Immunotherapy-Induced Pneumonia Following Neoadjuvant Chemoradiation Plus PD-1 Inhibitor in Locally Advanced Esophageal Squamous Cell Carcinoma | Removal of an Esophageal Foreign Body Penetrating Into the Mediastinum by Minimally Invasive Transcervical Mediastinoscopy-Assisted Approach

22 Feb 2022 01:00 03:00

Shanghai

Jie He Host

Case 1

Patient Profile & Initial Presentation

Patient: 61-year-old female
Initial Finding: Lesion at the lower thoracic esophagus found by gastroscopy during a routine check-up.
Pathology: Squamous cell carcinoma confirmed by biopsy.
Presentation of the Case: Yong Yang – Zerui Zhao (Guangzhou)

Initial Diagnostic Workup

EUS and Contrast CT Scan: cT2N1 locally advanced esophageal squamous cell carcinoma.
Respiratory Function: Normal respiratory function and diffusion capacity.

Neoadjuvant Treatment

The patient signed consent for participation in a phase II trial (NCT04006041) on the feasibility of combination of Toripalimab (PD-1 inhibitor) and neoadjuvant chemoradiation in esophageal cancer.

Chemoradiation: Started on April 1st, 2021.
Radiotherapy: 44 Gy in 20 fractions over 4 weeks.
Chemotherapy: 4 cycles of Paclitaxel with Cisplatin carried out weekly simultaneously.
Immunotherapy: 2 doses of PD-1 inhibitor on day 1 and day 22 during the same period.

Restaging After Neoadjuvant Treatment

Re-do EUS: Tumor shrinkage (Figure 1).
Subcarinal Lymph Node: Endo-bronchial ultrasound-guided needle aspiration suggested the existence of several atypical cells, with tumor metastases suspected.

Surgery

Procedure: Minimally invasive McKeown esophagectomy performed approximately 8 weeks following completion of neoadjuvant treatment.
Pathology: Pathological complete response with no evidence of tumor in either the primary tumor or resected lymph nodes.

Postoperative Complications

Pulmonary Dysfunction: Development of pulmonary dysfunction requiring mechanical ventilation during the first postoperative week.
Initial Management: Dyspnea did not remit following antibiotic treatment (Figure 2).
Laboratory Findings: Only mild elevation of white blood cells and procalcitonin was found on several blood tests.
Postoperative Day 15 CT Scan: Bilateral lung effusion and pneumonia (Figure 3).
Multidisciplinary Assessment: Specialists suggested that the patient might be experiencing immunotherapy-induced pneumonia.
Treatment: Administration of Prednisolone for 10 days resulted in significant remission of the pneumonia.
Postoperative Day 25 CT Scan: Regression of pneumonia following administration of Prednisolone (Figure 4).

Outcome

Discharge: Patient discharged on postoperative day 27.
Follow-up: Recovered uneventfully at the outpatient visit 6 months after surgery.

Figures

Figure 1. EUS and CT images before and after neoadjuvant treatment

Before (A) and after (B) neoadjuvant treatment showing tumor shrinkage.

Figure 2. Chest X-ray

Chest X-ray showing pulmonary effusion persisting after antibiotherapy.

Figure 3. CT Scan

CT scan performed 15 days postoperatively showing extensive bilateral effusion and pneumonia.

Figure 4. CT Scan

CT scan performed 25 days postoperatively, following 10 days of administration of Prednisolone, showing regression of pneumonia.

Discussion

Moderator: Yousheng Mao (Beijing)

Summary

Jianhua Fu (Guangzhou)

Case 2

Background

Ingestion of foreign bodies, especially animal bones, is one of the most common endoscopic emergencies, especially in China. Foreign bodies can be fishbones, pills, capsules, bottle lids and even false teeth. Fortunately, most of them can be easily be removed by skilled endoscopists, thanks to the development of endoscopic techniques. Only 1% or less require surgery, including foreign bodies with sharp-ends which penetrate the esophageal wall, causing esophageal perforations and remaining in the mediastinum space. The perforating esophageal foreign bodies may cause severe complications, including bleeding and migration.

Traditional approach can be surgery through cervical skin incision. However, for foreign bodies which penetrate in the thoracic esophagus (more than 20 cm from incisors), cervical approach may not be effective and surgery through the chest wall would be inevitable.

