Advanced esophageal cancer necrotizing through mediastinum into the right bronchus intermedius: a novel presentation of bronchoesophageal fistula

SESSION TITLE: Disorders of the Mediastinum Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Malignant bronchoesophageal fistulas are a known complication of advanced esophageal cancer. Typically, these cancers will erode into the left main bronchus or if high enough will create a tracheoesophageal fistula. Bronchoesophageal fistulas occur in only 6% of fistulas resulting from a primary esophageal tumor. In this case report we present a unique bronchoesophageal fistula resulting from esophageal cancer eroding through the mediastinum into the right bronchus intermedius. CASE PRESENTATION: A 59-year-old male with history of tobacco use presented to the emergency room with a four month history of fatigue, cough and weight loss. Patient also had complaints of a 1-week history of increased greenish-yellow sputum production. He reported a 20-pack year history although quit smoking 2 months ago.Initial work up with CT chest imaging had found a mid-esophageal rupture with communication to the right pleura. Also noted at that time was an expansive loculated right pleural effusion collapsing the right middle and lower lobes. Esophagram shortly after was diagnostic for right sided bronchoesophageal fistula. Initially it was thought that perhaps only an esophageal stent would be required, but potential pneumomediastinum would occur if stenting the bronchus did not coincide. Gastroenterology and interventional pulmonology worked together to provide the patient with palliative stenting of the esophagus and right bronchus intermedius followed by right surgical chest tube placement.Esophageal and tracheobronchial stenting were done under fluoroscopic guidance where fully covered stents were placed. A Merit 23x70mm EndoMAXX esophageal stent was placed distally at 35 cm from the incisor, followed by telescoping a Merit 19x70 mm EndoMAXX esophageal stent with proximal end 27 cm from the incisor. Lastly a Merit 12x20mm AERO tracheobronchial stent was placed to cover the tumor and fistula. The tumor was 5mm proximal to RML bronchial os and measured 10mm, while the fistula was measured 1.5cm above the RML bronchial os and measured 4mm. Patient tolerated the procedure well and was able to advance his diet the next day. Patient required antibiotics postoperatively as food particles had aspirated from the esophagus to the right bronchus intermedius. He also required 6 total intrapleural instillations of TPA and dornase for the loculated empyema. Biopsy of the esophageal mass reveal squamous cell carcinoma of which oncology organized treatment with radiation oncology. Patient was then discharged to the palliative care unit and subsequently home with follow up with pulmonology, gastroenterology, and oncology. DISCUSSION: Typical signs and symptoms of trachea-bronchoesophageal fistulas vary depending on the size and location. Most likely symptoms include cough, aspiration, fever, and dysphagia of which this patient had. In this patient's case there was no direct fistulation between the esophagus to the trachea or left main bronchus but rather an extended tract across the mediastinum from the left posterior mediastinum into the right hemithorax. Aspiration in this patient required food particles to traverse through the mediastinum. CONCLUSIONS: As far as we know, this presentation of BE fistula has not been reported. Despite its novel appearance with aspiration through the mediastinum, the management remains the same in terms of standard of care. REFERENCE #1: Argüder E, Aykun G, Karalezli A, Hasanoğlu HC. Bronchoesophageal fistula. J Bronchology Interv Pulmonol. 2012 Jan;19(1):47-9. doi: 10.1097/LBR.0b013e31823fc99e. PMID: 23207263. REFERENCE #2: Kim HS, Khemasuwan D, Diaz-Mendoza J, Mehta AC. Management of tracheo-oesophageal fistula in adults. Eur Respir Rev. 2020 Nov 5;29(158):200094. doi: 10.1183/16000617.0094-2020. PMID: 33153989; PMCID: PMC9488631. REFERENCE #3: Smith C, Bannon M, Ashraf A, Kaushik P, Marak C. Bronchoesophageal fistula: An unusual manifestation of lung cancer. Respir Med Case Rep. 2022 Mar 21;37:101634. doi: 10.1016/j.rmcr.2022.101634. PMID: 35345567; PMCID: PMC8956807. DISCLOSURES: No relevant relationships by Kendall Creed No relevant relationships by Arjan Flora No relevant relationships by Savannah Hauter No relevant relationships by Chloe Hundman