Respiratory tract fistulae in recurrent aerodigestive cancers after chemotherapy

Bronchoesophageal fistulae, a form of respiratory tract fistula, occurred in four patients with squamous cell carcinoma arising in the esophagus or left bronchus after cytoreductive chemotherapy. All four had locoregional cancer, recurrent after high-dose external radiation therapy. Esophageal cancer was treated with sequential intravenous cisplatin 100 mg/m2 (day 1) and 5-fluorouracil (5-FU) 40 mg/m2/hour X 120 (days 2-7). Lung cancer was treated with sequential intravenous cisplatin 100 mg/m2 (day 1), 5-FU 40 mg/m2/hour X 72 (days 2-5), and etoposide 80 mg/m2/day X 3 (days 2, 3, and 4). All patients had symptomatic relief and tumor regression after oncolytic chemotherapy, which was well tolerated with no hematologic toxicity. After the second or third cycle of chemotherapy, bronchoesophageal fistula occurred in all four patients with manifestations of pneumonia, which proved fatal in two patients. The other two patients were effectively palliated for 14 and 36+ weeks after celestin tube placement. Bronchoesophageal fistula should be managed by antibiotics and respiratory support followed by elective placement of celestin tube in most patients and by esophageal exclusion or esophageal bypass in a few select patients. In aerodigestive cancers, respiratory tract fistula may be a rare and potentially fatal complication of chemotherapy induced tumor lysis.