In our case, instead of a traditional transcervical approach, we tried a novel, minimal invasive approach with the help of a mediastinoscope.

Patient Profile & Clinical Presentation

Patient: 65-year-old woman
History: Swallowed a fishbone 10 hours before she was admitted to our hospital with substernal pain.
Presentation of the Case: Lijie Tan – Zongwei Chen (Shanghai)

Diagnostic Workup

CT Scan and EUS: Upper-thoracic esophageal perforation caused by a foreign body, with the distal end at the level of the aortic arch.
Foreign Body Location: Located outside the esophageal wall and adjacent to the upper edge of the aortic arch.

Endoscopic Procedure

A transparent cap was attached to the front of the endoscope, showing a longitudinal ulcer, about 0.8 cm in length, 20 cm from the incisors.
A hook knife was used to cut the esophageal wall along the damaged area and to expose the submucosal and muscular layers.
In spite of careful examination, no foreign body was found.
After hemostasis with hot biopsy forceps, the wound was closed with clips (Figure 1).

Surgical Treatment

Indication: Surgery was therefore needed.
Position: Patient was placed in supine position under general anesthesia with bilateral lung ventilation.
Cervical Incision: A 5 cm incision was made about 1 cm lateral to the SCM.
Port Placement: A lap-protector (FF00707 Hakko Co Ltd, Japan) with matched retractor (Hakko Co Ltd, Japan), each pre-inserted with three E-Z Trocars (5-70 mm Short Hakko Co Ltd, Japan), was inserted into the cervical incision.
Mediastinal Access: Carbon dioxide was insufflated at a pressure of 8 mmHg into the mediastinum to enlarge the very limited mediastinal surgical field.
Visualization: VISERA ELITE II System OTV-S300 with deflectable laparoscope (Olympus Corporation, Tokyo, Japan) was used as a mediastinoscope to ensure the maximal surgical view for the operator.
Dissection: The operator first inserted a Ligasure™ Maryland Jaw sealer (Medtronic) held in the right hand into the upper mediastinum under endoscopic vision, and then inserted a suction stick, which also acted as a retractor, held in the left hand to provide counter traction and remove smoke produced by Ligasure.
Assistant: The assistant surgeon controlled a 5 mm Olympus deflectable laparoscope.
Esophageal Mobilization: Mobilization of the upper thoracic esophagus was performed, starting from the left and posterior side of the esophagus.
Foreign Body Removal: The tip of the fishbone was found in the mediastinum before reaching the aortic arch, and a dissecting forceps was used to remove the whole fishbone from the mediastinum.
Closure: The incision was closed after a drainage tube was placed in the surgical field.

Postoperative Outcome

The patient was discharged two days after surgery and had a quick recovery.

Figures

Figure 1. Endoscopic Procedures

Endoscopic procedures performed during evaluation and attempted removal of the foreign body.

Figure 2. CT Scan Prior to Surgery

CT scan demonstrating the location of the esophageal foreign body and associated perforation.

Figure 3. Cervical Skin Incision and Port Placement

Cervical skin incision and port placement for the transcervical approach.

Figure 4. Mediastinoscopic Procedure

Mediastinoscopic procedure used for minimally invasive removal of the fishbone from the mediastinum.

Figure 5. Cervical Incision and the Fishbone

Cervical incision and the removed fishbone.

Discussion

For most cases of esophageal foreign bodies, a gastroscope is effective. However, once penetrating the esophageal wall, the foreign body cannot be found by gastroscope, and surgery is needed.

In this case, referring to mediastinoscope and laparoscope-assisted esophagectomy, we used the minimally invasive transcervical approach with the help of a deflectable laparoscope to remove the foreign body in the mediastinal space.

Preoperative workup is crucial, to investigate the location of the foreign body as to the surrounding important tissues and organs or arteries.

Previous reports demonstrated that CT was useful for a precise, definitive diagnosis of an esophageal foreign body, or when complications were suspected.

CT should be performed again before surgery, because of the risk of migration of the foreign body following the previous maneuvers such as EUS, or movements of the patient.

Discussion

Moderator: Zhentao Yu (Shenzen)