Esophageal perforation during or after conformal radiotherapy for esophageal carcinoma

Perforated Esophageal Cancer

Esophageal perforation in the setting of malignancy is a surgical emergency for which there is little direct evidence in the literature to guide treatment. Instead, treatment is based on a combination of our understanding of managing benign esophageal perforations and a contemporary understanding of the treatment and prognosis of esophageal cancer. Due to the numerous challenges of managing perforated esophageal cancer, incorporating clinicians with expertise in esophageal cancer, advanced endoscopy, and esophageal surgery into shared decision-making discussions with patients and their families is essential.

The sparing effect of ultra-high dose rate irradiation on the esophagus

Background and purpose

Current studies have substantiated the sparing effect of ultra-high dose rate irradiation (FLASH) in various organs including the brain, lungs, and intestines. Whether this sparing effect extends to esophageal tissue remains unexplored. This study aims to compare the different responses of esophageal tissue in histological and protein expression levels following conventional dose rate irradiation (CONV) and FLASH irradiation to ascertain the presence of a sparing effect.

Methods and materials

C57 female mice were randomly divided into three groups: control, CONV, and FLASH groups. The chest region of the mice in the radiation groups was exposed to a prescribed dose of 20 Gy using a modified electron linear accelerator. The CONV group received an average dose rate of 0.1 Gy/s, while the FLASH group received an average dose rate of 125 Gy/s. On the 10th day after irradiation, the mice were euthanized and their esophagi were collected for histopathological analysis. Subsequently, label-free proteomic quantification analysis was performed on esophageal tissue. The validation process involved analyzing transmission electron microscopy images and utilizing the parallel reaction monitoring method.

Results

Histopathology results indicated a significantly lower extent of esophageal tissue damage in the FLASH group compared to the CONV group (p < 0.05). Label-free quantitative proteomic analysis revealed that the sparing effect observed in the FLASH group may be attributed to a reduction in radiation-induced protein damage associated with mitochondrial functions, including proteins involved in the tricarboxylic acid cycle and oxidative phosphorylation, as well as a decrease in acute inflammatory responses.

Conclusions

Compared with CONV irradiation, a sparing effect on esophageal tissue can be observed after FLASH irradiation. This sparing effect is associated with alleviated mitochondria damage and acute inflammation.

Multi-stage surgery to treat oesophageal fistula that developed after chemoradiotherapy in two patients with oesophageal cancer: A case report

INTRODUCTION AND IMPORTANCE

Oesophageal fistula is a severe complication that may occasionally develop after chemoradiotherapy (CRT) for oesophageal cancer and is difficult to treat.

CASE PRESENTATION

A 51-year-old man who had undergone CRT for oesophageal cancer presented with haematemesis and was diagnosed with a descending aortic aneurysm and an oesophageal fistula. Thoracic endovascular aneurysm repair was performed to achieve haemostasis. After 3 days, the patient underwent subtotal oesophagectomy and cervical oesophagostomy with delivery of a pedicled omental flap to the exposed aortic stent. Six months later, ileocecal reconstruction was performed. The second patient was a 49-year-old woman who had undergone CRT 1 year previously. She complained of leg weakness and gait disorder. After a workup, she was diagnosed with perforation of the posterior wall of the cervical oesophagus with abscess formation and purulent spondylitis. After two spinal fusion surgeries, we performed tracheotomy and drained the cervical region to reduce local infection. After 7 days, she underwent pharyngolaryngoesophagectomy and reconstruction using a gastric conduit, to which a large section of the omental flap was attached. After the multi-stage surgery, oral intake became possible, and both patients were discharged.

CLINICAL DISCUSSION

The optimal treatment strategy for post-CRT oesophageal fistula remains controversial. Radical surgery, including oesophagectomy, is the treatment of choice, although it is associated with high mortality rates. Multi-stage surgery may be useful for reducing surgical stress in moribund patients.

CONCLUSION

We reported two cases involving radiation-induced oesophageal fistula successfully treated by multi-stage surgery without major complications.

Clinical-radiomics nomogram for the risk prediction of esophageal fistula in patients with esophageal squamous cell carcinoma treated with intensity-modulated radiation therapy or volumetric-modulated arc therapy

Background

Esophageal fistula (EF) is a serious adverse event as a result of radiotherapy in patients with esophageal cancer (EC). We aimed to identify the predictive factors and establish a prediction model of EF in patients with esophageal squamous cell carcinoma (ESCC) who underwent intensity-modulated radiation therapy (IMRT) or volumetric-modulated arc therapy (VMAT).

Methods

Patients with ESCC treated with IMRT or VMAT from January 2013 to December 2020 at Xijing Hospital were retrospectively analyzed. Ultimately, 43 patients with EF and 129 patients without EF were included in the analysis and propensity-score matched in a 1:3 ratio. The clinical characteristics and radiomics features were extracted. Univariate and multivariate stepwise logistic regression analyses were used to determine the risk factors associated with EF.

Results

The median follow-up time was 24.0 months (range, 1.3-104.9 months), and the median overall survival (OS) was 13.1 months in patients with EF. A total of 1,158 radiomics features were extracted, and eight radiomics features were selected for inclusion into a model for predicting EF, with an area under the receiver operating characteristic curve (AUC) value of 0.794. Multivariate analysis showed that tumor length, tumor volume, T stage, lymphocyte rate (LR), and grade IV esophagus stenosis were related to EF, and the AUC value of clinical model for predicting EF was 0.849. The clinical-radiomics model had the best performance in predicting EF with an AUC value of 0.896.

