Stage IV Squamous Lung Cancer Complicated by an Esophageal-Mediastinal Fistula

What happened, in summary

A 74-year-old man was diagnosed in July 2020 with Stage IV squamous cell carcinoma of the right lung. He had multiple lung lesions together with mediastinal and hilar lymph-node involvement, bone metastases, and brain metastases.

He first received pembrolizumab with albumin-bound paclitaxel and carboplatin. After later lung progression, treatment was changed to nivolumab plus anlotinib. A major heart attack and ventricular aneurysm forced systemic treatment to stop. His lung tumors slowly enlarged, and he then received a course of local palliative radiation with limited effect.

In July 2023, he was hospitalized to try immunotherapy again and received tislelizumab. Within days he developed high fever, worsening cough, shortness of breath, and later coughing up blood. Imaging identified an esophageal-mediastinal fistula next to the cancer and enlarged mediastinal disease. Surgery and stenting were considered too risky because of his heart disease, so the fistula was managed with fasting, gastrointestinal decompression, infection treatment, nutrition support, and other supportive measures.

His symptoms improved. Four months later, CT showed no obvious fistula, and both the lung tumor and metastatic hilar nodes had decreased even though he had received no further antitumor treatment after discharge.