Malignant Esophageal Fistulas Research Articles

Prediction of malignant esophageal fistula in esophageal cancer using a radiomics-clinical nomogram

BackgroundMalignant esophageal fistula (MEF), which occurs in 5% to 15% of esophageal cancer (EC) patients, has a poor prognosis. Accurate identification of esophageal cancer patients at high risk of MEF is challenging. The goal of this study was to build and validate a model to predict the occurrence of esophageal fistula in EC patients.MethodsThis study retrospectively enrolled 122 esophageal cancer patients treated by chemotherapy or chemoradiotherapy (53 with fistula, 69 without), and all patients were randomly assigned to a training (n = 86) and a validation (n = 36) cohort. Radiomic features were extracted from pre-treatment CTs, clinically predictors were identified by logistic regression analysis. Lasso regression model was used for feature selection, and radiomics signature building. Multivariable logistic regression analysis was used to develop the clinical nomogram, radiomics-clinical nomogram and radiomics prediction model. The models were validated and compared by discrimination, calibration, reclassification, and clinical benefit.ResultsThe radiomic signature consisting of ten selected features, was significantly associated with esophageal fistula (P = 0.001). Radiomics-clinical nomogram was created by two predictors including radiomics signature and stenosis, which was identified by logistic regression analysis. The model showed good discrimination with an AUC = 0.782 (95% CI 0.684–0.8796) in the training set and 0.867 (95% CI 0.7461–0.987) in the validation set, with an AIC = 101.1, and good calibration. When compared to the clinical prediction model, the radiomics-clinical nomogram improved NRI by 0.236 (95% CI 0.153, 0.614) and IDI by 0.125 (95% CI 0.040, 0.210), P = 0.004.ConclusionWe developed and validated the first radiomics-clinical nomogram for malignant esophageal fistula, which could assist clinicians in identifying patients at high risk of MEF.

Efficacy and Safety of Self-Expandable Metallic Stent Placement for Malignant Esophageal Fistula.

Patients with malignant esophageal fistulas often experience dysphagia and infection, resulting in poor prognoses. Self-expandable metallic stent (SEMS) placement is a palliative treatment option; however, its efficacy and safety are unclear. We aimed to determine the efficacy and safety of SEMS placement for malignant esophageal fistulas. We retrospectively investigated patients who underwent SEMS placement for malignant esophageal fistulas between 2013 and 2022 at the Cancer Institute Hospital. Dysphagia scores (DSs) before and after SEMS placement, adverse events, and overall survival from SEMS placement until death were evaluated. A total of 17 patients underwent SEMS placement, including 12 and 5 patients with esophageal and lung cancers, respectively. Prior treatments included chemoradiotherapy (n = 11), radiotherapy (n = 4), and chemotherapy (n = 4); two patients underwent palliative radiotherapy after chemotherapy. All procedures were technically successful. After SEMS placement, 14 (82.4%) patients were able to consume semisolid or solid food (DS ≤ 2). Major adverse events were encountered in only one case. The median survival time after SEMS placement was 71 days (range 17-247 days). SEMS placement allowed most patients to resume oral intake with a low rate of major adverse events. SEMS placement is a reasonable palliative treatment option for patients with malignant fistulas who have poor prognoses.

Development and validation of a prognostic nomogram for malignant esophageal fistula based on radiomics and clinical factors.

BackgroundThe current study aimed to comprehensively analyze the clinical prognostic factors of malignant esophageal fistula (MEF). Furthermore, this study sought to establish and validate prognostic nomograms incorporating radiomics and clinical factors to predict overall survival and median survival after fistula for patients with MEF.MethodsThe records of 76 patients with MEF were retrospectively analyzed. A stepwise Cox proportional hazards regression model was employed to screen independent prognostic factors and develop clinical nomograms. Radiomic features were extracted from prefistula CT images and post fistula CT images. Least absolute shrinkage and selection operator (LASSO) regression and Cox regression algorithm was used to filter radiomic features and avoid overfitting. Radiomic signature was a linear combination of optimal features and corresponding coefficients. The joint prognostic nomograms was constructed by radiomic signatures and clinical features. All models were validated by Harrell's concordance index (C‐index), caliberation and bootstrap validation.ResultsFor overall survival, age, prealbumin, KPS and interval between diagnosis of esophageal cancer and fistula were identified as independent prognostic factors and incorporated into the clinical nomogram. Age, prealbumin, serum albumin, KPS and neutrophil proportion were selected for the clinical nomogram of post fistula survival. The C‐index of overall survival nomogram was 0.719 (95% CI: 0.645–0.793) and that was 0.722 (95% CI: 0.653–0.791) in the post fistula survival nomogram. The radiomic signature developed by radiomic features of prefistula CT showed a significant correlation with both overall survival and post fistula survival. The C‐index of joint nomogarm for overall survival and post fistula survival was 0.831 (95% CI: 0.757–0.905) and 0.77 (95% CI: 0.686–0.854), respectively. The calibration curve showed the joint nomograms outperformed the clinical ones.ConclusionsThe study presents nomograms incorporating independent clinical risk factors and radiomic signature to predict the prognosis of MEF. This prognostic classification system has the potential to guide therapeutic decisions for patients with malignant esophageal fistulas.