Conclusions

The clinical-radiomics nomogram can predict the risk of EF in ESCC patients and is helpful for the individualized treatment of EC.

Key changes in the future clinical application of ultra-high dose rate radiotherapy

Ultra-high dose rate radiotherapy (FLASH-RT) is an external beam radiotherapy strategy that uses an extremely high dose rate (≥40 Gy/s). Compared with conventional dose rate radiotherapy (≤0.1 Gy/s), the main advantage of FLASH-RT is that it can reduce damage of organs at risk surrounding the cancer and retain the anti-tumor effect. An important feature of FLASH-RT is that an extremely high dose rate leads to an extremely short treatment time; therefore, in clinical applications, the steps of radiotherapy may need to be adjusted. In this review, we discuss the selection of indications, simulations, target delineation, selection of radiotherapy technologies, and treatment plan evaluation for FLASH-RT to provide a theoretical basis for future research.

Sintilimab as maintenance treatment for local/regional recurrent esophageal squamous carcinoma after concurrent chemoradiotherapy: a single-arm Ib/II phase study

Background

Esophageal cancer (EC) is an aggressive neoplasm of the gastrointestinal tract that is usually treated with a combination of chemotherapy, radiotherapy (RT), and/or surgery, according to disease status. Despite the availability of multimodal therapeutic strategies, local recurrence is frequently observed. However, there is no standard treatment or promising therapeutic approach for local recurrence or metastatic esophageal carcinoma after the RT. This study tended to investigate the efficacy and safety of sintilimab maintenance after concurrent chemoradiotherapy (CCRT) for local/regional recurrent esophageal squamous carcinoma.

Methods

This study was a single-arm, phase Ib/II trial conducted in a single site in China. Patients previously radically treated (surgery or CCRT), histologically confirmed, local or regional recurrence esophageal squamous carcinoma, qualified for the study design, were treated with 25-28 times radiotherapy plus raltitrexed once every 3 weeks for up to two cycles. Patients who have not progressed after CCRT received sintilimab as maintenance once every 3 weeks up to 1 year. Primary endpoints were overall survival (OS) and safety. Secondary endpoints were progression-free survival (PFS), objective response rate (ORR), and duration of response (DOR).

Results

Between September 2019 and March 2022, in a total of 36 enrolled patients, 34 pts completed CCRT. Three patients excluded due to violation of the exclusion criteria (1 pt) and consent withdrawal (2 pts). Finally, 33 pts were included in the final analysis, in which 3 pts had disease progression, and the remaining 30 entered maintenance therapy with sintilimab. The median follow-up time was 12.3 months. Median OS was 20.6 months (95%CI 10.5-NA) and the 1-year OS rate was 64%. Median PFS was 11.5 months (95%CI 5.29-21.3) and the 1-year PFS rate was 43.6%. The ORR was 63.6% (95%CI 44.6-77.8), including 2 cases of CR and 19 cases of PR. The DCR was 19.9%, the median DOR was 19.5 months, and the median TTR was 2.4 months. The rate of any grade TRAEs was 96.7%; ≥Grade 3 TRAE was 23.4%. The incidence of immune-related AE was 60%, most of which were grade 1-2, and only one case of thyroid-stimulating hormone increased was irAE with grade 3 or above.

Conclusion

Sintilimab has shown promising clinical efficacy and a manageable safety profile as maintenance therapy after CCRT for local/regional recurrent esophageal squamous carcinoma. In addition, further confirmation from a large-scale real-world study is still needed.

Retrospective cohort study on treatment modalities and survival time after oesophageal fistula in patients with oesophageal cancer in a regional cancer care centre in China

BACKGROUND

Oesophageal fistula (perforation) is a devastating complication in patients with oesophageal cancer . The optimal treatment remains uncertain.

OBJECTIVE

We sought to present real-world evidence on treatment modalities and survival postfistula in patients with oesophageal cancer.

DESIGN, SETTINGS AND MAIN OUTCOMES

This was a retrospective cohort study of patients with oesophageal cancer with oesophageal fistulae diagnosed between June 2010 and June 2020 in a regional cancer care centre in Zhengzhou, China (n=352). The treatment options included surgical resection, oesophageal stent grafting, gastrostomy, nasogastric tube and conservative care. The primary outcome was survival time (months) postfistula. Inverse probability of treatment weighting (IPTW) life regression was used to estimate the differences in survival time accounting for potential confounders.

RESULTS

The median survival time was 2.3 months (IQR: 0.7-6.0 months). Survival times were shorter in patients of male sex, T4 stage and oesophagotracheal versus oesophageal-mediastinal fistulae, and longer for any treatment option versus conservative care. The IPTW life regression analyses showed that in patients with oesophagotracheal fistulae, survival times were longer for stent grafting (+0.90 (95% CI 0.60 to 1.19) months) or gastrostomy (+0.81 (95% CI 0.47 to 1.13) months) versus nasogastric tube. In patients with oesophageal-mediastinal fistulae, survival times were shorter for stent grafting versus nasogastric tube (-0.36 (95% CI -0.63 to -0.09) months) and gastric tube (-0.29 (95% CI -0.50 to -0.08) months). Surgical resection was recorded in nine patients with oesophageal-mediastinal fistulae, and it was associated with the longest survival time in these patients.

