Bronchial-Esophageal Fistula: A Rare Initial Presentation of Squamous Cell Carcinoma of the Lung.

SESSION TITLE: Cancer Student/Resident Case Report Posters IIISESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Lung cancer can have diverse and dramatic presentations. We present a case of a bronchial-esophageal fistula as the initial presentation of lung cancer, resulting in respiratory failure and acute respiratory distress syndrome (ARDS).CASE PRESENTATION: A 61 year-old Caucasian male with hypertension and Hepatitis C presented to the emergency department with 7 days of productive cough and low-grade fevers despite outpatient therapy with oral Azithromycin. On initial evaluation, he was lethargic with peripheral cyanosis and oxygen saturation in the low 70s on room air. Non-invasive ventilation was initiated; however, his respiratory status worsened necessitating endotracheal intubation. Chest imaging showed diffuse bilateral infiltrates compatible with the diagnosis of ARDS. The patient developed profound hypoxemia despite 100% FiO2, PEEP of 18 and 40 ppm of nitric oxide and on day 2 of his admission, veno-veno extracorporeal membrane oxygenation (ECMO) was initiated. While receiving ECMO, bronchoscopy was performed to collect additional culture specimens but instead revealed a necrotic ulcer on the posterior wall of the left mainstem bronchus compatible with a bronchial-esophageal fistula. Histologic samples of the ulcer were taken, and once the fistula was confirmed by endoscopy, an esophageal stent was placed. Histology returned with a diagnosis of poorly differentiated squamous cell carcinoma of the lung. Despite stenting of the fistula and ECMO support, the patient progressed to multi-organ failure. His clinical status precluded the possibility of systemic chemotherapy; patient was made comfort care and expired 5 days after initial evaluation.

DISCUSSION: Bronchial-esophageal fistula is a severe and life-threating complication, most commonly associated with advanced esophageal or lung cancer after radiation and chemotherapy, rarely occurring in early disease and seen in only <1% of lung cancer patients. Rapid diagnosis is imperative to prevent soilage of the tracheo-bronchial tree and rapid progression to respiratory failure. The best palliation for this complication is endoscopic placement of stents, after the fistula is confirmed by endoscopy.

CONCLUSIONS: This case shows that neither radiation, chemotherapy or advanced disease are necessary preconditions for fistula formation. In patients with high oxygen requirements despite all therapeutic measures, it is necessary to include bronchial-esophageal fistulas in the differential diagnosis as early treatment can increase life expectancy from days to months. Reference #1: Rodriguez AN, Malignant respiratory-digestive fistulas. Curr Opin Pulm Med 16:329-333 Reference #2: Grillo HC, Acquired tracheoesophageal and bronchoesophageal fistula. Surgery of the Trachea and Bronchi; 2003. p. 341-56.Reference #3: Reed MF, Mathisen DJ.Tracheoesophageal fistula.Chest Surg Clin N Am 2003; 13(2): 271-89.

DISCLOSURE: The following authors have nothing to disclose: Narjust Perez-Florez, Larysa Gromko, Steven Kim, Sean SadikotNo Product/Research Disclosure Information.