Case report
A 63 year-old female patient was transferred to our hospital for further evaluation
of an unusual tracheal lesion. In November 2011, an advanced ulcerating low differentiated
keratinizing squamous cell carcinoma (SCC) of the oesophagus had been diagnosed. Palliative
chemotherapy and radiotherapy had been performed in the past but had to be stopped
later on due to progressive disease and deterioration in ECOG (Eastern Cooperative
Oncology Group) Performance Status [1 ]. In February 2012, endoscopic dilation and implantation of an oesophageal stent
was necessary due to stenosis. Since the beginning of July 2012, the patient suffered
from hoarseness and progressive cough without expectoration and therefore was admitted
to the hospital where the oesophageal carcinoma (EC) was first diagnosed and treated.
Computed tomography ([Fig. 1 a – c ]) and bronchoscopy were performed before transfer to our hospital.
Fig. 1 Oesophago-tracheal fistula of 3.6 cm length after oesophageal stenting with high
grade tracheal stenosis.
On first inspection with flexible bronchoscopy a long segmental penetration of the
oesophageal stent into the trachea was obvious, covering the complete tracheal width
and a length of 3.6 cm ([Fig. 2 ]). The distance to the main carina was 3 cm and to the vocal cord-planar approximately
4 cm. The penetration caused a slot-shaped high grade stenosis of the trachea which
could be passed easily with the bronchoscope. Additionally, the mucosa of the middle
lobe was swollen with consecutive concentric constriction of the middle lobe ostium.
Histological analysis of the mucosal biopsy revealed SCC with adenocarcinoma components
according to a pulmonary metastasis of the EC. Implantation of a tracheal stent (80 mm × 20 mm)
via rigid bronchoscopy was performed and seemed to be successful with correct bronchoscopic
localization of the stent. However, the patient developed severe hypoxemia shortly
after the procedure. X-ray suggested a dislocation of the stent ([Fig. 3 a ]) which had to be retracted immediately. In a second session a covered expandable
nitinol stent (60 × 20 mm, nickel-titanium alloy, Micro-Tech Europe) was implanted
successfully ([Fig. 3 b ]) with a distance to both main carina and vocal cord planar of 1 cm, respectively
([Fig. 4 a, b ]). Flexible bronchoscopy confirmed the correct localization of the stent one day
after implantation. The patient could be re-transferred for further palliative treatment.
Fig. 2 Oesophageal stent penetrating the trachea through the dorsal tracheal wall and causing
high grade stenosis in bronchoscopy.
Fig. 3 a Infiltrative lesion in the left upper pulmonary lobe highly suggestive for dislocation
of the tracheal stent, b Correct localization of the oesophageal stent in X-ray. Due to reduced performance
status, a standing lateral radiograph to visualize the correct position of the tracheal
stent was not possible.
Fig. 4 Tracheal stent with a distance to both main carina and vocal cord planar of 1 cm,
respectively, in bronchoscopy.
Discussion
EC is the sixth most common cause among cancer related deaths [2 ]. Risk factors for EC identified so far include alcohol abuse [3 ], chewing tobacco [2 ] and low consumption of fruit and vegetable [4 ]. Diagnosis, treatment and follow-up should be performed according to current guidelines
[5 ]
[6 ]. Advanced EC may erode into adjacent structures and hereby cause esophagorespiratory
fistulas (ERF). This complication with relevant impact on prognosis occurs in less
than 20 % of patients with EC [7 ]. The main fistula site is the trachea [8 ]. Several fistulas may occur in the same patient [9 ]. Computertomography and bronchoscopy are the main diagnostic tools for further evaluation.
In patients with EC and good performance status, surgery remains a treatment option
for ERF. Besides surgical treatment, stenting of oesophagus, airway or both is an
efficient palliative therapeutic alternative which can relieve symptoms and may improve
survival [10, 11]. Symptoms can be mainly attributed to pulmonary infections due to
recurrent aspiration.
Tracheal perforation has been a common complication in 15 to 40 % of patients after
oesophageal stenting with conventional unexpandable plastic prostheses which was the
treatment of choice for ERF until the early 1990s [12 ]. Nowadays, the use of covered expandable metallic stents has been established as
these stents show less procedural complications [13 ]. However, perforation of the trachea by this type of oesophageal stents has also
been described [14 ].
