. Stereotactic body high-dose fraction radiation therapy (SBRT) has shown a high local control rate however it is not without complications.

CASE PRESENTATION: A 66 year old male with medical history of RCC clear cell type s/p left nephrectomy in 2007 with metastasis to bone presented to clinic with persistent cough and submassive hemoptysis. Bronchoscopy revealed tracheal mass nearly obstructing the tracheal lumen 1 cm proximal to main carina. Endobronchial biopsy, cytology brush, and bronchoalveolar lavage were all negative for malignant cells. PET/CT showed avidity with SUV 5.0 in distal trachea. Multidisciplinary discussion occurred and decision was made to proceed with SBRT for presumptive metastatic renal cell carcinoma with tracheal invasion. Patient completed 5000 cGy radiation in 5 equal fractions with improvement in symptoms. Repeat bronchoscopy 4 months after SBRT therapy revealed necrotic tracheal tissue with concern of mediastinitis. Hospitalization 5 months after SBRT was due to recurrence of submassive hemoptysis. Repeat CT chest revealed acute mediastinitis with aortic ulceration of ascending aorta. Patient also reported expectorating pieces of thick tissue found to be remnants of tracheal cartilage. Rapid decline in hemodynamic status ensued and patient subsequently exsanguinated from ultimate aortic perforation.

DISCUSSION: Without definitive therapy this patient would almost certainly have died of metastatic carcinoma to trachea. The patient could also die from aggressive treatment in context of treatment-related complications affecting lung parenchyma and adjacent vasculature.

CONCLUSIONS: SBRT continuously evolves and is at the precipice of the technological advancements in image guidance, dosimetric parameters, and radiation delivery to direct radiation ablation doses to tumors. Careful evaluation and management of patients in multidisciplinary clinical setting, as well as a very thorough informed consent process are essential to ensuring the best possible treatment and outcome.

Reference #1: 1. Jemal A. Cancer statistics, 2013. CA Cancer J Clin 2013

DISCLOSURE: The following authors have nothing to disclose: Nataliya Kozodoy, Anthony Boulos, Abdulmonam Ali, Fadi Safi

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