Locally advanced lung adenocarcinoma: neoadjuvant treatment, surgery, and fistula repair

What happened, in summary

This 65-year-old woman, with no prior medical history, was diagnosed with lung adenocarcinoma in the left lower lobe. The tumor infiltrated the fissure and involved N2 lymph nodes, supporting locally advanced disease; distant metastasis was not reported. She received neoadjuvant chemotherapy and immunotherapy before surgery. During the fourth chemotherapy cycle, which included paclitaxel, she developed toxicity, and surgery was proposed. At operation, the tumor extended from the apical segment of the left lower lobe into the fissure and upper lobe, involving bronchial and vascular branches and the adventitia of the aortic arch. Surgeons performed an extensive en-bloc resection of the left lung, parietal pleura, and part of the aortic adventitia, with lymphadenectomy. On postoperative day 8, fever, inflammatory markers, purulent drainage, and food particles in the chest tube led to diagnosis of an esophagopleural fistula. An esophageal stent was attempted, but the leak persisted and cultures grew Enterobacter cloacae, Enterococcus faecium, and Streptococcus oralis. She required optimized antibiotics, pleural lavage, open thoracostomy with debridement, and nutritional rebuilding through a nasojejunal feeding tube before definitive repair. Surgeons later excluded the damaged thoracic esophagus and restored digestive continuity with a gastric conduit brought up to the cervical esophagus, plus jejunostomy support. She recovered in intensive care until postoperative day 3, then returned to the ward. Liquids resumed by postoperative day 10, the cervical drain was removed on day 16, and she was discharged 28 days after reconstruction. At 3-month follow-up, she had improved nutrition, normal-range BMI, and no contrast leak at the esophagogastric anastomosis.