Refractory recurrent bleeding as a late mortal complication of chest wall irradiation.

Radiation therapy is used to treat breast malignancies. Old external radiotherapy protocols included high-dose schedules and were associated with late complications. We describe the case of a 72-year-old woman who was admitted with recurrent bleeding from chest wall. Arteriovenous fistulae were diagnosed. Embolization therapy was initially successful, even though the bleeding episodes became recurrent. Arteriovenous fistulae should be included among differential diagnosis of thoracic bleeding in patients with history of local radiation therapy. The prognosis is poor and endovascular treatment may be considered a first-line treatment.

Radiation therapy is used to treat many breast and lung malignancies. A variety of adverse effects may occur after irradiation to the thorax.[1] Old external radiotherapy protocols included high-dose schedules and were associated with late complications. Bleeding as the result of vascular fistulae represents a very unusual chest wall complication that may be fatal.

Case Report

A 72-year-old woman was admitted in the Internal Medicine service because of heavy nontraumatic bleeding from the anterior right chest wall, associated with malaise and hypotension. She had been diagnosed a right breast cancer at the age of 30 years and had been treated with radical mastectomy and external radiotherapy with an unknown total radiation dose. She denied hemorrhagic diathesis, use of warfarin or other anticoagulant therapy or previous bleeding events.

Physical examination revealed tachycardia, tachypnea, and hypotension. An extended pachydermia of the right chest wall was noted, involving the mastectomy area. An opened bleeding lesion of about 2 cm of diameter was recognized at fourth intercostal space level. Initial laboratory values revealed anemia (hemoglobin = 8.52 g/dL) without alterations in the platelet number or the main coagulation parameters.

A thoracic computed tomography showed right-displaced mediastinum, reduced right lung parenchyma volume, and absence of adenopathies or local or hepatic metastases. Total bone scintigraphy did not reveal distant metastases.

Bleeding was initially stopped with hard local compression. The patient was given packed red cells to optimize her hemodynamic status. A selective right upper limb arteriography was performed. Two arteriovenous fistulae were identified, both draining into the superior vena cava. The first fistula originated from a pectoral collateral branch of right subclavian artery, whereas the second fistula originated in the ipsilateral axilohumeral artery [Figure 1]. Selective embolization therapy was indicated, with transient resolution. However, the patient experimented recurrent bleeding in several opportunities. Neither a second embolization procedure nor local therapy with fibrin precursors was successful. She died due to an infectious complication after 4 weeks.

Figure 1

Arteriovenous fistulae (black arrow)

Discussion

A variety of changes may occur after thorax radiotherapy. Spontaneous pneumothorax, mesothelioma, lung cancer, calcified lymph nodes, esophageal injuries, and a second breast cancer can be seen in these patients.[1] Among chest wall injuries due to radiation therapy, osteochondroma, and rib fractures are frequent complications that may be misinterpreted as recurrent tumors. Cardiovascular diseases are among the main long-term complications of radiotherapy.[2] Among women who had received radiotherapy for a left-sided breast cancer had a 1.56-fold higher risk of dying of cardiac disease than those treated for a right-sided breast cancer.[2] Aortoesophageal fistula has been previously described as a cause of mortality in irradiated subjects.[3] However, to the best of our knowledge, arteriovenous fistulae don′t represent a frequent vascular-related cause of mortality among patients who had received thoracic radiation therapy. Modern postmastectomy radiotherapy protocols are associated with a lower rate of thoracic complications without an increased locoregional recurrence risk.

It should be noted that the therapy of cancer hemorrhagic complication may not improve patient's survival, but could be associated with better quality of life and lower levels of anxiety both in the patient and their caregivers.[4]

In summary, we consider that arteriovenous fistulae should be included among differential diagnosis of thoracic bleeding in patients with a history of local radiation therapy. The prognosis is poor and endovascular treatment may be considered a first-line treatment.