Yikes… spikes! Exposed tracheal cartilaginous spikes at EGD from malignant tracheoesophageal fistula

A 67-year-old woman with squamous cell carcinoma of the lung that had been diagnosed 6 months earlier, and recent biopsy-proven metastasis to her right hip, presented with 3 months of progressive dysphagia and involuntary weight loss. Physical examination revealed temporal wasting, clear lung fields, a normal abdomen, and brown stool without occult blood. The results of all laboratory studies were normal except for a hemoglobin of 8.7 g/dL, microcytic indices, and a serum albumin level of 3.4 g/dL. Videoesophagography revealed barium spilling rapidly into the left main bronchus. EGD demonstrated a tight stricture that contained exposed cartilaginous tissue, with adjacent mucosal nodularity and pooled proximal debris 25 cm from the incisors (A). After irrigation, close endoscopic examination revealed paired, mirror-image, curvilinear, spike-like, cartilaginous projections protruding into the esophageal lumen (B). The cartilaginous appearance and axial orientation of this paired projection was consistent with a tracheal cartilaginous ring. The endoscope was in the esophagus, not the trachea, as demonstrated by endoscopic intubation and extubation under visual guidance and by the absence of serial tracheal rings; the stricture was not traversed. Endoscopic biopsy specimens revealed cartilage and poorly differentiated squamous cell carcinoma, with tumor histologic appearance that was identical to that of the primary lesion and hip metastasis (C). The patient refused esophageal stenting and pursued hospice care.