대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Esophago-Tracheal Fistula after Radiation Therapy in a Patient with Esophageal Cancer

Radiologic Findings

CT scans show the communication between the posterior wall of the trachea and esophageal lumen. The esophageal wall is thickened. Pneumonic consolidation is noted in right upper lobe. Pleural effusion is associated. HRCT scan shows fibrotic consolidation with traction bronchiectasis in paramediastinal portions of both upper lobe, indicating radiation fibrosis.

Brief Review

Malignant fistula between the esophagus and the respiratory tract or the mediastinum is a serious complication of esophageal carcinoma. Bronchopneumonia and sepsis usually are the terminal events. Because the esophagus lacks a serosa and is attached to neighboring structures by only a loose adventitia, there is no anatomic barrier to prevent spread of tumor into the adjacent mediastinum. Therefore, esophageal cancer has a marked tendency to invade contiguous structures in the neck or chest, such as the thyroid, larynx, trachea, bronchi, aorta, thoracic duct, lung, pericardium, and diaphragm. The tracheobronchial tree is a particularly common site of involvement; tracheoesophageal or esophagobronchial fistulas develop in 5 to 10% of all patients with esophageal cancer.
Increased morbidity or mortality may also be attributed directly to complications of treatment (e.g., radiation therapy and/or chemotherapy) such as esophageal ulceration, perforation, and fistula formation. Involvement of the respiratory tract without fistulae often leads to fistula formation during treatment due to the necrosis of the tumor or natural progression of the disease. Approximately 10-20% of esophageal carcinoma patients develop a fistula after radiation. However, there is no evidence that radiation increases the incidence of fistula formation. It also is difficult to distinguish whether the development of fistula during CRT is due to an adverse event or natural tumor invasion.

References

1. Elkon D, Lee MS, Hendrickson FR: Carcinoma of the esophagus: sites of recurrence and palliative benefits after definitive radiotherapy. Int J Radiat Oncol Biol Phys 1978;4:615-620.
2. Muto M, Ohtsu A, Miyamoto, S, et al. Concurrent chemoradiotherapy for esophageal carcinoma patients with malignant fistulae. Cancer 1999;86:1406-1413.

Keywords

Esophagus, Airway, Non-infectious inflammation, fistula,