A Case of Aortoesophageal Fistula Following Concurrent Chemoradiotherapy of Esophageal Cancer

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.