CONCLUSIONS

Stent grafting or gastrostomy may be preferable to nasogastric tube in survival prognosis for patients with oesophageal cancer with oesophagotracheal fistulae. In contrast, stent grafting may be not preferable to nasogastric tube or gastrostomy in survival prognosis for patients with oesophageal-mediastinal fistulae.

Low body mass index is associated with poor treatment outcome following radiotherapy in esophageal squamous cell carcinoma

Purpose: We aimed to determine whether patients with esophageal cancer with a low baseline body mass index (BMI) have a poor prognosis following radiotherapy (RT).Materials and Methods: We retrospectively analyzed data from 50 patients with esophageal cancer to determine whether a low starting BMI (before RT) was associated with a poor outcome. All study participants were diagnosed with non-metastatic esophageal squamous cell carcinoma (SCC).Results: The number of patients at each T stage were as follows: 7 (14%) patients at T1, 18 (36%) at T2, 19 (38%) at T3, and 6 (12%) at T4. Based on BMI, 7 (14%) patients were defined as underweight. A low BMI was common in patients with T3/T4 stage esophageal cancer (7/43, p = 0.01). Overall, the 3-year progression-free survival (PFS) and overall survival (OS) rates were 26.3% and 69.2%, respectively. In univariate analysis, clinical factors associated with poor PFS included being underweight (BMI <18.5 kg/m2; p = 0.011) and a positive N status (p = 0.017). Univariate analysis also revealed that being underweight was associated with a decrease in OS (p = 0.003). However, being underweight was not an independent prognostic factor for PFS and OS. Conclusion: Patients with esophageal SCC with a low starting BMI (BMI <18.5 kg/m2) are more prone to have a negative survival outcome following RT than patients who are considered to be normal weight or overweight. For this reason, it is important that clinicians pay more attention to BMI when treating patients with esophageal SCC.

Risk factors and prognosis for esophageal fistula in patients with esophageal squamous cell carcinoma during radiotherapy

PURPOSE

To determine risk factors, treatment outcomes, and prognostic factors for esophageal fistula (EF) in patients with esophageal squamous cell carcinoma (ESCC) during radiotherapy.

METHODS

Between 2010 and 2018, 109 patients with EF during radiotherapy were retrospectively collected. A controlled cohort including 416 patients who received definitive chemoradiotherapy without EF was used to compare risk factors and survival outcomes. Univariate and multivariate logistic regression analyses were performed to identify predictors of EF. Propensity score matching (PSM) was applied to adjust for potential confounding factors.

RESULTS

Multivariate analysis demonstrated that sex, body mass index, alcohol history, esophageal ulceration, primary tumor length, T stage, and absolute lymphocyte count were independent risk factors for EF. After PSM, patients with EF showed remarkably worse prognosis than those without EF (median overall survival: 13.0 versus 20.5 months; P = 0.009). For patients with EF, serum albumin level (≥ 35 g/L), subsequent radiotherapy, and fistula closure were associated with significantly prolonged survival. In addition, esophageal-mediastinum fistula and subsequent radiotherapy were positive predictors for fistula closure.

CONCLUSIONS

We identified risk factors for radiotherapy-related EF and its unfavorable prognosis in patients with ESCC. Of them, patients with serum albumin level of ≥ 35 g/L, subsequent radiotherapy after EF, and fistula closure had a more favorable survival.

Response Evaluation Following Radiation Therapy With 18F-FDG PET/CT: Common Variants of Radiation-Induced Changes and Potential Pitfalls

Radiation therapy (RT) is one of the cornerstones in cancer treatment and approximately half of all patients will receive some form of RT during the course of their cancer management. Response evaluation after RT and follow-up imaging with ¹⁸F-Fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) can be complicated by RT-induced acute, chronic or consequential effects. There is a general consensus that ¹⁸F-FDG PET/CT for response evaluation should be delayed for 12 weeks after completing RT to minimize the risk of false-positive findings. Radiation-induced late side effects in normal tissue can take years to develop and eventually cause symptoms that on imaging can potentially mimic recurrent disease. Imaging findings in radiation induced injuries depend on the normal tissue included in the irradiated volume and the radiation therapy regime including the total dose delivered, dose per fraction and treatment schedule. The intent for radiation therapy should be taken in consideration when evaluating the response on imaging, that is palliative vs curative or neoadjuvant vs adjuvant RT. Imaging findings can further be distorted by altered anatomy and sequelae following surgery within the radiation field. An awareness of common PET/CT-induced changes/injuries is essential when interpreting ¹⁸F-FDG PET/CT as well as obtaining a complete medical history, as patients are occasionally scanned for an unrelated cause to previously RT treated malignancy. In addition, secondary malignancies due to carcinogenic effects of radiation exposure in long-term cancer survivors should not be overlooked. ¹⁸F-FDG PET/CT can be very useful in response evaluation and follow-up in patients treated with RT, however, variants and pitfalls are common and it is important to remember that radiation-induced injury is often a diagnosis of exclusion.

Survival rates and safety associated with chemoradiotherapy followed by surgery and chemoradiotherapy alone for patients with T4 esophageal cancer: a systematic review and meta-analysis

BACKGROUND

The optimal treatment approach for T4 esophageal cancer is not well established. We aimed to perform a systematic review and meta-analysis to determine the survival rates and safety of chemoradiotherapy followed by surgery (CRT-S) and chemoradiotherapy alone (CRT) in patients with T4 N_any M0 esophageal cancer.

