Bronchial stenosis and sclerosing mediastinitis: an uncommon complication of external thoracic radiotherapy

Abstract

aaThoracic radiotherapy is one of the major treatment modalities in lung cancer. Radiation pneumonitis and fibrosis are well-known side-effects. ''Radiation bronchitis" in the form of inflammatory reaction of the airways mucosa following therapeutic external-beam radiation and highdose endobronchial radiation (brachytherapy) has also been reported. Otherwise, there is very little mention in the literature regarding the effects of the radiation on the airways.In this article, we report a case of sclerosing mediastinitis with bronchial stenosis discovered 1 yr after external thoracic radiotherapy. Case reportA right upper lobectomy for a peripheral adenocarcinoma of the ventral segment of the right upper lobe was performed on a 59 yr old woman in November 1992. This patient had a relevant medical history of a 40 pack-year history of smoking, a left sylvian stroke in 1988, and an inferior myocardial infarction in 1990. The postoperative staging (tumour, node, metastasis (TNM) classification), using a systematic mediastinal sampling, was T3N0M0 in view of an extension to the parietal pleura and the absence of metastases.External radiation therapy was, therefore, performed using an 18 MeV photon linear accelerator. Doses of 2 Gray (Gy) each were delivered in 27 fractions by a combination of anteroposterior parallel opposed fields (16 fractions), anterior direct fields (seven fractions), and anteroposterior opposed oblique angle wedge fields (four fractions). The total dose applied to the tumour bed and the right hilum was around 57 Gy. The total dose applied to the paratracheal left chain was approximately 45 Gy, and the spinal cord received about 42 Gy.In November 1993, the patient complained of persistent cough and a gradual onset of dyspnoea. On physical examination, a decrease in the breath sounds over the right lung was noted, the left lung being clear; no other findings of note were detected. Blood results were normal except for a slight elevation of hepatic enzymes. The carcinoembryonic antigen (CEA) was 10 ng·mL -1 (normal values <7 ng·mL -1 ), the level before the operation being 15 ng·mL -1 . The Mantoux test was negative.Chest radiography disclosed a right hilar enlargement and a right apical thickening. Thoracic computed tomography (CT) showed the presence of a right paratracheal mass with extension around the right main-stem bronchus, the lumen of which was severely narrowed ( fig. 1). The subcarinal area was also involved. A slight heterogeneous enhancement was observed after administration of contrast material. An area of soft tissue density containing dilated bronchi, with a straight edge corresponding to radiation fibrosis localized in the middle lobe with adjacent pleural thickening was present conforming to the radiation port. Magnetic resonance imaging (MRI) revealed that this mass had a low intensity signal both in T1 and T2 weighted images. This short T2 relaxation time was said to be suggestive of a benign fibrous process.Fibreoptic examination revealed an 80% extrinsic stenosis of the right ma...

A case of idiopathic sclerosing mediastinitis in a 7-year-old Japanese boy

“…Sclerosing mediastinitis was first described by Hallet in 1948 [3] and many similar case reports followed [1,2,4,5,6,7,8,9,10,11,12]. Recently, Rossi et al [9] reviewed the current understanding of sclerosing mediastinitis and indicated the clinical manifestations that might allow us to suspect this disorder.…”

Fibrosing mediastinitis causing rapidly progressive dyspnea, pulmonary edema and death in a 16 yr old male

“…Other diseases that have been associated with fibrosing mediastinitis include autoimmune disease, Behçet disease, rheumatic fever and other idiopathic fibro-inflammatory disorders such as retroperitoneal fibrosis, sclerosing cholangitis, Riedel thyroiditis, and pseudotumor of the orbit [6,7,10,11]. Trauma, radiation, methysergide maleate have also been associated with the development of fibrosing mediastinitis [5,6,12] Idiopathic cases are more often of the diffuse type while post inflammatory cases are more frequently localised [8].…”

A case of mediastinal fibrosis due to radiotherapy and ‘downhill’ esophageal varices: a rare cause of upper gastrointestinal bleeding

“…Although the cause and pathogenesis remain unknown, granulomatous diseases (e.g., histoplasmosis, tuberculosis, sarcoidosis), radiation therapy and drugs (methysergide) are the most common causes. An idiopathic form has also been described [4].…”