Delayed esophageal perforation from stereotactic body radiation therapy for locally recurrent central nonsmall cell lung cancer
An 85-year old male with medical history of hypertension, type-2 diabetes, and coronary artery disease underwent a right lower lobectomy for a T2bN0M0 Stage 1b squamous cell carcinoma of the lung. After 1 year, the patient developed a local recurrence adjacent to the inferomedial aspect of the right upper lobe. A PET scan performed showed no evidence of disease elsewhere. The patient was considered unfit for a completion pneumonectomy. The recurrence was treated by SBRT using a Cyber knife Stereotactic Radiosurgery System (Accuracy, Sunnyvale, CA) with a prescription dose of 50 Gy in five fractions given every other day. Five months after the SBRT, the patient presented acutely with an empyema of the right chest. Flexible bronchoscopy showed a well-healed lower lobe bronchus. A barium swallow showed an extravasation of the oral contrast into the right pleural space []. An upper gastrointestinal endoscopy revealed a single 2.5 cm perforation in the distal thoracic esophagus and no tumor ingrowth. The patient was treated with a Wall flex fully covered esophageal stent (Boston Scientific, Natick, MA), sealing the esophageal perforation []. The patient also needed an open drainage of his right chest. However, the patient did not do well and succumbed to the esophageal perforation.\nA 73-year old female with medical history of hypertension underwent a right lower lobectomy for a T1N0M0 Stage 1A adenocarcinoma of the lung. After 4 years, the patient developed a new primary in the right upper lobe. A completion pneumonectomy and four cycles of adjuvant chemotherapy with cisplatin and paclitaxel were given for this T2N2M0 stage 3 adenocarcinoma of the right upper lobe. The patient did well for 2 years, after which she developed a regional recurrence near the right main stem bronchus stump. The patient was given SBRT to the recurrence site with a Cyber knife Stereotactic Radiosurgery System (Accuracy, Sunnyvale, CA), with a prescription dose of 50 Gy in five fractions given every other day. Seven months after SBRT, the patient presented with a hydropneumothorax in the postpneumonectomy space on routine surveillance chest x-ray. Bronchoscopy showed a well-healed bronchial stump. The CT scan of the chest showed oral contrast extravasation into the right pneumonectomy space []. An upper esophagogastroscopy confirmed two esophageal perforations at 22 and 37 centimeters from the incisors. Both were treated with a Wall flex fully covered esophageal stents (Boston Scientific, Natick, MA), and the right chest was drained with a tube thoracotomy. The patient did well, with retrieval of the stent at 5 weeks post placement.