Akiyama Procedure for Esophageal Cancer Complicated with Aspergillosis – Case Report

Abstract Background Esophageal cancer is a challenging diagnosis especially in its advanced stages, with poor prognosis. However, advances in surgical technique and chemo-radiotherapeutical modalities has improved the outcomes. The main histological types are adenocarcinoma and squamous cell carcinoma, with the latter more prevalent in the upper parts of the esophagus and more aggressive. Certain risk factors have been identified, such as smoking, alcohol consumption, a diet poor in fruits and vegetables, high BMI and reflux disease. Some stages of the disease are considered resectable, and may benefit from surgical interventions. Morbidity and mortality rates are in decline in recent decades, with the improvement of perioperative intensive care. Case presentation The 52-year-old male patient was diagnosed with squamous cell carcinoma of esophagus, located between the upper and middle 1/3 portions. He underwent the full cycles of chemoradiotherapy according to current oncological protocols. As an accompanying condition, the patient had a cavernous aspergilloma of the right lung apex of 4cm diameter. This report presents the successful surgical management, with the Akiyama Procedure (subtotal esophagectomy and cervical esogastric anastomosis with a retrosternal tubularised stomach) and right upper lobe pulmonary resection. The patient tolerated the procedure well, with uneventful post-operative course. He was discharged in good health on the 14th post-operative day, following successful barium radiograph test and food deglutition. Discussion Aspergillomas can form on pre-existing lung cavities, in patient that have recovered from cavernous tuberculosis. Immunosuppressed patients treated for rheumatoid arthritis, inflammatory bowel disease or undergoing chemotherapy are also susceptible to aspergillomas. The patient was carefully evaluated by the respiratory medicine specialist and antifungal medication was started prior to surgery. However, surgical treatment for esophageal cancer could not be delayed indefinitely and the patient was proposed the concurrent surgery for both esophageal cancer and pulmonary aspergilloma. Conclusion Current guidelines for patients in stages T1 or T2, N0 recommend surgery. In T3 patients or N1/M1 chemo-radiotherapy prior to any surgical decision is recommended. Advanced stages of the disease are referred for chemoradiotherapy alone or palliative treatment. Regarding pulmonary aspergillomas, surgical treatment aims to resect the affected cavity, along with the obliteration of the fungal mass. The recommended surgical approach is an anatomical resection of the pulmonary lobe, which may not be well tolerated in patients with poor physical reserves.