title: Bronchial fistula associated with sunitinib in a patient previously treated with radiation therapy.
abstract: OBJECTIVE
  To report a case of bronchial fistula associated with sunitinib in a patient previously treated with radiation therapy.
  
  
  METHODS
  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 Sunitinib was immediately withdrawn and antibiotic prophylaxis was instituted.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.
  
  
  CONCLUSIONS
  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).
authors.affiliation: Centre Hospitalier Saint Quentin, Saint Quentin, France.
authors.forename: Damien
authors.initials: D
authors.lastname: Basille
authors.forename: Michel
authors.initials: M
authors.lastname: Andrejak
authors.forename: Houcine
authors.initials: H
authors.lastname: Bentayeb
authors.forename: Marc
authors.initials: M
authors.lastname: Kanaan
authors.forename: Clément
authors.initials: C
authors.lastname: Fournier
authors.forename: Emmanuelle
authors.initials: E
authors.lastname: Lecuyer
authors.forename: Marie
authors.initials: M
authors.lastname: Boutemy
authors.forename: Réda
authors.initials: R
authors.lastname: Garidi
authors.forename: Youcef
authors.initials: Y
authors.lastname: Douadi
authors.forename: Charles
authors.initials: C
authors.lastname: Dayen
mesh_terms: D000328:Adult; D000970:Antineoplastic Agents / Q000009:adverse effects* / Q000627:therapeutic use; D001983:Bronchial Fistula / Q000139:chemically induced*; D001984:Bronchial Neoplasms / Q000556:secondary / Q000628:therapy; D002292:Carcinoma, Renal Cell / Q000473:pathology / Q000628:therapy; D003131:Combined Modality Therapy; D006801:Humans; D007211:Indoles / Q000009:adverse effects* / Q000627:therapeutic use; D007680:Kidney Neoplasms / Q000473:pathology / Q000628:therapy; D008175:Lung Neoplasms / Q000556:secondary / Q000628:therapy; D008297:Male; D008479:Mediastinal Neoplasms / Q000556:secondary / Q000628:therapy; D011758:Pyrroles / Q000009:adverse effects* / Q000627:therapeutic use; D000077210:Sunitinib
chemical_list: D000970:Antineoplastic Agents; D007211:Indoles; D011758:Pyrroles; D000077210:Sunitinib