MATERIALS AND METHODS

We searched databases for eligible prospective or retrospective studies. The outcomes of interest were overall survival (OS) at 1, 3 and 5 years, treatment-related fistula formation and mortality rates. Meta-analyses were performed using the random effects models separately for studies evaluating CRT-S and CRT. Subgroup analyses were performed based on histology, radiation dose, chemotherapy regimen and duration of the interval between CRT and surgery.

RESULTS

We identified 23 studies including 1,119 patients with predominantly squamous cell carcinoma (93%) and adenocarcinoma (3%) histology. The OS rates of patients receiving CRT-S were 65%, 36% and 20% at 1, 3 and 5 years, respectively. The OS rates of patients receiving CRT were 30%, 11% and 10% at 1, 3 and 5 years, respectively. Treatment-related fistula formation rates were 4% for CRT-S and 9% for CRT. Treatment-related mortality rates were 3% for both groups. Subgroup analyses showed that the interval of >2 months between CRT and surgery was associated with significantly improved OS rates at 1, 3 and 5 years.

CONCLUSION

Chemoradiotherapy is an efficacious treatment approach for T4 esophageal cancer, with clinically acceptable rates of treatment-related fistula formation and mortality. Tri-modality approach with surgery can be considered in carefully selected patients. Our study findings should be interpreted with caution due to the lack of high-quality evidence. Randomized controlled trials are warranted to confirm these findings.

Incorporation of PET Metabolic Parameters With Clinical Features Into a Predictive Model for Radiotherapy-Related Esophageal Fistula in Esophageal Squamous Cell Carcinoma

Purpose

To determine whether the addition of metabolic parameters from fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) scans to clinical factors could improve risk prediction models for radiotherapy-related esophageal fistula (EF) in esophageal squamous cell carcinoma (ESCC).

Methods and Materials

Anonymized data from 185 ESCC patients (20 radiotherapy-related EF-positive cases) were collected, including pre-therapy PET/CT scans and EF status. In total, 29 clinical features and 15 metabolic parameters from PET/CT were included in the analysis, and a least absolute shrinkage and selection operator logistic regression model was used to construct a risk score (RS) system. The predictive capabilities of the models were compared using receiver operating characteristic (ROC) curves.

Results

In univariate analysis, metabolic tumor volume (MTV)_40% was a risk factor for radiotherapy (RT)-related EF, with an odds ratio (OR) of 1.036 [95% confidence interval (CI): 1.009–1.063, p = 0.007]. However, it was excluded from the predictive model using multivariate logistic regression. Predictive models were built based on the clinical features in the training cohort. The model included diabetes, tumor length and thickness, adjuvant chemotherapy, eosinophil count, and monocyte-to-lymphocyte ratio. The RS was defined as follows: 0.2832 − (7.1369 × diabetes) + (1.4304 × tumor length) + (2.1409 × tumor thickness) – [8.3967 × adjuvant chemotherapy (ACT)] − (28.7671 × eosinophils) + (8.2213 × MLR). The cutoff of RS was set at −1.415, with an area under the curve (AUC) of 0.977 (95% CI: 0.9536–1), a specificity of 0.929, and a sensitivity of 1. Analysis in the testing cohort showed a lower AUC of 0.795 (95% CI: 0.577–1), a specificity of 0.925, and a sensitivity of 0.714. Delong’s test for two correlated ROC curves showed no significant difference between the training and testing sets (p = 0.109).

Conclusions

MTV_40% was a risk factor for RT-related EF in univariate analysis and was screened out using multivariate logistic regression. A model with clinical features can predict RT-related EF.

Unrecognized digestive toxicities of radiation therapy

The aim of this article is to review unrecognized toxicities resulting from radiation therapy of digestive neoplasms. Due to their precocious occurrence, acute toxicities are well-known by radiation oncologist, and their treatment well-established. Thus, acute toxicities will not be described in this review. We will focus on incidence, diagnosis, and management of late and uncommon toxicities occurring in the digestive tract and digestive organs. Prevention, by respecting healthy tissues constraints, is the main tool to reduce incidence of those rare complications. Nonetheless, once installed, late toxicities remain a major burden in terms of quality of life and can even be life threatening. Hence, information and education about their diagnosis and management is important.

The addition of flexible endoscopic suturing to stenting for the management of transmural esophageal wall defects: a single tertiary center experience

BACKGROUND AND AIMS

Endoscopic stenting is the standard of care for full thickness esophageal wall defects. The aim of this study is to evaluate outcomes of endoscopic closure of esophageal defects using stenting, with or without endoscopic suturing.

METHODS

This is a single-center retrospective study of patients with esophageal wall defects who underwent endoscopic interventions. Outcomes of stenting with or without endoscopic suturing of the defect were assessed. Univariate and multivariate logistic regression models were used to examine factors associated with successful defect closure.

RESULTS

One hundred and fourteen patients with esophageal wall defects underwent 254 endoscopies with an overall complete closure rate of 75.8%. Twenty-three (20.2%) patients underwent primary closure using endoscopic suturing and subsequent esophageal stenting, while 91 (79.8%) underwent esophageal stenting only. The dual modality group (versus the stent-only group) had similar defect closure rates (84.2 vs. 73.8%, p = 0.55) and time to stent migration (37 vs. 12.5 days, p = 0.07), but was associated with longer procedure times (60 vs. 36 min, p < 0.01) and fewer additional endoscopic procedures (13.6 vs. 43.2%, p = 0.01). Stent suturing significantly decreased migration (35.5 vs. 58.5%, p = 0.04), was associated with fewer additional endoscopies (15.4 vs. 50%, p < 0.01) and reduced need for additional stents (7.7 vs. 34.3%, p < 0.01). On multivariate analysis, chronic defects (> four weeks old) were 81% less likely to close compared to acute (≤ 4 weeks) defects (OR 0.19, CI 0.04-0.77, p = 0.02), and large diameter stents (23 mm) were associated with higher odds of defect closure (OR 3.36, CI 1.02-11.4, p = 0.04).

