Central airway obstruction (CAO) due to malignancy is an oncological emergency that requires prompt management. On the other hand, esophagobronchial fistula (EBF) is also a serious condition that can lead to aspiration pneumonia and difficulty with oral intake. Secondary involvement due to malignant lymphoma is a very rare cause of both CAO and EBF. Here, we report a case of esophageal bypass surgery for an EBF that became apparent after palliative irradiation for left main bronchial obstruction caused by mediastinal malignant lymphoma. A 76-year-old man was referred to our hospital with a chief complaint of dyspnea and dysphagia. Contrast-enhanced chest CT revealed a 10-cm irregularly shaped space-occupying lesion (SOL) in the middle mediastinum, involving the left main bronchus and esophagus. The left main bronchus was obstructed by the SOL, and the presence of gas within the lesion suggested the formation of a fistula between the tumor and the bronchus. Bronchoscopy revealed almost complete obstruction of the left main bronchus due to an ulcerative tumor. Upper gastrointestinal endoscopy revealed a deeply excavated esophageal ulcer, raising suspicion of a fistulous connection with the tumor. Although fistula formation between the tumor and the bronchus and/or esophagus was suspected, due to the oncological emergency of CAO presumably caused by mediastinal-type lung cancer, palliative irradiation and intravenous administration of betamethasone sodium phosphate were initiated prior to obtaining a pathological diagnosis. The tumor shrank remarkably after the treatment. However, as the tumor regressed, an EBF became apparent. Given the patient's strong desire to resume oral intake and the need for a definitive diagnosis, we planned a surgical intervention (esophageal bypass surgery with lymph node sampling). The patient's postoperative course was uneventful. He resumed oral intake on POD 9, and was discharged on day 20. Histopathological examination of the lymph nodes revealed diffuse large B-cell lymphoma. The patient began chemotherapy for malignant lymphoma 2 months after surgery. Esophageal bypass surgery is a valuable option for patients with an EBF, as it improves QOL and enables subsequent chemotherapy.
An et al. (Wed,) studied this question.
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