C0228 - A Rare Case of Esophageal Perforation in Liposarcoma After Cryoablation

Introduction: Liposarcoma is a locally aggressive solid tumor where mainstay treatments typically include surgical resection or debulking. Recently, cryoablation in liposarcomas has been utilized as a safe and well-studied modality for limiting tumor growth and subsequent symptoms of mass effect. Cryoablation is considered palliative for solid tumors and can prolong patient survival in advanced or recurrent cancer. Cryoablation can cause a variety of adverse events, including fevers, skin frostbite, and local nerve injury secondary to localized edema. Our case presentation showcases the only reported case demonstrating esophageal perforation following cryoablation thought to be related to local nerve injury.

Case Description/Methods: Our patient is a 64-year-old male with an extensive mediastinal sclerosing liposarcoma who underwent debulking surgery in 2018 with subsequent tumor enlargement. Given the precarious location of the enlarging mediastinal mass with major compression of the carina, mainstem bronchi, left atrium, and encasement of the esophagus and descending aorta, a complicated resection was deferred, and instead, extensive palliative treatment modalities were explored where cryoablation to the subcarinal area was selected as being the safest and most effective. He initially did well post-procedure, but 13 days later, developed worsening stridor which progressed to hematemesis, prompting the patient to present to the ED. He underwent emergent bronchoscopy demonstrating external carinal compression of mainstem bronchi and EGD confirmed a large contained full-thickness esophageal perforation (Figure 1) He did not develop of sepsis or mediastinitis. For additional airway protection, he underwent a Y-stent with eventual improvement and healing of the esophagus and resumed a normal oral diet.

Discussion: The large mediastinal liposarcoma extending to the carina caused several compressive symptoms, including difficulty breathing and stridor. Although palliative CT-guided cryoablation accurately targeted the carina, while avoiding large, important structures, the patient developed severe coughing. This was believed to be related to local edema affecting the vagus nerve which may have led to a Mallory Weiss tear, resulting in hematemesis. Although local nerve injury is a known possible side effect of cryoablation, our case is one of the first to highlight such severe injury to the extent of esophageal perforation.