CONCLUSION

Endoscopic treatment of esophageal wall defects is safe, effective, and more likely to be successful in acute defects using larger caliber stents. Stent suturing reduces migration, need for additional endoscopic procedures, and stent exchanges. Further comparative studies with larger cohorts are needed to validate our results.

Esophageal fistula after definitive concurrent chemotherapy and intensity modulated radiotherapy for esophageal squamous cell carcinoma

Background

The literature regarding esophageal fistula after definitive concurrent chemotherapy and intensity modulated radiotherapy (IMRT) for esophageal squamous cell carcinoma (ESCC) remains lacking. We aimed to investigate the risk factors of esophageal fistula among ESCC patients undergoing definitive concurrent chemoradiotherapy (CCRT) via IMRT technique.

Methods

A total of 129 consecutive ESCC patients receiving definitive CCRT with IMRT between 2008 and 2018 were reviewed. The cumulative incidence of esophageal fistula and survival of patients were estimated by the Kaplan–Meier method and compared between groups by the log-rank test. The risk factors of esophageal fistula were determined with multivariate Cox proportional hazards regression analysis.

Results

Median follow-up was 14.9 months (IQR, 7.0–28.8). Esophageal perforation was identified in 20 (15.5%) patients, resulting in esophago-pleural fistula in nine, esophago-tracheal fistula in seven, broncho-esophageal fistula in two, and aorto-esophageal fistula in two patients. The median interval from IMRT to the occurrence of esophageal fistula was 4.4 months (IQR, 3.3–10.1). Patients with esophageal fistula had an inferior median overall survival (10.0 vs. 17.2 months, p = 0.0096). T4 (HR, 3.776; 95% CI, 1.383–10.308; p = 0.010) and esophageal stenosis (HR, 2.601; 95% CI, 1.053–6.428; p = 0.038) at baseline were the independent risk factors for esophageal fistula. The cumulative incidence of esophageal fistula was higher in patients with T4 (p = 0.018) and pre-treatment esophageal stenosis (p = 0.045). There was a trend toward better survival after esophageal fistula among patients receiving repair or stenting for the fistula than those only undergoing conservative treatments (median survival, 5.9 vs. 0.9 months, p = 0.058).

Conclusions

T4 and esophageal stenosis at baseline independently increased the risk of esophageal fistula in ESCC treated by definitive CCRT with IMRT. There existed a trend toward improved survival after the fistula among patients receiving repair or stenting for esophageal perforation.

Survival and prognostic factors of patients with esophageal fistula in advanced esophageal squamous cell carcinoma

The aim of the present study was to investigate the survival and prognostic factors of patients who were with advanced esophageal squamous cell carcinoma (ESCC) and developed an esophageal fistula. The data from 221 patients with advanced ESCC developed esophageal fistula from January 2008 to December 2017 at the Harbin Medical University Cancer Hospital was retrospectively analyzed. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated by the Cox proportional hazard models. The median survival time after a diagnosis of the esophageal fistula was calculated using the Kaplan–Meier method. We found that the pathogens infected by patients are common bacteria in nosocomial infection. Besides, the incidence rate of esophagomediastinal fistula was the highest (54.2%) in the lower third of the esophagus. Kaplan–Meier analysis revealed a median survival time of 11.00 months and a median post-fistula survival time of 3.63 months in patients who developed esophageal fistula in advanced esophageal cancer. In the univariate analysis, gender, therapies for ESCC before the development of fistula, type of esophageal fistula, treatment of esophageal fistula and hemoglobin (Hb) level were the factors with significant prognostic value. Gender, type of esophageal fistula and Hb level were identified as independent prognostic factors in further multivariate analysis. In summary, our study demonstrated that several factors are significantly related to patients with esophageal fistula and should be concerned about in clinical practice.

Clinical Application of Oral Meglumine Diatrizoate Esophagogram in Screening for Esophageal Fistula During Radiotherapy or Chemoradiotherapy for Esophageal Cancer

Background: This study aimed to investigate the specificity and sensitivity of oral meglumine diatrizoate esophagogram in screening for esophageal fistula during radiotherapy or chemoradiotherapy for esophageal cancer and determine if early detection and intervention could improve the prognosis of esophageal fistulas.

Methods: Esophageal cancer patients undergoing radiotherapy or chemoradiotherapy were included. Weekly oral meglumine diatrizoate esophagograms were performed to screen for esophageal fistulas during radiotherapy. When an esophageal fistula was detected, fibroesophagoscopy and computed tomography (CT) were used for confirmation; once confirmed, radiotherapy was discontinued, and the patient received intervention. The esophagogram results were reviewed weekly to assess the recovery of the esophageal fistula. If the fistula was healed, the patient resumed and completed radiotherapy.

Results: A total of 206 patients with cancer of the esophagus undergoing chemotherapy/radiotherapy were included. During radiotherapy, 10 cases of esophageal fistula were detected or suspected based on the oral meglumine diatrizoate esophagography findings, and eight of those cases were confirmed by CT and esophagoscopy. All patients with esophageal fistula received intervention; among them, 62.5% (5/8) recovered after 1 to 2 weeks of treatment and continued radiotherapy to completion. The sensitivity and specificity of oral meglumine diatrizoate esophagography in screening for esophageal fistulas during radiotherapy or chemoradiotherapy were 100 and 98.9%, respectively. The median survival period of patients with esophageal fistulas was 6.4 months.

