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 Table of Contents     
CASE REPORT
Year : 2013  |  Volume : 28  |  Issue : 3  |  Page : 176-177  

Broncho-esophageal fistula leading to lung abscess: A life-threatening emergency detected on FDG PET/CT in a case of carcinoma of middle third esophagus


Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India

Date of Web Publication9-Oct-2013

Correspondence Address:
Venkatesh Rangarajan
Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Parel, Mumbai 400 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.119543

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   Abstract 

Sinister undesirable pathologies often accompany malignancies. Though the entire emphasis is on cancer management, these benign conditions are more life-threatening than the primary malignancy itself. We report an interesting imaging finding of broncho-esophageal fistula leading to lung abscess on 18 F- fluoro-deoxy-glucose positron emission tomography/computed tomography (FDG PET/CT) in large middle esophageal cancer, which due to early detection, was promptly managed.

Keywords: Broncho-esophageal, computed tomography, endoscopy, esophageal cancer, fistula, fluoro-deoxy-glucose positron emission tomography


How to cite this article:
Puranik AD, Purandare NC, Agrawal A, Shah S, Rangarajan V. Broncho-esophageal fistula leading to lung abscess: A life-threatening emergency detected on FDG PET/CT in a case of carcinoma of middle third esophagus. Indian J Nucl Med 2013;28:176-7

How to cite this URL:
Puranik AD, Purandare NC, Agrawal A, Shah S, Rangarajan V. Broncho-esophageal fistula leading to lung abscess: A life-threatening emergency detected on FDG PET/CT in a case of carcinoma of middle third esophagus. Indian J Nucl Med [serial online] 2013 [cited 2019 Oct 22];28:176-7. Available from: http://www.ijnm.in/text.asp?2013/28/3/176/119543


   Introduction Top


Secondary implications of malignancies are often more life-threatening than the malignancy itself and need early detection and urgent intervention. We report a similar case of a young gentleman, with a bulky friable middle esophageal mass, which invaded the bronchus, resulting in a broncho-esophageal (BE) fistula, resulting in lung abscess. This early detection on FDG PET/CT led to immediate management. This highlights the importance of FDG PET/CT in detecting associated life threatening condition in an oncological setting.


   Case Report Top


A 37-year-old male presented with grade III dysphagia. He also had recent onset high grade fever with chills. Nasogastric tube (NGT) was placed. Upper gastro-intestinal endoscopy (UGIE) showed friable mass in the middle third of esophagus, biopsy from which showed adenocarcinoma cells. Staging FDG PET/CT study was done. Maximum intensity projection image showed an hypermetabolic area in mid-thorax [Figure 1]a-thick arrow] with diffuse low grade uptake around it [Figure 1]a-thin arrow]. Axial fused PET/CT image [Figure 1]b and c- arrow showed a large intensely FDG avid soft-tissue mass in the middle third of esophagus, closely abutting the right main and segmental bronchi, measuring 32 mm × 32 mm, with maximum standardized uptake value of 27.2. Abutting this mass, a centrally necrotic ill-defined mass, with air pockets within and peripheral low intensity FDG uptake in the thick walls; was seen in the right lung parenchyma, in the lower lobe [Figure 1]b and c-arrow heads. Minimum intensity projection (minIP) reformatted sagittal [Figure 2]a and axial CT [Figure 2]b images showed a definite communication (arrow-head) between the mass (thick arrow) and the right lower lobar bronchus (thin arrow). Patient, when again asked for any complaints, said to have coughing immediately after swallowing. On collating history and imaging findings and also considering the fact that the patient underwent interventions like NGT placement and UGIE, a diagnosis of lung abscess secondary to BE fistula was made. Patient was started immediately on antibiotics and underwent esophageal stenting. Radiotherapy, though indicated, was ruled out due to presence of BE fistula.
Figure 1: (a) MIP image showing intense FDG uptake in mid-thorax (thick arrow) with an area of low grade uptake abutting it (thin arrow), (b and c) Axial PET/CT images show large middle esophageal mass with bronchial invasion (arrow) with a centrally necrotic ill-defined mass adjacent to it (arrow heads)

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Figure 2: Sagittal (a) and axial (b) reformatted CT images in MinIP window showing definite communication (arrow head) between the mass (thick arrow) and right lower lobar bronchus (thin arrow)

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   Discussion Top


BE fistulas in adults have not been commonly reported in literature. Most common cause of BE fistula is malignancy involving the esophagus and adjacent structures. These are frequently misdiagnosed. They present as bouts of coughing while eating or drinking, known as Ohno's sign and sometimes with recurrent pulmonary infections. [1] FDG PET/CT is routinely used for staging of esophageal cancers. [2] Characteristically FDG localizes in neoplastic as well as inflammatory cells. [3],[4] In our case, difference in density and FDG uptake intensity of the two adjacent lesions on CT and PET images respectively and radiological features of central necrosis with few air-pockets in the lung parenchymal lesion, confirmed it to be an abscess. [5] Also, reformatted images showed a fistulous communication between the mass and the bronchus. Following interventions, especially in the presence of a large tumor with friable margins in close proximity with bronchi, there is a greater risk of perforation and fistula formation. [6] This is of particular importance in cancers involving middle third of esophagus, where there is close proximity of primary mass to trachea and bronchus. [7] Since the entire focus is on tumor staging and management, specific symptoms as seen in our patient are often ignored. However, proper assimilation of history and imaging findings, with use of reconstruction techniques on PET/CT helped us pick up this life threatening condition in a case of esophageal cancer, which led to urgent intervention and also a drastic change in the management of primary malignancy.

 
   References Top

1.Lim KH, Lim YC, Liam CK, Wong CM. A 52-year-old woman with recurrent hemoptysis. Chest 2001;119:955-7.  Back to cited text no. 1
    
2.Barber TW, Duong CP, Leong T, Bressel M, Drummond EG, Hicks RJ. 18F-FDG PET/CT has a high impact on patient management and provides powerful prognostic stratification in the primary staging of esophageal cancer: A prospective study with mature survival data. J Nucl Med 2012;53:864-71.  Back to cited text no. 2
    
3.Shreve PD, Anzai Y, Wahl RL. Pitfalls in oncologic diagnosis with FDG PET imaging: Physiologic and benign variants. Radiographics 1999;19:61-77.  Back to cited text no. 3
    
4.Gorospe Sarasúa L, Echeveste Aizpurúa J, Raman S. Positron-emission tomography/computed tomography: Artifacts and pitfalls in cancer patients. Radiologia 2006;48:189-204.  Back to cited text no. 4
    
5.Williford ME, Godwin JD. Computed tomography of lung abscess and empyema. Radiol Clin North Am 1983;21:575-83.  Back to cited text no. 5
    
6.Aggarwal D, Mohapatra PR, Malhotra B. Acquired bronchoesophageal fistula. Lung India 2009;26:24-5.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.Argüder E, Aykun G, Karalezli A, Hasanoğlu HC. Bronchoesophageal fistula. J Bronchology Interv Pulmonol 2012;19:47-9.  Back to cited text no. 7
    


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