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Rare chemotherapy-related tracheoesophageal fistula secondary to lymphoma
Ang Qi Xuan1, Sakina Ghauth2, Liew Yew Toong2
1 Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
2 Department of Otorhinolaryngology, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| Date of Submission | 15-Dec-2020 |
| Date of Decision | 12-Jun-2021 |
| Date of Acceptance | 18-Jun-2021 |
| Date of Web Publication | 29-Jun-2022 |
Correspondence Address:
Liew Yew Toong,
Department of Otorhinolaryngology, University Malaya Medical Centre, Kuala Lumpur
Malaysia
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/ijc.IJC_1350_20
Tracheoesophageal fistula (TEF) is a rapidly fatal condition where patients usually succumb to death from intractable aspiration pneumonia.[1] Acquired TEF due to neoplastic processes are commonly associated with primary esophageal or pulmonary carcinoma.[2] Here, we report a rare case of postchemotherapy TEF secondary to Hodgkin lymphoma.
A 27-year-old lady without any underlying medical condition presented with diffuse painless neck swelling for 3 months. The mass was progressively increasing in size, associated with low-grade fever, progressive dysphagia, and shortness of breath. Clinical examination revealed diffuse cervical lymphadenopathy, which was confirmed by a contrasted computed tomography (CT) of the neck. There was also diffuse mediastinal lymphadenopathy. The diagnosis of Stage 3 Hodgkin lymphoma was established from the core needle biopsy of the cervical lymph node. She was started on a chemotherapy regime consisting of Adriamycin, bleomycin, vinblastine, and dacarbazine. After the second cycle of chemotherapy, she developed multiple episodes of aspiration pneumonia with choking, and needed intubation to protect the airway. A massive TEF of 2 cm in length, 1.2 cm in diameter, was detected at the level of C7 from endoscopic esophagoscopy [Figure 1] and [Figure 2] and CT of the neck [Figure 3]. After intubation, she was managed conservatively with intravenous antibiotics, feeding gastrostomy and antisialagogue but to no avail. Endoscopic insertion of dual stentings – both esophagus and trachea – was performed to provide structural support to maintain luminal patency and to seal the fistula. [Figure 4] We used the tracheal stent as well due to the mass effect on the trachea from mediastinal nodes. She recovered from pneumonia gradually and remained asymptomatic with normal oral intake after the completion of chemotherapy and is currently under remission. TEF usually develops during or after the completion of radiotherapy and/or chemotherapy.[3] The exact mechanism is still unclear. It is believed to be due to rapid tissue necrosis. The prognosis of TEF associated with lymphoma is generally better than those associated with primary esophagus or lung carcinoma.[4] Dual stenting with airway and esophageal stent insertion is proven to be safe[5] and effective in TEF closure.[6] It improves the quality of life as well as the survival of patients with malignant TEF.[1] | Figure 1: OGDS view: A fistula occluded by endotracheal tube balloon (pointed with an arrow)
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 | Figure 2: OGDS view: Another view showing the extent of the fistula (pointed with an arrow)
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 | Figure 3: Contrasted CT coronal view: The continuation between trachea and esophagus (pointed with an arrow)
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Declaration of patient consent
Informed consent has been obtained from the patient for the publication of this case report and any accompanying images.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| » References | |  |
| 1. | Reed MF, Mathisen DJ. Tracheoesophageal fistula. Chest Surg Clin N Am 2003;13:271-89.  |
| 2. | Burt M, Diehl W, Martini N, Bains MS, Ginsberg RJ, McCormack PM, et al. Malignant esophagorespiratory fistula: Management options and survival. Ann Thorac Surg 1991;52:1222-8; discussion 1228-9. |
| 3. | Balazs A, Kupcsulik PK, Galambos, Z. Esophagorespiratory fistulas of tumorous origin. Non-operative management of 264 cases in a 20-year period. Eur J Cardiothorac Surg 2008;34:1103-7. |
| 4. | Perry RR, Rosenberg RK, Pass HI. Tracheoesophageal fistula in the patient with lymphoma: Case report and review of the literature. Surgery 1989;105:770-7. |
| 5. | Bi Y, Ren J, Chen H, Bai L, Han X, Wu G. Combined airway and esophageal stents implantation for malignant tracheobronchial and esophageal disease. Medicine 2019;98:e14169. |
| 6. | Paganin F, Schouler L, Cuissard L, Noel JB, Becquart JP, Besnard M, et al. Airway and esophageal stenting in patients with advanced esophageal cancer and pulmonary involvement. PLoS One 200;3:e3101. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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