Endoscopic Ultrasound-Guided Drainage of a Cystic Metastasis in the Mediastinum that Caused Tracheal Obstruction

We read with great interest the recent article by Mohl et al. reporting the endoscopic transhiatal drainage of a mediastinal pancreatic pseudocyst, clearly demonstrating the extension of the role of endoscopic ultrasound (EUS)-guided therapy beyond the abdominal cavity [1]. We describe a case where a cystic mediastinal lesion was drained into the esophagus.

A 72-year-old woman underwent operation for a T2N0M0 squamous carcinoma of the lower third of the esophagus with esophageal resection and gastric interposition. Three years after surgery she presented with a short history of dyspnea and stridor. A computed tomography (CT) examination showed a 3-cm cystic lesion in the upper mediastinum, in close proximity to the esophagus and displacing and compressing the trachea (Fig. [1]). EUS-guided puncture of the lesion was performed, using a curvilinear-array instrument (Olympus GF-UC160P-OL5; Olympus, Hamburg, Germany) and a fine needle (Olympus NA-200H-8022). The patient experienced immediate relief of symptoms when 20 ml of brownish fluid was aspirated. Cytology confirmed a metastatic lesion and she was referred for chemoradiotherapy. The symptoms recurred within a week, and EUS-guided aspiration was repeated with symptom relief lasting 24 hours. A third EUS procedure was performed during which the cyst was punctured using a needle-papillotome and a 7-Fr 4-cm double pigtail stent was placed between the esophagus and the cyst. A CT examination 6 weeks later showed almost complete regression of the lesion (Figure [2]). The patient received chemoradiotherapy and died 18 months later from disseminated disease, without recurrence of respiratory symptoms.

Figure 1 a Chest radiograph, and b computed tomography (CT) of the thorax; showing displacement and compression of the trachea by the cystic lesion.

Figure 2 a Chest radiograph, and b CT of thorax; showing status 6 weeks after stent placement, with the trachea in a normal position and regression of the lesion.

Tracheal compression due to esophageal cancer is usually caused by direct tumor infiltration. Airway stenting provides relief of symptoms in the majority of cases [2] [3]. However, stent-related complications occur in up to 42 % of patients, with as many as 40 % requiring additional stent procedures [2]. Necrotic metastatic lymph nodes may present as cystic lesions. As demonstrated in this case, good palliation can be achieved by EUS-guided drainage and stent placement in patients in whom such lesions cause obstructive respiratory symptoms.

References

• 1 Mohl W, Moser C, Kramann B. et al . Endoscopic transhiatal drainage of a mediastinal pancreatic pseudocyst.  Endoscopy. 2004;  36 467
• 2 Wood D E, Liu Y H, Vallieres E. et al . Airway stenting for malignant and benign tracheobronchial stenosis.  Ann Thorac Surg. 2003;  76 167-172
• 3 Nomori H, Horio H, Imazu Y, Suemasu K. Double stenting for esophageal and tracheobronchial stenoses.  Ann Thorac Surg. 2000;  70 1803-1807