Conclusion: Oral meglumine diatrizoate esophagography has high sensitivity and specificity in screening for esophageal fistulas during radiotherapy or chemoradiotherapy with minimal side effects. Early diagnosis and timely intervention can significantly improve the prognosis and prolong the survival period of patients.

Trial Registration: Chictr.org.cn, Identifier: ChiCTR-DDD-17012617. Registered on September 7, 2017. The first participant was enrolled on September 25, 2017. http://www.chictr.org.cn/showproj.aspx?proj=21526.

Efficacy and toxicity of re-irradiation for esophageal cancer patients with locoregional recurrence: a retrospective analysis

INTRODUCTION

There is no standard treatment for locoregional recurrent (LR) esophageal squamous cell carcinoma (ESCC) patients treated with radiotherapy (RT) previously. This retrospective study aimed to examine the efficacy and toxicity of re-irradiation (re-RT) for ESCC patients with LR.

PATIENTS AND METHODS

A total of 252 patients were enrolled. Gross tumor volumes for re-RT were defined using contrast enhanced computed tomography and/or positron emission tomography/computed tomography. Overall survival (OS), after recurrence survival (ARS) and toxicities were assessed.

RESULTS

Through a median follow-up of 38 months, the median OS and ARS were 39.0 and 13.0 months, respectively. The 6-, 12-, and 24-month ARS rates were 81.9%, 50.5%, and 21.8%, respectively. Multivariate analyses showed that chemotherapy, esophageal stenosis and recurrence-free interval (RFI) may be independent prognostic factors for ARS. The incidence of esophageal fistula/perforation (EP), radiation-induced pneumonitis and esophagorrhagia was 21.4%, 12.8% and 9.1%, respectively. RFI ≤ 12 months, esophageal stenosis and fat space between tumor and adjacent tissue disappeared were independent risk factors for the development of EP after re-RT.

CONCLUSIONS

Re-RT was feasible for LR ESCC patients after RT initially, the complication occurred in re-RT is acceptable. Patients with RFI ≤ 12 months, esophageal stenosis and fat space between tumor and adjacent tissue disappeared should be closely observed during and after re-RT.

Impact of Extracapsular Lymph Node Involving the Esophagus in Esophageal Perforation During and After Radiotherapy: A Propensity Score-Matched Analysis

Background

This study aimed to analyze the risk factors for esophageal squamous cell carcinoma (ESCC), especially extracapsular lymph node involving the esophagus (ECLNIE), occurring during or after radiotherapy (RT) in patients with esophageal perforation (EP).

Methods

In total, 306 patients with ESCC who received RT and/or chemotherapy between January 2016 and December 2017 in our hospital and who met the inclusion criteria of the study were recruited. The continuous variables were converted into classification variables using the receiver operating characteristic curve or common clinical parameters. Risk factors for EP were examined by univariable analysis using the chi-square test or Fisher’s exact and by multivariable analysis using logistic regression model. Propensity score matching (PSM) was used to compensate for the differences in baseline characteristics, and the incidence of EP was compared after matching.

Results

EP was observed in 26 patients (incidence rate, 8.5%). Univariable analysis revealed that age, BMI, T4 stage, tumor length, esophageal wall thickness, ECLNIE, necrotic areas, niche sign by esophagogram before RT, neutrophil-to-lymphocyte ratio, and prognostic nutritional index were significantly associated with EP among patients with ESCC who received radiotherapy. Multivariable analysis demonstrated that age, ECLNIE, esophageal wall thickness, and niche sign by esophagogram before RT were independent risk factors for EP. After PSM, compared with patients without ECLNIE, patients with ESCC and ECLNIE had a significantly higher risk of EP.

Conclusion

The presence of ECLNIE could be a strong risk factor of EP during and after RT.

Analysis of fistula formation of T4 esophageal cancer patients treated by chemoradiotherapy

BACKGROUND AND AIM

Fistula is one of the known complications of T4 esophageal cancer (T4-EC). The standard treatment for T4-EC is chemoradiotherapy, but detailed data about fistula resulting from chemoradiotherapy in this condition are limited. In particular, radiographic findings of T4-EC with fistula have not been reported. This study assessed the risk factors of fistula based on clinical information on patients with chemoradiotherapy for T4-EC.

METHODS

We retrospectively reviewed the clinical data of 59 T4-EC patients who had squamous cell carcinoma without any fistula before receiving definitive or palliative chemoradiotherapy.

RESULTS

A fistula was observed in 18 patients (31%) throughout their clinical course. The overall survival in the fistula group was significantly shorter than that in the non-fistula group (259 vs. 346 days; p = 0.0341). The axial tumor size on computed tomography (CT) was confirmed as an independent risk factor for esophageal fistula in multivariate analysis of stepwise methods [OR 1.226; 95% CI 1.109-1.411; p < 0.0001]. Twelve out of 14 patients with an axial tumor size of 50 mm or greater had developed a fistula.

CONCLUSIONS

A large tumor size on the axial plane on CT is a risk factor for fistula formation.

