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A 7 year old girl presented with a one month history of lethargy, intermittent lower abdominal pain, and an abdominal mass. She was diagnosed as having spindle cell sarcoma of the right kidney following radiological investigations and biopsy of the lesion. She also had an isolated left lung lesion, presumed metastasis, at the time of diagnosis. She was commenced on multi-agent sarcoma chemotherapy. Six months later she underwent right nephrectomy. Three months post-nephrectomy she received radiotherapy to the right flank and both lungs. One year later CT scan of the chest showed a small isolated left upper lobe lesion that was removed by wedge excision. Pathology showed blastemal elements in keeping with a metastatic nodule of a Wilms’ tumour, originally a sarcomatous variant; she was treated with topotecan and cyclophosphamide.
CT scan of the chest, performed one month post-lung nodule resection, showed aneurysmal dilatation with two adjacent distended vessels, assumed to be an intercostal artery and vein, both in the left upper lobe. Adjacent pleural thickening was consistent with previous surgery. This aneurysmal dilatation was not seen on previous scans. The CT scan (fig 1) showed a serpiginous enhancing vascular structure at the site of the previous nodule and wedge excision. Two vessels were visible on coronal reconstruction coursing to the chest wall, indicating an acquired bronchial artery to bronchial vein fistula that, to our knowledge, has not been previously reported. Systemic artery to pulmonary vein fistulas,1–3 and other fistulas such as broncho-pleural,4 broncho-oesophageal,5 and broncho-biliary,6 have been described in the past, but bronchial artery to bronchial vein fistula does not appear to have been reported. We assume surgery to the lung nodule here somehow allowed development of this fistula, and that the prior lung nodule may have had preferential arterial supply from the bronchial rather than the pulmonary arterial circulation. Bronchial artery to bronchial vein fistula may thus be a rare complication of thoracic surgery to the lung. This finding may have been made easier in this case by our recent acquisition of a new, state-of-the-art, 16 slice multi-detector CT scanner which allows faster scanning, and better contrast enhancement with improved spatial resolution. The patient was considered to be in complete remission and has undergone high dose consolidation treatment with melphalan and autologous peripheral blood stem cell rescue.
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