TRACHEOESOPHAGEAL FISTULA SECONDARY TO METASTATIC MEDIASTINAL LYMPH NODE FROM PROSTATE CANCER

Abstract

Tracheoesophageal (TE) fistula is most commonly associated with a primary thoracic malignancy such as esophageal cancer. It has also been associated with radiation esophagitis, and there are reports of TE fistula secondary to heterotopic gastric mucosa, invasive aspirgillosis, infectious esophagitis, wegener's granulomatosis, and Hodgkin's lymphoma. No reported cases of TE fistula secondary to metastatic prostate cancer could be found through pub med search. Case Report: An 85 y/o African American man presented with progressive cough and choking with swallowing liquids but not solids for 3 months. He had a history of prostate cancer (Gleason stage 9) diagnosed 8 years ago, treated with orchiectomy and antiandrogen agents. He had evidence of metastatic disease to the sacral area, bladder outlet obstruction and a progressively increasing PSA (from 2 to 44 ng/ml) over the preceding year, but no other known distant metastatic disease. His other medical problems were CVA, HTN, PVD, and GERD. He had no history of smoking or alcohol use. Upper GI x-ray done 4 yrs prior to the current presention following CVA showed esophageal dysmotility, but an otherwise normal esophagus. Video flouroscopic swallowing study done few weeks earlier was normal. Repeat barium swallow at this presentation revealed presence of a TE fistula in the mid esophagus. An enlarged mediastinal lymph node were noted at level of TE fistula on CT scan. Bronchoscopy revealed two fistulous tracts with surrounding friable mucosa but no mass. Biopsies done from the friable areas on bronchoscopy showed respiratory mucosa with squamous metaplasia. Upper endoscopy revealed a diverticulum at 27 cm from the incisors without evidence of an esophageal mass. Patient underwent right thoracotomy which confirmed the presence of the fistula between the bronchus intermedius and the esophageal diverticulum. The tract was separated and an enlarged lymph node 4 × 1 × 0.8 cms in size was removed. Primary repair of the fistula with serratus anterior flap was performed. Pathology specimen from the lymph node showed presence of metastatic adenocarcinoma of prostate primary, chronic lymphadenitis and focal calcification. Unfortunately, the patient succumbed 2 weeks after surgery. Conclusion: Metastatic prostate cancer should be considered in the differential diagnosis of a patient with history of prostate cancer presenting with TE fistula.