Risk Factors for Esophageal Fistula in Esophageal Cancer Patients Treated with Radiotherapy: A Systematic Review and Meta-Analysis

<b><i>Objective:</i></b> Esophageal fistula is a critical and fatal complication of esophageal cancer. The aim of this meta-analysis was to explore the risk factors for esophageal perforation in esophageal cancer patients treated with radiotherapy. <b><i>Methods:</i></b> Data from the PubMed and Embase databases were retrieved for clinical research published between 1990 and 2018. The Newcastle-Ottawa Scale was used to evaluate the quality of the articles. A meta-analysis was performed using the RevMan 5.3 software provided by the Cochrane Collaboration Network. <b><i>Results:</i></b> Seventeen articles were eligible for the meta-analysis. In these articles, over 35 risk factors for esophageal fistula formation were described and 17 risk factors were analyzed. Significant differences in the odds of developing an esophageal perforation were found with regard to age (OR 2.34, 95% CI 1.08–5.03, <i>p</i> = 0.001), ulcerative type (OR 2.72, 95% CI 1.43–5.16, <i>p</i> = 0.002), histology (OR 4.16, 95% CI 1.14–15.12, <i>p</i> = 0.03), T stage (OR 2.66, 95% CI 1.44–4.91, <i>p</i> = 0.002), short-term response (OR 2.21, 95% CI 1.06–4.62, <i>p</i> = 0.03), chemotherapy regimen (OR 2.80, 95% CI 1.38–5.68, <i>p</i> = 0.005), and stenosis (OR 2.00, 95% CI 1.03–3.89, <i>p</i> = 0.04). <b><i>Conclusions:</i></b> An age of &#x3c;60–65 years, ulcerative type, squamous cell cancer, T4 stage, incomplete response, fluorouracil-based regimen, and stenosis were associated with an increased risk of esophageal fistula during or after radiotherapy. However, further, large-scale prospective studies are needed to establish the validity of this associ­ation.

Combination of checkpoint inhibitors with radiotherapy in esophageal squamous cell carcinoma treatment: A novel strategy

Despite the rapid development of numerous types of treatment, including radiotherapy (RT) as the main strategy, esophageal squamous cell carcinoma (ESCC) has a poor prognosis. Recent studies demonstrated that immunotherapy can improve the survival of patients with locally advanced and metastatic ESCC. Furthermore, previous studies reported that the expression of programmed death-ligand 1 is significantly associated with esophageal cancer prognosis. At present, several ongoing clinical trials have extended the use of immunotherapy from palliative and salvage treatments to neoadjuvant treatment with concurrent chemoradiation. The first- or second-line treatments were used to explore antitumor efficacy with reduced adverse events. The combination of RT and immunotherapy can exert a local therapeutic effect and improve the function of the immune system, enhancing antitumor efficacy. This review investigated the role of immunotherapy and radiotherapy in ESCC and described the potential efficacy of combining immunotherapy with radiotherapy in ESCC.

Development and validation of a risk prediction model for radiotherapy-related esophageal fistula in esophageal cancer

Objectives

We aimed to identify the risk factors and provide a nomogram for the prediction of radiotherapy-related esophageal fistula in patients with esophageal cancer (EC) using a case-control study.

Patients and methods

Patients with esophageal fistula who received radiotherapy or chemoradiotherapy between 2003 and 2017 were retrospectively collected in two institutions. In the training cohort (TC), clinical, pathologic, and serum data of 136 patients (cases) who developed esophageal fistula during or after radiotherapy were enrolled and compared with 272 controls (1:2 matched with the diagnosis time of EC, sex, marriage, and race). After the univariable and multivariable logistic regression analyses, the independent risk factors were identified and incorporated into a nomogram. Then the nomogram for the risk prediction was externally validated in the validation cohort (VC; 47 cases and 94 controls) using bootstrap resampling.

Results

Multivariable analyses demonstrated that ECOG PS, BMI, T4, N2/3 and re-radiotherapy were independent factors for esophageal fistula. Then a nomogram was constructed with the C-index of 0.805 (95% CI, 0.762–0.848) for predicting the risk of developing esophageal fistula in EC patients receiving radiotherapy. Importantly, the C-index maintained 0.764 (95% CI, 0.683–0.845) after the external validation.

Conclusions

We created and externally validated the first risk nomogram of esophageal fistula associated with radiotherapy. This will aid individual risk stratification of patients with EC developing esophageal fistula.

Successful Stenting Followed by Surgery for Perforated Esophageal Cancer Due to Chemotherapy

Perforation of esophageal cancer solely due to preoperative chemotherapy is extremely rare, but can be associated with pyothorax and can be difficult to treat. Here, we report the case of a successfully treated patient with thoracic esophageal cancer who had esophageal perforation during docetaxel, cisplatin, and 5-fluorouracil chemotherapy. A 73-year-old patient had esophageal perforation on the fourth day of the first docetaxel, cisplatin, 5-fluorouracil cycle. The second docetaxel, cisplatin, 5-fluorouracil cycle was administered after insertion of esophageal stenting and subtotal esophagectomy. Early drainage and stent placement were crucial for achieving infection control and allowing for a subsequent complete resection.

Performance status is a predictive factor of dysphagia improvement after esophageal stenting in patients with malignant esophageal strictures and fistulas

BACKGROUND

Malignant strictures and fistulas of the esophagus adversely affect quality of life (QOL) and prognosis, and stenting is considered a useful therapy for improving QOL. However, the predictive factors for improving dysphagia after esophageal stenting are unclear. This retrospective cohort study aimed to evaluate patients with esophageal malignant strictures and fistulas who underwent stenting and investigate the factors for dysphagia improvement after stenting.

