Esophagopericardial fistula (EPF) is an exceptionally rare and life-threatening condition historically associated with esophageal carcinoma, postoperative complications, peptic ulcer disease, or radiotherapy. Fewer than 70 cases have been reported since 1931, and no previous case has been attributed to metastatic renal cell carcinoma (RCC). The mortality remains extremely high due to purulent pericarditis, cardiac tamponade, and sepsis. We present the first reported case of EPF originating from a paraesophageal RCC metastasis, successfully diagnosed and managed through advanced endoscopy. 

Our patient is a 65-year-old male with metastatic RCC with mediastinal lymph node progression infiltrating the esophagus (Figure 1), for which cabozantinib is initiated. One month later, he presented with shock, severe metabolic acidosis, acute kidney injury and elevated lactate. Imaging revealed bilateral pleural effusions and a progressive pericardial effusion. Purulent pericardiocentesis yielded Enterococcus faecium and Candida albicans. CT showed pneumopericardium and air tracking between the mid-thoracic esophagus and pericardium (Figure 2), raising suspicion of fistulization, particularly in the context of a previously treated mediastinal paraesophageal metastatic mass. 

Bedside gastroscopy in ICU revealed, in the middle third of the esophagus, fibrin, purulent exudate and a 4 cm long orifice confirming EPF (Figure 3). Given the patient’s critical instability, endoscopic therapy was selected as the safest option. A fully covered 18 cm × 28 mm esophageal stent was deployed under endoscopic guidance and secured with an over-the-scope clip. Initial sealing and expansion were satisfactory. Two days later, he developed persistent sepsis and hypotension. Chest X-ray demonstrated that the prior stent had migrated caudally (Figure 4). The displaced stent was removed endoscopically. A longer fully covered 24 cm × 28 mm bariatric-type stent was deployed and fixed with an over-the-scope clip, achieving complete coverage. A new pericardiocentesis was performed, obtaining purulent exudate. 

Subsequent CT imaging confirmed marked reduction of pericardial collections and resolution of contrast leakage. The patient improved hemodynamically and was successfully extubated. Multidisciplinary management continued with pericardiectomy and targeted antimicrobial therapy. 

EPF is usually related to primary esophageal malignancy; most of literature cases describe esophageal carcinoma as the malignant etiology. This is the first documented EPF arising from RCC metastasis. Early endoscopic diagnosis was crucial, and therapeutic stenting—despite migration—provided effective fistula sealing and stabilization in a critically ill patient. This case underscores the pivotal role of advanced endoscopy in the diagnosis, treatment and rescue management of malignant EPF.