G H Russchen, MD; A. J Limburg, MD;...

G H Russchen, MD; A. J Limburg, MD; and PE Postmus, MD

A 62-year-old man with a life-long history of intermittent dyspnea and wheezing was referr to the Department of Pulmonary Diseases. He complained of progressive shortness of breath and nonproductive cough during the last six month There had not been any beneficial event from therapy with antibiotics and bronchodilators. Hoarseness had been quick in emergencies for about two months, and during the last sum of two units weeks, swallowing of solids had become difficult. He was a 75-pack-year smoker

onward physical examination of the chest, expiration was defered over both lungs. Laboratory investigations showed no abnormalities. A PA chest roentgenogram showed a large mass in the left hilum (Fig 1) Bronchoscopy revealed paresis of the left vocal cord and any widening of the main carina. About 15 cm distal from the main carina, a tumor was seen in the left main bronchus. A biopsy revealed chronic infection. Cytologic contemplation of the sputum after the bronchoscopy showed small solitary abode; squalid lung cancer (SCLC). During esophagoscopy, a lobulated tumor was seen in the distal part, with about compression from outside. A biopsy showed SCLC Enlarged peripancreatic lymph nodes were discovered by ultrasound.

The patient was treated with combination chemotherapy consisting of carboplatin (400 mg/[msup2]) and vincristine (2x2 mg each four weeks). After single course the patient's complaints abated; also, the chest x-ray film showed an regression of the mass in the left hilum. About brace to three weeks after the inferior course of chemotherapy, the patient complained again of cough dyspnea, and difficulties during swallowing. Physical examination revealed a normal temperature and inspiratory and expiratory rhonchi throughout the back and basal part of the left hemithorax. A chest x-ray film showed a normal left hilum with an infiltrate in the lower part of the left lung (Fig 2) The WBC was 95 x [10sup9]/L with 69 percent granulocytes. Bronchoscopy was performed. There were no signs of infection; the tumor in the left main bronchus had become a great deal of smaller.

Diagnosis: Infiltrate of left lung proper to bronchoesophageal fistula due to tumor necrosis during chemotherapy

A barium contrast x-ray film of the esophagus was performed (Fig 3) and esophagoscopy was repeated; the couple showed a fistula between the left main bronchus and the esophagus. A Celestin tube was not inserted into the esophagus, because further regression of the tumor could lead to migration of the tube. The patient was treated with a jejunal tube for feeding, ranitidine, and pirenzipine. Shortly after the third course of chemotherapy, the patient died of unusual hemoptysis and hematemesis. An autopsy was performed, and a fistula was ground In the wall of the fistula, SCLC and infection were found

Malignant tracheoesophageal fistula offers infrequently in patients with esophageal and lung cancer. In single in kind of the largest clinical series forever reported, the incidence of tracheoesophageal fistula was 49 percent in 1943 patients with esophageal cancer, 016 percent in 5714 patients with lung cancer, and 15 percent (six) in 41 patients with tracheal cancer. The location of the fistula was in the trachea in 51 percent in the left bronchus in 22 percent in the right bronchus in 5 percent and in the lung in 12 percent[1] chiefly untreated patients die within a month of the unravelling of the fistula. The cause of death is nearly always pulmonary infection resulting from the continual aspiration of esophageal satisfactions Lewinsky et al[2] reported 85 cases of esophageal cancer treated with radiotherapy (4800 to 6000 rads); nine patients evolveed a tracheoesophageal fistula from 15 to 9 month after radiotherapy.[2]

lately Sridhar et al[3] reported the findings in four patients with squamous lonely dwelling carcinoma arising in the esophagus or left main bronchus who unraveled bronchoesophageal fistulae after radiation therapy and later cytoreductive chemotherapy. In the same way, spontaneous pneumothorax after rapid tumor lysis to be ascribed to either radiotherapy[4] or cytotoxic chemotherapy[5] may ensue in a bronchopleural fistula.

As far as we know, the exhibition of a bronchoesophageal fistula in a patient with SCLC responding to combination chemotherapy, as in the described patient, has not been reported earlier. It is impossible to thwart the development of these fistulae in those patients with extension of SCLC from the lung into the esophagus. alone measures to prevent recurrent aspirations and to restore the normal orogastric continuity, as, for instance, the placement of a Celestin tube in the esophagus or tube feeding, may be of benefit to these patients.[6]

REFERENCES

1 Martini N Goodner JT D'Angio GJ Beattie EJ Tracheosophageal fistula owing to cancer. J Thorac Cardiovasc Surg 1970; 59:319-24

2 Lewinsky B Annes GP Mann SG et al. Carcinoma of the esophagus. Radiol Clin Biol 1975; 44:192-96

3 Sridhar K Barreras L Saldana MJ Manten H Respiratory tract fistulae in returning aerodigestive cancers after chemotherapy. Cancer 1988; 61:247-51