Tracheomediastinal fistula: complication of mediastinal lymphoma

Posted By Maria Andrea Calderón A
Tracheomediastinal fistula: complication of mediastinal lymphoma

Gender, Age

Male, 17

Diagnosis

Tracheomediastinal fistula secondary to mediastinal lymphoma

History

17-year-old male patient with a history of mediastinal T lymphoblastic lymphoma with prevascular mediastinal lymph node involvement, under management with Vincristine, Daunorubicin, and L-Asparaginase, who initially consulted the emergency department due to headache and venous sinus thrombosis was detected in a skull tomography. During hospitalization, the patient presented bronchospasm and signs of respiratory distress and was transferred to the Intensive Care Unit. Tomographic acquisition of the thorax with contrast identified a decrease in the caliber of the tracheal lumen in the subglottic region, which is attributed as responsible for the stridor; prevascular conglomerates with peripheral enhancement and low internal density, suggesting necrosis (Figure 1), which have decreased in size compared to the previous study were also documented. A solution of continuity of the anterior wall of the trachea and fistulous path with air communicating with the prevascular space (Figure 2a and 2b), associated with a low level of liquid inside the trachea, confirms the passage of the mediastinal necrotic material into the airway. The surgical service considers expectant management and possible spontaneous closure of the fistula due to its small size and the absence of pneumomediastinum, cardiac tamponade, or associated mediastinitis. Days later, the patient presented with ventilatory failure, and he underwent emergency surgery for placement of a tracheostomy, and a new tomographic acquisition of the thorax was performed after the procedure. Occlusion of the solution of continuity of the anterior wall of the trachea is reported (Figure 3a and 3b) employing the tracheostomy cannula; however, multilobar pneumonia secondary to aspiration is currently evidenced (Figure 4). The patient is reassessed by the surgery department who report that there is no requirement for surgical intervention due to the absence of mediastinal infectious involvement and that the tracheostomy tube occludes the fistula. The pulmonology department tried to dilate the tracheal stenosis, by fiberoptic bronchoscopy, which was unsuccessful. Currently, the patient restarted cycles of chemotherapy with Cytarabine and completed antibiotic management due to the pulmonary infectious process. The latest thoracic tomographic acquisition showed spontaneous closure of the fistula, without the need of previous surgical intervention besides the tracheostomy.

Findings

Tomographic acquisition of the thorax with contrast identified a decrease in the caliber of the tracheal lumen in the subglottic region, which is attributed as responsible for the stridor; prevascular conglomerates with peripheral enhancement and low internal density, suggesting necrosis (Figure 1), which have decreased in size compared to the previous study were also documented. A solution of continuity of the anterior wall of the trachea and fistulous path with air communicating with the prevascular space (Figure 2a and 2b), associated with a low level of liquid inside the trachea, confirms the passage of the mediastinal necrotic material into the airway. Days later, the patient presented with ventilatory failure, and he underwent emergency surgery for placement of a tracheostomy, and a new tomographic acquisition of the thorax was performed after the procedure. Occlusion of the solution of continuity of the anterior wall of the trachea is reported (Figure 3a and 3b) employing the tracheostomy cannula; however, multilobar pneumonia secondary to aspiration is currently evidenced (Figure 4).

Discussion

Abnormal communications between the airway and adjacent structures occur mainly with the esophagus, less frequently with the pleural space, and rarely with the mediastinum. Likewise, primary neoplasms of the trachea represent approximately 0.1% of malignant neoplasms. The involvement of the tracheobronchial tree due to lymphoma is anecdotal, and little has been described about the contiguous infiltration of the airway by mediastinal lymphoma. Tracheo-mediastinal fistulas are very rare and with an unknown incidence, however, they are important causes of increased morbidity and mortality in patients. Its origin can be malignant in cases of mediastinal lymphoma, squamous cell carcinoma, and lung adenocarcinoma. There are case reports describing fistulas of benign origin, secondary to necrotizing mediastinitis, infectious complications after heart-lung transplantation, long-term sequelae of cardioverter-defibrillator implantation, migration of bronchial metal stents, or tuberculous lymphadenitis. Regarding the development of fistulas secondary to treatments, the respiratory tract is sensitive to chemo and radiotherapy, with complications such as fistulas in a period within 2 and 4 months after start of treatment. Pathophysiological changes include a temporary inflammatory reaction associated with ciliary paralysis, as well as reactive fibrosis and endarteritis of the tissues subjected to chemo and radiotherapy that compromises the vascular supply, creating a hypoxic environment for malignant cells and normal tissue. Hypoxia leads to mucosal edema, associated with cartilage necrosis, and perforation of the tracheal wall. In patients with non-small cell lung carcinoma, the use of Bevacizumab in addition to chemotherapy, reduces progression - free survival. However, it is associated with adverse effects such as hypertension, thromboembolism, bleeding and gastrointestinal perforation. Although tracheal fistulas in the setting of the patient with lung carcinoma are a known complication, they are quite rare. Bevacizumab is a monoclonal antibody directed against vascular endothelial growth factor, inhibiting angiogenesis and therefore delaying wound healing, fulfilling a determining factor in the development of this rare complication. Prevascular or paratracheal mediastinal lymph nodes treated with chemo or radiation therapy show changes due to necrosis, fibrosis, or scarring. These changes traction the airway and cause the fistulous path. The presence of enlarged lymph nodes in contact with the tracheal wall may increase the likelihood of fistula development. The clinical presentation is variable, with manifestations such as cough with expectoration, tension pneumothorax, massive compressive hemothorax or mediastinal infections. The most frequent complications of tracheal-mediastinal fistulas are mediastinitis and the development of multilobar pneumonia secondary to aspiration of necrotic material.

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