title: Malignant tracheal-mediastinal-parenchymal-pleural fistula after chemoradiation plus bevacizumab: management with a Y-silicone stent inside a metallic covered stent.
abstract: Tracheal or bronchial-mediastinal fistulas are a rare entity associated to high mortality. We report a case of a 58-year-old man with an unresectable non-small cell carcinoma of the lung, treated with chemoradiation followed by bevacizumab. Approximately, 6 weeks after starting bevacizumab he developed a severe cough with copious secretions He could not lie supine due to the feeling of drowning. Investigations revealed a large tracheo-mediastinal-parenchymal-pleural fistula. Palliative management was offered with interventional bronchoscopic techniques. He was found to have a large central airway defect that obliterated almost 40% of the trachea. Under general anesthesia and positive pressure ventilation, a unique approach was used to rebuild an eroded tracheal and right main stem bronchial wall. A self-expanding metallic stent (SEMS) was placed to provide a scaffold of support, whereas a Dumon Y-stent was placed inside the SEMS. This combination allowed for a patent, stable airway; recreating the normal anatomy in a minimally invasive manner walling off the fistula. The patient was discharged 2 days after the bronchoscopic intervention, with significant palliation of his symptomatology. Eighteen months later, the upper lobe cavity persists with a stable airway and stents perfectly positioned with clinically insignificant evidence of stent related granulation in the upper trachea.
authors.affiliation: *Pulmonary, Critical Care Medicine and Sleep Consultants, Houston Methodist Hospital, Houston, TX †Pulmonary, Critical Care & Sleep Medicine Consultants, Texas Medical Center, Houston, TX ‡Pulmonary, Allergy & Critical Care Medicine, University of Alabama, Tuscaloosa, AL.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Machuzak
authors.forename: Jose F
authors.initials: JF
authors.lastname: Santacruz
authors.forename: Wissam
authors.initials: W
authors.lastname: Jaber
authors.forename: Thomas R
authors.initials: TR
authors.lastname: Gildea
mesh_terms: D061067:Antibodies, Monoclonal, Humanized / Q000008:administration & dosage; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D000068258:Bevacizumab; D001999:Bronchoscopy / Q000379:methods; D002289:Carcinoma, Non-Small-Cell Lung / Q000473:pathology* / Q000628:therapy*; D059248:Chemoradiotherapy; D006801:Humans; D008175:Lung Neoplasms / Q000473:pathology* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D010166:Palliative Care; D016156:Respiratory Tract Fistula / Q000473:pathology* / Q000601:surgery*; D015607:Stents; D016896:Treatment Outcome
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D000068258:Bevacizumab