Clinical Instructor House Staff The Ohio State University Wexner Medical Center Columbus, OH
Mitchell L. Ramsey, MD1, Sebastian G. Strobel, MD2, Peter P. Stanich, MD1; 1The Ohio State University Wexner Medical Center, Columbus, OH; 2Roswell Park Cancer Institute, Buffalo, NY
Introduction: Patients with cancer may develop dysphagia during the course of anti-neoplastic treatment. While esophagitis is common in this population, aerodigestive fistulae should be considered in the differential diagnosis. We present a case of a tracheoesophageal fistula caused by a lung metastasis.
Methods: A 51 year old female with breast cancer metastatic to brain, lungs, and bones, previously treated with breast radiation and currently on treatment with oral alpelisib, presented with acute-onset dysphagia. Vital signs, chest X-ray, and leukocyte count were unremarkable. A bedside swallow test with clear liquid demonstrated immediate coughing and regurgitation of the fluid. The physical examination was otherwise unremarkable. Suspecting oropharyngeal dysphagia, speech and language pathology were consulted. A modified barium swallow was performed and revealed a tracheoesophageal fistula (Figure 1). A tracheoesophageal fistula was identified (Figure 2) on upper endoscopy and a fully covered metal stent was deployed. Pulmonology then conducted a bronchoscopy which revealed a patent airway. After 48 hours, an esophagram demonstrated the stent in appropriate position (Figure 3). She was discharged on post-procedure day 5, tolerating a modified diet. During the follow-up period, her cancer progressed despite therapy and she elected for hospice care. Discussion: Malignant aerodigestive fistulae may complicate the management of cancers involving the esophagus, trachea or, less commonly, the lungs. The incidence increases with tumor size and sensitivity to chemotherapy or radiotherapy: treatment-related tumor necrosis may lead to fistulization in large, sensitive cancers. Once reserved for palliation of aerodigestive fistulae, endoscopic management is increasingly employed as definitive therapy. Several treatment strategies have been investigated, with the largest body of evidence supporting the use of partially or fully covered self-expanding metallic stents (SEMS) in the esophagus. Respiratory stent placement may be an alternative or complementary therapy for some patients. Treatment with a combination of esophageal and tracheal stents should be considered for large fistulae or when there is risk of respiratory tract compression from placement of the esophageal stent. Other endoscopic therapies include fistula closure using over-the-scope clips, tissue adhesives, or endoluminal vacuum-assisted closure.
Figure 1: Modified barium swallow demonstrates contrast in the right mainstem bronchus and secondary bronchi
Figure 2: Upper endoscopy shows a fistula (arrow) in the distal esophagus
Figure 3: Esophagram reveals an esophageal stent without leakage of contrast
Disclosures: Mitchell Ramsey indicated no relevant financial relationships. Sebastian Strobel indicated no relevant financial relationships. Peter Stanich indicated no relevant financial relationships.