Bronchial fistula associated with sunitinib in a patient previously treated with radiation therapy.

OBJECTIVE: To report a case of bronchial fistula associated with sunitinib in a patient previously treated with radiation therapy. CASE SUMMARY: A 40-year-old man with renal cell cancer diagnosed in 2005 and initially treated by radical nephrectomy presented in March 2007 with a recurrence with cerebral, mediastinal, and lung metastases. A thoracic computed tomography (CT) scan showed a subcarinal tumor obstructing the bronchus intermedius. The patient was initially treated with cerebral and thoracic radiotherapy and then with sunitinib 50 mg/day (4 weeks on, 2 weeks off). Two months after the beginning of treatment, a CT scan revealed a dramatic reduction in the size of the tumor, associated with a bronchial fistula. This was confirmed by flexible bronchoscopy, which showed complete necrosis of the tumor and a large perforation of the bronchus intermedius. Sunitinib was immediately withdrawn and antibiotic prophylaxis was instituted. It was not possible to place an endobronchial stent. Two weeks later, flexible bronchoscopy revealed the reappearance of a yellowish mass protruding into the bronchus intermedius (40% obstruction). A few months later, the obstruction of the bronchus intermedius progressed to 90% and was associated with a contralateral obstruction of the left mainstem bronchus (20%). A rigid bronchoscopy was then performed to clear the obstruction and an endobronchial stent was placed, with satisfactory initial results. In February 2008, the patient presented with new bronchial obstruction under the endobronchial stent but refused a rigid bronchoscopy and died in March 2008. DISCUSSION: Sunitinib, a multitarget tyrosine kinase inhibitor with antiangiogenic and antitumoral activities, has been approved for the treatment of advanced renal cell carcinoma. This treatment is generally well tolerated. Serious complications may occur, however. According to the Naranjo probability scale, the bronchial fistula was possibly related to sunitinib treatment. CONCLUSIONS: This is a rare case of a bronchial perforation leading to a fistula associated with sunitinib treatment after mediastinal radiation therapy. Clinicians may consider strict follow-up of patients with proximal lung metastases treated with sunitinib (CT scan and, if appropriate, placement of an endobronchial stent).

Turpentine-induced chemical pneumonitis with broncho-pleural fistula.

Turpentine is a volatile hydrocarbon used in polishes, solvents, paints and textile industry. When hydrocarbons are aspirated into the lung, they cause chemical pneumonitis, acute respiratory distress syndrome (ARDS), and rarely pneumatoceles and pneumothorax. We report a 20-year old boy with turpentine-induced chemical pneumonitis that evolved into a bronchopleural fistula. He was treated with oxygen, steroids and intercostal tube drainage. This is the first reported case of turpentine-associated bronchopleural fistula.

Medication-induced oesophageal injury leading to broncho-oesophageal fistula.

Medication-induced oesophageal injury is one of the least recognised side-effects of oral medication and, in contrast to other oesophageal pathologies, is rarely considered in the differential diagnosis of chest pain. We describe a case of medication-induced oesophageal injury with a rare complication in which the diagnosis was not considered until the characteristic features were demonstrated at endoscopy.

Bronchoesophagopleural fistula after photodynamic therapy for malignant mesothelioma.

A 66-year-old woman presented with a bronchoesophagopleural fistula 10 weeks after thoracic photodynamic therapy for malignant mesothelioma. This is the third reported case of an esophagopleural fistula developing subsequent to photodynamic therapy for mesothelioma. We review the literature on this topic and report our successful management of this complication.

Respiratory tract fistulae in recurrent aerodigestive cancers after chemotherapy.

Bronchoesophageal fistulae, a form of respiratory tract fistula, occurred in four patients with squamous cell carcinoma arising in the esophagus or left bronchus after cytoreductive chemotherapy. All four had locoregional cancer, recurrent after high-dose external radiation therapy. Esophageal cancer was treated with sequential intravenous cisplatin 100 mg/m2 (day 1) and 5-fluorouracil (5-FU) 40 mg/m2/hour X 120 (days 2-7). Lung cancer was treated with sequential intravenous cisplatin 100 mg/m2 (day 1), 5-FU 40 mg/m2/hour X 72 (days 2-5), and etoposide 80 mg/m2/day X 3 (days 2, 3, and 4). All patients had symptomatic relief and tumor regression after oncolytic chemotherapy, which was well tolerated with no hematologic toxicity. After the second or third cycle of chemotherapy, bronchoesophageal fistula occurred in all four patients with manifestations of pneumonia, which proved fatal in two patients. The other two patients were effectively palliated for 14 and 36+ weeks after celestin tube placement. Bronchoesophageal fistula should be managed by antibiotics and respiratory support followed by elective placement of celestin tube in most patients and by esophageal exclusion or esophageal bypass in a few select patients. In aerodigestive cancers, respiratory tract fistula may be a rare and potentially fatal complication of chemotherapy induced tumor lysis.

[Late sequelae of caustic esophagitis]. / Le sequele tardive delle esofagiti da caustici.

The caustic burns of the oesophagus still play a significant role in the framework of oesophageal conditions, both in terms of therapeutic approach in the acute phase, when high morbidity and mortality rates are recorded, and of long-term consequences. These are as follows: stenoses of varying extent, carcinoma, wall deformation, oesophago-bronchial fistulae and motor disturbances. This paper is concerned with the clinical, diagnostic and therapeutic implications of these late consequences.

Role of oxygen radicals in endotoxin-induced lung injury.

We tested the hypothesis that the increased permeability in the pulmonary microcirculation seen with endotoxin is caused by the release of oxygen radicals from activated neutrophils. We first compared the pulmonary injury in sheep caused by low-dose endotoxin with that produced by phorbol myristate acetate, an agent that selectively causes the release of oxygen radicals from neutrophils. We then determined the degree of lung tissue lipid peroxidation, a reflection of direct oxygen radical damage after endotoxin and phorbol myristate acetate. Both agents produced a nearly identical increase in protein permeability; however, peroxidation was only evident with phorbol myristate acetate. Higher doses of endotoxin did result in increased lung peroxidation as well as a more severe physiologic injury. We can conclude that oxygen radical release, most likely from neutrophils, occurs with endotoxin. However, the permeability injury may not be the direct result of increased lipid peroxidation, as increased permeability can be seen without measurable increases in this parameter.

Broncho-oesophageal fistula: a late complication of endoscopic variceal sclerotherapy.

A case is reported of delayed broncho-oesophageal fistula presenting several weeks after fibreoptic injection sclerotherapy for oesophageal varices in a patient with chronic active hepatitis who eventually died from bronchopneumonia. Such serious complications of injection sclerotherapy should be kept in mind with the increasing popularity of this method of early treatment of bleeding oesophageal varices.