When Esophagus Met Bronchus: And Itʼs not a Love Story

Abstract

Esophagopulmonary fistula is a devastating complication of advanced esophageal cancer (EC). Embryonically, the trachea and esophagus are derived from the foregut. When these structures meet again, they impact oral feeding and quality of life. This connection during development likely causes future malignant invasion into the respiratory tract. The incidence of stage T4, in which the tumor invades adjacent structures, is reported to be 8-30% among thoracic esophageal carcinomas.WhileEC accounts for 1% of all newly diagnosed cancers in the US, it is the 7th leading cause of cancer deaths among men. The 5-year survival rate of EC is 18% at diagnosis drops to 5% with stage IV disease, likely due to complications. We present one such complication, esophagopulmonary fistula, diagnosed with esophagogastroduodenoscopy (EGD). A 60-year-old Caucasian male presented with back pain, 10 lb. weight loss, and progressive dysphagia for 2 weeks. He had history of hypertension and a hiatal hernia, but denied heartburn. He was a former smoker, 1 pack/day for 5 years, with an average BMI. Barium esophagogram revealed a lobulated soft tissue mass near the GEJ. Contrast CT demonstrated a large heterogeneous enhancing esophageal soft tissue mass, as well as bilateral pulmonary nodules. Endoscopy revealed an esophageal mass from 29cm to the GEJ at 37cm, encompassing 75% of the lumen. Our advanced endoscopist was able to pass the endoscope into the stomach. While maneuvering around the mass, a pulmonary fistula was observed on the right side of the esophagus at 30cm. Given the location and the two lumens, this fistula was believed to connect to the right middle lobe bronchus. Biopsies were consistent with esophageal adenocarcinoma. He was palliatively treated with a covered stent, allowing him to eventually eat solids. ECs are aggressive and often diagnosed at later stages when complications are increased, namely esophagopulmonary fistulas. Making screening in this population is of utmost concern. Our patient adamantly denied heartburn or acid regurgitation. However, his wife reported that he had daily reflux and chronic cough, but declined to seek medical evaluation. This case serves to highlight the importance of strong patient and primary care provider relationships, to hopefully discover more EC cases in earlier stages. This case also affirms that covered expandable metallic stents allow for feeding, safely prevent aspiration from the fistula, and improve quality of life.Figure: Anatomical Reference - Esophagus cm from Incisors.Figure: Proximal Portion of Esophagopulmonary Fistula.Figure: Communication between Esophagus and Right Middle Lobe Bronchus.