METHODS

Twenty-four patients with malignant esophageal strictures and fistulas were treated with a self-expandable metallic stent over a period of 5 years and 6 months. The main outcome was improvement in the dysphagia score. We divided the patients into dysphagia improved and non-improved groups after esophageal stenting. Sex, age, cause of stenting (primary or non-primary esophageal cancers), prior treatments, such as chemotherapy and radiation, type of esophageal stents (covered or non-covered), dysphagia score before stenting, and Eastern Cooperative Oncology Group (ECOG) performance status (PS) of the patients before stenting were evaluated. Student's t test and Fisher's exact test were used for continuous and categorical variables, respectively. Factors with a P value < 0.2, age, and sex were included and evaluated using a multiple logistic regression model. Statistical significance was defined as a P value < 0.05.

RESULTS

Stent placements succeeded in all cases without fatal complications. The dysphagia score improved in 15 patients. Twelve patients had primary lesions, and another 12 had non-primary lesions. The reasons for stenting were malignant strictures in 20 patients and esophageal fistulas in 4 patients. There were no significant differences in any factors, except PS before stenting (P = 0.003), between the improved and non-improved groups. Multiple logistic regression analysis results demonstrated that improvement in the dysphagia score was significantly associated with PS before stenting (adjusted odds ratio = 0.035, 95% CI 0.003-0.44, P = 0.009).

CONCLUSIONS

Esophageal stenting is safe and effective in patients with malignant esophageal strictures and fistulas. PS is an independent factor for dysphagia improvement after stenting.

Survival benefit of re-irradiation in esophageal Cancer patients with Locoregional recurrence: a propensity score-matched analysis

BACKGROUND

To investigate the treatment failure pattern and factors influencing locoregional recurrence of esophageal squamous cell carcinoma (ESCC) and examine patient survival with re-irradiation (re-RT) after primary radiotherapy.

METHODS

We retrospectively analyzed 87 ESCC patients treated initially with radiotherapy. Failure patterns were classified into regional lymph node recurrence only (LN) and primary failure with/without regional lymph node recurrence (PF). Patients received either re-RT or other treatments (non-re-RT group). Baseline covariates were balanced by a propensity score model. Overall survival (OS) and toxicities were assessed as outcomes.

RESULTS

The median follow-up time was 87 months. Thirty-nine patients received re-RT. Failure pattern and re-RT were independent prognostic factors for OS (P = 0.040 and 0.015) by Cox multivariate analysis. Re-RT with concomitant chemotherapy showed no survival benefit over re-RT alone (P = 0.70). No differences in characteristics were found between the groups by Chi-square tests after propensity score matching. The Cox model showed that failure pattern and re-RT were prognostic factors with hazard ratios (HR) of 0.319 (P = 0.025) and 0.375 (P = 0.002), respectively, in the matched cohort. Significant differences in OS were observed according to failure pattern (P = 0.004) and re-RT (P < 0.001). In the re-RT and non-re-RT groups, 9.09% and 3.03% of patients experienced tracheoesophageal fistulas, and 15.15% and 3.03% of patients developed pericardial/pleural effusion, respectively (P > 0.05). The incidence of radiation pneumonitis was higher in the re-RT group (24.24% vs. 6.06%, P = 0.039), but no cases of pneumonia-related death occurred.

CONCLUSIONS

Re-RT improved long-term survival in patients with locoregional recurrent ESCC. Despite a high incidence of radiation pneumonitis, toxicities were tolerable.

Esophageal Metal Stents with Concurrent Chemoradiation Therapy for Locally Advanced Esophageal Cancer: Safe or Not?

BACKGROUND

The purpose of this study was to review the risks and benefits of concurrent chemoradiation therapy (CCRT) with esophageal self-expandable metal stents (SEMS) for the treatment of locally advanced esophageal cancer.

MATERIALS AND METHODS

Between January 2014 and December 2016, the data from 46 locally advanced esophageal cancer patients who received CCRT at our institution were retrospectively reviewed. Eight patients who received CCRT concomitant with SEMS placement (SEMS plus CCRT group) and thirty-eight patients who received CCRT without SEMS placement (CCRT group) were identified. The risk of developing esophageal fistula and the overall survival of the two groups were analyzed.

RESULTS

The rate of esophageal fistula formation during or after CCRT was 87.5% in the SEMS plus CCRT group and 2.6% in the CCRT group. The median doses of radiotherapy in the SEMS plus CCRT group and the CCRT group were 47.5 Gy and 50 Gy, respectively. SEMS combined with CCRT was associated with a greater risk of esophageal fistula formation than CCRT alone (hazard ratio [HR], 72.30; 95% confidence interval [CI], 8.62-606.12; p < .001). The median overall survival times in the SEMS plus CCRT and CCRT groups were 6 months and 16 months, respectively. Overall survival was significantly worse in the SEMS plus CCRT group than in the CCRT group (HR, 5.72; 95% CI, 2.15-15.21; p < .001).

CONCLUSION

CCRT concomitant with SEMS for locally advanced esophageal cancer results in earlier life-threatening morbidity and a higher mortality rate than treatment with CCRT alone. Further prospective and randomized studies are warranted to confirm these observations.

IMPLICATIONS FOR PRACTICE

Patients treated with SEMS placement followed by CCRT had higher risk of esophageal fistula formation and inferior overall survival rate compared with patients treated with CCRT alone. SEMS placement should be performed cautiously in patients who are scheduled to receive CCRT with curative intent.