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Bilateral Airway Necrosis

Angel, Luis F. M.D.*; Dushay, Kevin M. M.D.; Ernst, Armin M.D.*

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Divisions of Pulmonary and Critical Care Medicine, *Beth Israel Deaconess Medical Center, Boston; and †St. Vincent's Hospital, Worcester, Massachusetts, U.S.A.

Address reprint requests to Dr. Armin Ernst, Beth Israel Deaconess Medical Center, West Campus, One Deaconess Road, Boston, MA 02115 USA; e-mail: aernst@caregroup.harvard.edu

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CASE

A 66-year-old man was transferred from an outside hospital for evaluation and management of a bronchoesophageal fistula. The patient was in his usual state of health until 12 months before admission, when he developed a cough that persisted for more than 6 months. Six months later he developed hemoptysis. Evaluation by chest radiography indicated a right hilar mass. Flexible bronchoscopy showed a necrotic tumor protruding into the proximal bronchus intermedius. The area was debrided and a diagnosis of Hodgkin's lymphoma was made. Computed tomography of the chest revealed a marked subcarinal tumor as well as a right hilar mass. The patient underwent chemotherapy and radiation therapy to the right hilar and subcarinal region totaling 1,600 cGy. After finishing the external radiation he presented with right lower lobe pneumonia and sequelae of malnutrition. Repeat bronchoscopy showed a necrotic crater in the left mainstem bronchus distal to the main carina. The lesion was suspicious for a fistula. The right main bronchus was also suspicious for a fistulous tract extending into the subcarinal mediastinum. Computed tomography and barium swallow confirmed a bronchoesophageal fistula extending to the right bronchus intermedius. At this point the patient underwent esophageal stenting. Unfortunately, the follow-up barium swallow showed persistent leakage from the esophagus.

The patient was then transferred to our institution for evaluation and management of the persistent fistula. A rigid bronchoscopy was performed. The main carina was involved diffusely with tumor (Fig. 1), the right mainstem had a large medial defect involving the right middle lobe uptake and free view of the mediastinum (Fig. 2), and the right lower lobe was completely occluded with purulent material. The left mainstem bronchus had a large medial defect and free access to the mediastinum. A covered, metallic, self-expandable stent was placed in the left main bronchus. The patient opted for comfort care from thereon and died 4 weeks later.

FIG. 1.

FIG. 1.

FIG. 2.

FIG. 2.

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DISCUSSION

Hodgkin's lymphoma frequently presents as a mediastinal mass. Large mass size and direct invasion of the adjacent lung are adverse prognostic factors. Many of these masses compromise some mediastinal structures including the trachea and subcarinal space. 1

Perforation of the gastrointestinal tract at the site of disease in patients with gastrointestinal lymphoma who are receiving chemotherapy has been well described 2; however, severe bilateral airway necrosis and perforation after chemotherapy and radiation for mediastinal lymphoma has not been reported previously.

Radiation necrosis of the tracheal cartilages and mucosa is an uncommon complication of radiotherapy for lymphoma or other mediastinal tumors. It is a devastating process for which there currently is no good therapy. 3

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REFERENCES

1. Strollo DC, Rosado-de-Christenson ML, Jett JR. Primary mediastinal tumors: part II. Tumors of the middle and posterior mediastinum. Chest 1997; 112:1344–57.
2. Melnyk A, Graham NJ, Weber D, et al. Lethal tracheal dissolution during treatment for thyroid lymphoma. Thorax 1995; 50:1120–1.
3. Oppenheimer RW, Krespi YP, Einhorn RK. Management of laryngeal radionecrosis: animal and clinical experience. Head Neck 1989; 11:252–6.
© 2002 Lippincott Williams & Wilkins, Inc.