Acquired Bronchoesophageal Fistula After Intensity-Modulated Radiation Therapy

Abstract

INTRODUCTION: Concurrent chemoradiation therapy (CCRT) is the standard of care for inoperable locally advanced nonsmall cell lung cancer (NSCLC). Intensity modulated radiation therapy (IMRT) is an advanced radiation delivery technique that customizes radiation dose distribution effectively reducing the dose to adjacent normal tissue. Rarely does this modality cause toxicity beyond esophagitis and pneumonitis. 1 This is a case of a patient who received IMRT and subsequently acquired a fatal bronchoesophageal fistula (BEF). CASE PRESENTATION: A 51-year-old woman with a history of lung adenocarcinoma, T4N3M1, presented with nausea and vomiting with oral intake. She also reported fever, dyspnea, and right-sided chest pain. Patient was undergoing CRT with weekly carboplatin and paclitaxel. At the time of presentation, she had received 9 cycles of chemotherapy and 52 Gy of IMRT targeting her mediastinal mass. Physical exam was remarkable for tachycardia, tachypnea and diffuse rales. CT thorax showed a thickwalled air collection posterior to the right mainstem bronchus (RMB) with marked consolidation of the right lung. Patient was treated with antibiotics and underwent fiberoptic bronchoscopy that revealed necrotic RMB with absent posterior wall and no definable distal anatomy. Subsequent esophagogastroduodenoscopy showed an esophageal perforation with direct communication into the mediastinum and RMB. Anatomy was not amenable to stenting and patient subsequently expired after family decided to pursue comfort measures. DISCUSSION: CCRT has been the preferred modality of treatment for inoperable locally advanced NSCLC for years given its survival benefits. However, this does come with increased risk of esophageal toxicity. Patients with gastrointestinal symptoms and persistent infiltrates must be evaluated to ensure absence of a BEF. This case highlights that further investigation is warranted into optimal treatment duration, dose, and fraction schedules to limit severe toxicity in this patient population. CONCLUSIONS: The formation of a BEF following concurrent CRT, though rare, can be a devastating and lethal event. As new technology in radiation therapy emerges, this case underscores the continued vigilance that must be sought in identifying patient and tumor specific characteristics that predict adverse outcomes.