A Case of Aortoesophageal Fistula Following Concurrent Chemoradiotherapy of Esophageal Cancer

食道癌接受放化合併治療後發生食道動脈瘻管之病例報告

10.6316/TRO/201421(4)327

郭登宇(Deng-Yu Kuo)；黃日新(Jih-Hsin Huang)；陳友強(Yu-Chiang Chen)；蕭吉晃(Chi-Hung Hsiao)；熊佩韋(Pei-Wei Shueng)

主動脈內套膜支架 ； 加利氏三合症 ； 放射線治療 ； 經導管動脈栓塞 ； Aortic endografting ； Chiari's triad ； Radiotherapy ； Transcatheter arterial embolization

放射治療與腫瘤學

21卷4期（2014 / 12 / 01）

327 - 331

英文

我們報告一位五十歲男性經診斷為中段食道鱗狀細胞癌的患者，在接受同步放化療後發生罕見但卻致命的食道動脈瘻管併發症。放射治療乃採用強度調控方式，總計量為50.4 Gy，分成28次給予。治療結束一個月後，病患突發大量的吐血及低容性休克，由於出血無法控制，安排了血管攝影，希望藉由動脈栓塞止血，在顯影劑測試期看到了顯影劑流入食道，高度懷疑有主動脈弓下方的食道動脈瘻管。但由於沒有找到明確的供血動脈分支，血管栓塞並未進行，病人改接受緊急的主動脈內套膜支架手術，之後生命徵象漸趨穩定。然而，病人在移除呼吸器三天後出現了急性呼吸窘迫症候群且死亡。由於主動脈有強韌的肌肉層，我們不認為中等的放射線劑量會直接造成此併發症，可能病人在接受完放化療後，吞嚥困難改善而吃了較堅硬的食物；另外在治療中安排的電腦斷層影像，顯示疑似腫瘤侵犯至主動脈外壁，綜合上述因素造成相對較脆弱的食道壁和主動脈間的瘻管。由於此併發症很少，無法由過去案例去歸納分析主動脈的閾值劑量。然而，我們仍需了解這致命性極高的併發症並且在治療前告知病人。

Aortoesophageal fistula (AEF) is a rare but lethal condition. Here, we present a case of AEF following concurrent chemoradiotherapy (CCRT). A 50-year-old man was diagnosed with squamous cell carcinoma of the middle third esophagus and was treated by CCRT with a total dose of 50.4 Gy in 28 fractions using IMRT. AEF developed within 1 month after completion of CCRT, with a presentation of massive hematemesis and hypovolemic shock. For uncontrolled bleeding, angiography for transcatheter arterial embolization was arranged. A subarcuate AEF was highly suspected with contrast flow along the esophagus noted in the contrast test series. No definite feeding arterial branch of the hemorrhagic lesion could be recognized, thus an embolizing procedure was not performed. Then he received emergent descending aortic endografting for AEF. His hemodynamic status and oxygenation became relatively stable. However, the patient developed acute respiratory distress syndrome and passed away three days later. The aorta consists of strong muscular layer, and we do not believe the moderate dose of radiotherapy alone induced such rare complication. We are inclined to assume that solid food induced a penetrating ulcer of the esophagus and thoracic aorta after improvement of dysphagia. Owing to the rare occurrence, it is hard to set a tolerance dose threshold to the aorta in treating tumors adjacent to it. Nevertheless, we still should keep in mind the possibility of this rare complication with substantial mortality and inform patients before beginning radiotherapy.