1. Esophagopleural Fistula After Atezolizumab Treatment in Esophageal Adenocarcinoma
Jessica D. Rich, DOa, Muhannad Al Hanayneh, MDb, Kathryn Foutch, DOc
aNorton Community Hospital Internal Medicine , Mountain States Health Alliance, Norton, VA
bDepartment of Gastroenterology, The University of Texas Medical Branch, Galveston, TX
cDepartment of Internal Medicine, Legacy Health, Portland, OR
Imaging
Introduction
Conclusion
Esophageal adenocarcinoma is becoming more prevalent in the western world, with a generally poor prognosis.
Immunotherapy with PD-L1 inhibitors has been successful in numerous unresectable and metastatic solid tumors with a favorable adverse event profile.
This patient supports literature describing severe side effects of pneumonitis and empyema after a trial of atezolizumab for esophageal adenocarcinoma
Such serious respiratory complications have not been previous documented with PD-L1 administration and should be considered when initiating therapy in esophageal adenocarcinomas and possibly other gastrointestinal carcinomas.
The current National Comprehensive Cancer Network guideline for treatment of esophageal cancers in non-surgical candidates recommends combination radiation therapy and fluoropyrimidine- or taxane- based chemotherapy, with palliative treatment for locoregional recurrence (1)
With the advent of immunotherapy, more treatment options are being explored for second and third line therapy in this solid tumor.
We report a case of esophageal adenocarcinoma in a clinical trial treated with the PD-L1 inhibitor, atezolizumab, subsequently complicated by pneumonitis and an esophagopleural fistula.
Figure 1. Right sided fluid collection on Gastrogafin swallow.
Figure 2. Esophagopleural fistula noted on Gastrografin swallow.
Case Presentation
References
HPI: 68 year old male presented with severe right-sided shoulder pain of 3 days duration and a leukocytosis to 37.3K/uL. His only past medical and surgical history included unresectable T3N2 esophageal adenocarcinoma with stenting and a recent hospital stay for pneumonia 4 weeks prior.
History of Malignancy:
One year prior, diagnosed with adenocarcinoma of the esophagogastric junction
Failed initial therapy with paclitaxel, carboplatin, and radiation
Failed salvage chemotherapy with 5-fluorouracil and cisplatin
Esophageal stent placed after further disease progression
Trial therapy with PD-L1 inhibitor, atezolizumab, in combination with angiogenesis inhibitor bevacizumab; tolerated 2 full doses atezolizumab and 1 dose bevacizumab before discontinuation due to disease progression
Hospital Course: A CT scan shortly after admission revealed pneumonitis and right-sided empyema (Figure 3). A chest tube was inserted with copious output, and the patient continued to decompensate. An esophagopleural fistula was discovered via Gastrogafin swallow (Figures 1, 2), followed by an unsuccessful attempt at esophageal re-stenosis. After an extended hospital stay with symptomatic treatment, comfort care was initiated and the patient subsequently passed away from pulmonary complications.
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Figure 3. Extensive fluid and gas collection in right hemithorax on CT scan, consistent with empyema.
Discussion
Programmed Death-Ligand 1 (PD-L1) inhibitors have had success in several solid tumors, including non-small cell lung cancer, metastatic melanoma, and advanced or metastatic urothelial carcinoma (3-6).
These checkpoint inhibitors have had a good safety profile and evaluation has begun on various other solid malignancies (2).
Common side effects including fatigue, nausea, and decreased appetite have been reported with PD-L1 inhibitors, as well as a severe adverse effect of pneumonitis in lung, skin, and genitourinary cancers (2).
Acknowledgements
Dr. Haines, Norton Community Hospital Department of Radiology, for his time, assistance, and teaching with imaging