A Case for Caution in a New Era of Managing Patients with Locally Advanced Non-Small Cell Lung Cancer: Fatal Bronchial-Esophageal Fistula After Neoadjuvant Chemo-Immunotherapy Followed by Definitive Chemoradiation Therapy.

Abstract

This case highlights the challenges of treating patients with non-small cell lung cancer who initially receive neoadjuvant chemoimmunotherapy (chemo-IO) and do not proceed to planned surgery. After multidisciplinary evaluation, a 58-year-old man with stage IIIA squamous cell carcinoma of the left lower lobe received neoadjuvant chemo-IO and was planned for definitive surgical resection. His neoadjuvant course was complicated by the development of IO-related dermatitis and colitis. He was ultimately not offered definitive surgery, representing the ∼20% of patients on neoadjuvant chemo-IO trials that do not proceed to planned surgical resection. The patient completed chemoradiation therapy with 60 Gy in 30 fractions. He subsequently developed multiple significant postradiation toxicities, including a grade 5 bronchial-esophageal fistula, which was managed with palliative intent. This case underscores the importance of comprehensive multidisciplinary discussion before definitive treatment, the data-free zone for the management of patients who receive neoadjuvant chemo-IO and do not undergo definitive resection, and the potential for increased completed chemoradiation toxicity in this setting.