| BackgroundEsophagorespiratory fistula (ERF) is a serious complication of esophageal cancer caused by tumor and its treatment. Reviewed early literature the incidence of esophagorespiratory fistulain esophagus cancer is only5%.However, With the development of the diagnosis and treatment in these years, some recent studies have found its incidence much higher, estimating that up to10%of the patients with esophagus cancer will develop a malignant fistula.Patients present mainly with intractable cough and repeated respiratory infections. Rapid deterioration and death results if this condition is left untreated.ObjectiveTo analysis the characteristics and treatment choices ofesophageal cancer patients withERF and investigate prognostic factorsfor survival.MethodsRecords of82esophageal cancer patients with esophagorespiratory fistula (not caused by treatment directly) treated in Shandong provincial hospital from2002to2013were reviewed and followed up until February1,2013. Prognostic factors were analyzed by Kaplan-Meier method and Cox regression model with SPSS21.0software.Results 1.Clinical features:The mean age of patients with fistula was60.0±10.5years. The ratio between men and women was found to be4:1.Characteristics of esophageal cancer:Location:involved cervical segment were8cases (9.8%),upper thoracic segment were21cases (25.6%),middle thoracic segment were37cases (45.1%), lower thoracic segment were16cases (19.5%). Pathology:all were squamous-cell carcinoma,78cases (95.1%) were moderately or poorly differentiated,4cases (4.9%) were highly differentiated.Morphology:46cases (56.1%)weremedullary type,21cases(25.6%) were ulcerativetype,5cases (6.1%) werefungating type,3cases (3.7%) were constrictive type,7cases (8.5%) were unknown.29cases(35.4%) were treated with surgery,5cases (6.1%) were treated with chemotherapy alone,16cases (19.5%) were treated with radiotherapy alone,41cases (50.0%) were treated with radiotherapy and chemotherapy.In addition, because of esophageal stenosis,15patients (18.3%) received expansion or stent treatment.During the development of ERF, mediastinal lymph node metastaseswere detected in73(89.0%) patients. Distant metastases were found in32(39.0%)patients,involvedthe distant lymph nodewere14cases (17.1%), lung were9cases (11.0%), liver were5cases (6.1%), bonewere3cases (3.6%), stomachwas1cases (1.2%). characteristics of ERF:The median time from diagnosis of the esophageal cancer toERF development were9.4months, The ERF wasfound in13cases (15.9%)before treatment,11cases (13.4%) during treatment,58cases (70.7%) after treatment.Types of ERF:tracheoesophageal fistula (TEF) accounted for62.2%,bronchoesophageal fistula (BEF) accounted for37.8%. ERF Position: involved sites ofesophageal:24.9±4.5cm.(The distance from the incisors).involved sites of respiratory:75.9%in trachea (after surgery),37.7%in trachea and32.1%in right bronchial (without surgery).2.Prognostic factors:median survival time (MST) from ERF diagnosis was2.5months.The results of multivariate analysis showed that distant metastases, anti-tumor and palliative treatment after ERF formation were related to prognosis (p <0.05). The death risk was2times increased by distant metastases. The efficacy of stent placement was better thanfeeding tube and parenteral nutrition. Because of the limited sample size, whether the efficacy of stent placement is better than gastrostomy or jejunostomy need to be further study.What’s more, patients received anti-tumor treatment had better prognosis.The mediansurvival time inthese patients whose fistula observed before treatmentwas longer than thatdeveloped after treatment, the Stage III disease was longer than Stage IV disease, the fistula closedwas longer than not closed.The median dose of radiotherapy was58Gy.Closure of the fistula was observed in2cases with chemoradiotherapy,1case with radiotherapy, none with chemotherapy.Conclusion1. The main type of ERF was tracheoesophageal fistula (TEF) in esophageal cancer. Primary tumorsusually located in the middle portion of esophagus.Thehistomorphological study suggests that fistula formation is associated with medullary and ulcerative types, low and middle differentiated squamous cell carcinoma.2.During ERF formation, most esophageal cancers had mediastinal lymph node metastases. Except distant lymph node, distant metastases were found in lung most frequently. Perforation form a new way for spreading of the esophageal cancer into the airway and lung.3.Majority of ERF were found after esophageal cancer treatment. In addition to the tumor invasion,post-operative stenosis of the anastomotic orifice, rapid tumorregressionwith esophagus inflammation and fibrosis caused by radiotherapy andchemotherapy, expansion or stents mechanical damage could induce ERF.4. The survival time of esophageal cancer with ERF was limited. The distant metastases inferred poor prognosis. Patients received stent placementand anti-tumor treatment had better prognosis. 5. The anti-tumor treatment made better effect inthe patients whose fistula observed before treatment and without distant metastasis.On the basis of supportive treatments, such ascovered-stent placement, the radiotherapy or combined with chemotherapy should start immediately after controlled infection. |
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