Suetsugu Tomonari, Tanaka Yoshihiro, Sato Yuta, Fukada Masahiro, Yasufuku Itaru, Yoshida Kazuhiro
Department of Gastroenterological Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan.
Department of Gastroenterological Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan.
Int J Surg Case Rep. 2022 Apr;93:106944. doi: 10.1016/j.ijscr.2022.106944. Epub 2022 Mar 22.
Esophageal fistula after treatment is a critical and fatal complication of esophageal cancer. A fistula forming from lower thoracic esophageal cancer to the peritoneum through lymph node metastases following chemotherapy has not been reported. We report a case of peritonitis due to lymph node perforation through the tumor ulcer after induction of biweekly docetaxel, cisplatin, and 5FU combined chemotherapy (Bi-DCF) for advanced esophageal squamous cell carcinoma (ESCC).
A 48-year-old woman was referred to us with a diagnosis of lower thoracic ESCC and thoracoabdominal aortic aneurysm. Esophagogastroduodenoscopy showed a circumferential type 3 tumor with stenosis in the lower thoracic esophagus. Contrast-enhanced computed tomography (CT) showed a thoracoabdominal aortic aneurysm and wall thickening of the lower thoracic esophagus that was suspicious of esophageal cancer. Lymph node metastases dumpling from around the tumor to abdominal cavity were also observed. The initial diagnosis was ESCC T3 N3 M1 (para-aortic lymph nodes and liver) Stage IVB. She was started on Bi-DCF (docetaxel 35 mg/m days 1/15, cisplatin 40 mg/m days 1/15, 5FU 400 mg/m days 1-5, 15-19) as the first-line regimen. The third day after starting chemotherapy, she felt strong abdominal pain, and internal necrosis of lymph nodes around the primary lesion and free air in the abdominal cavity were found. Peritonitis was diagnosed due to a fistula formed from the lower thoracic ESCC to the peritoneum through lymph node metastases. She underwent emergency laparoscopic drainage, omental filling, and jejunostomy. Postoperatively, her general condition and inflammatory findings improved within 10 days, and she could continue intensive chemotherapy as scheduled.
Because of the risk of perforation and fistula in regimens that are expected to cause tumor shrinkage, careful observation may be required after starting chemotherapy.
We report the first case of peritonitis caused by perforation through lymph node metastasis of thoracic esophageal cancer.
治疗后食管瘘是食管癌的一种严重且致命的并发症。化疗后下胸段食管癌通过淋巴结转移至腹膜形成瘘管的情况尚未见报道。我们报告一例晚期食管鳞状细胞癌（ESCC）患者，在接受每两周一次的多西他赛、顺铂和5-氟尿嘧啶联合化疗（Bi-DCF）诱导治疗后，因肿瘤溃疡导致淋巴结穿孔引起腹膜炎。
一名48岁女性因诊断为下胸段ESCC和胸腹主动脉瘤转诊至我院。食管胃十二指肠镜检查显示下胸段食管有一环形3型肿瘤伴狭窄。增强计算机断层扫描（CT）显示胸腹主动脉瘤及下胸段食管壁增厚，怀疑为食管癌。还观察到肿瘤周围的淋巴结转移灶如饺子样延伸至腹腔。初步诊断为ESCC T3 N3 M1（腹主动脉旁淋巴结和肝脏）IVB期。她开始接受Bi-DCF（多西他赛35mg/m²第1天和第15天；顺铂40mg/m²第1天和第15天；5-氟尿嘧啶400mg/m²第1 - 5天、第15 - 19天）作为一线治疗方案。化疗开始后第三天，她感到剧烈腹痛，发现原发灶周围淋巴结内部坏死及腹腔内游离气体。诊断为下胸段ESCC通过淋巴结转移至腹膜形成瘘管导致的腹膜炎。她接受了急诊腹腔镜引流、网膜填塞和空肠造口术。术后，她的一般情况和炎症表现在10天内有所改善，并且能够按计划继续强化化疗。
由于预期会导致肿瘤缩小的治疗方案存在穿孔和瘘管形成的风险，化疗开始后可能需要仔细观察。
我们报告了首例胸段食管癌淋巴结转移穿孔导致腹膜炎的病例。