Covered metallic stent for the treatment of malignant esophageal fistula combined with stricture

BackgroundEsophageal fistula and stricture is rare but life-threatening complication for esophageal cancer. The management of esophageal fistula and stricture remains challenging. We aimed to determine the safety, feasibility and efficacy of covered metallic stent and three tubes placement for the management of esophageal fistula and stricture.MethodsBetween May 2012 and March 2018, all patients with esophageal fistula and stricture were treated using three tubes or covered metallic stent placement. Patients in group A received covered stents and three tubes placement. Patients in group B only received three tubes placement. Continue abscess drainage and nutritional support was performed after procedure. Three tubes or esophageal stents were removed once esophageal fistula heals. The related medical records were retrospectively assessed.ResultsThirty-seven consecutive patients with esophageal fistula and stricture were enrolled, including 26 patients in group A and 11 patients in group B. Stent placement procedure was technically successful in 25 patients (96.2%). A total of 42 covered stents were inserted. Seventeen esophageal stents were successfully removed from 10 patients. The median retention duration was 3.3 months and 3.4 months for stent and abscess drainage tubes, respectively. One perioperative death due to massive hemorrhage was observed 21 days after stent placement. The abscess cavity was decreased or disappeared in 17 cases and 4 cases in group A and group B, respectively. During follow up, patients in group A still showed a significant better condition of normal diet than that in group B (p < 0.05). Fourteen patients died of cancer recurrence, 3 patients died of massive digestive bleeding and 2 patients died of severe pulmonary infection. The median survivals were 14.8 months and 13.2 months for group A and group B, respectively.ConclusionsCovered metallic stent placement is safe, feasible and efficacious for treatment of esophageal fistula and stricture, with a better condition of normal diet than patients only received three tubes placement.

Surgical treatment of esophageal carcinoma complicated by fistulas.

The locally advanced esophageal carcinoma can be complicated by fistulas. According to published data, the incidence rate of malignant esophageal fistulas is about 13%. The range of treatment modalities proposed by different authors varies from palliation to active and, if possible, radical surgical interventions. In the present study, we investigated combined esophagectomies as a radical treatment of the malignant esophageal fistulas. Thirty-five patients (aged 28--67) with malignant esophageal fistulas of different localizations were operated over a period from 1990 to 2000. The tumor was located in the upper, middle and lower thoracic esophagus in four, 20 and 11 cases, respectively. The malignant fistula with the mediastinum, pleural cavity, lungs, bronchi and trachea was observed in 21, two, five, four and three cases, respectively. Subtotal esophagectomy and esophagogastroplasty were performed in 18 patients; subtotal esophagectomy with intrapleural coloesophagoplasty was performed in one case; proximal gastric and lower thoracic esophageal resection from the left-side abdominothoracic approach was performed in three cases. Esophagogastric bypass anastomoses were formed in ten patients. Gastrostomy was performed in three patients. The complication rate was 40% (14 out of 35); the postoperative mortality was 14.3% (five out of 35). In patients after esophageal resection, the mortality rate was 13.6% (three out of 22). With a median survival of 13 months (range, 3--31), the 2-year survival rate was 21% after combined esophagectomies. The goal of surgery for esophageal cancer with various fistulas is to completely resect the primary tumor and involved adjacent structures with clear surgical margins and extended two-field lymphadenectomy. The importance of performing a complete resection is stressed by the absence of 1-year survivors among patients who underwent bypass surgery or gastrostomy. We consider that en-bloc combined resection of esophageal cancer complicated by fistula can be done with a low mortality.

Esophagopleural fistula treated endoscopically with argon beam electrocoagulation and clips

Fistulas of the esophagus can extend into the pleural cavity, mediastinum, or bronchial tree and can be caused by trauma and bacterial infections, in particular mycobacterial disease. However, they most frequently occur as a result of malignancies of the esophagus, lungs, or mediastinum, either as a primary complication or after treatment of these cancers with radiotherapy or chemotherapy. Under these circumstances, palliation can be obtained by esophageal stenting, preferably with a self-expandable coated stent. 1 Morgan PRA Ellul JPM Denton ERE Glynos M Mason RC Adam A. Malignant esophageal fistulas and perforations: management with plastic-covered metallic endoprostheses. Radiology. 1997; 204: 527-532 PubMed Google Scholar , 2 Raijman I Lynch P. Coated expandable esophageal stents in the treatment of digestive-respiratory fistulas. Am J Gastroenterol. 1997; 92: 2188-2191 PubMed Google Scholar , 3 Spivak H Katariya K Lo AY Harvey JC. Malignant tracheo-esophageal fistula: use of esophageal endoprosthesis. J Surg Oncol. 1996; 63: 65-70 Crossref PubMed Scopus (21) Google Scholar Although clinically successful in more than 95% of patients, 1 Morgan PRA Ellul JPM Denton ERE Glynos M Mason RC Adam A. Malignant esophageal fistulas and perforations: management with plastic-covered metallic endoprostheses. Radiology. 1997; 204: 527-532 PubMed Google Scholar , 4 Bethge N Sommer A Vakil N. Treatment of esophageal fistulas with a new polyurethane-covered, self-expanding mesh stent: a prospective study. Am J Gastroenterol. 1995; 90: 2143-2146 PubMed Google Scholar the use of these stents has disadvantages. Esophageal perforations and lethal hemorrhages occur in 2% to 5% of cases. 5 Swain CP Gong F Murfitt J. Difficulties with placement of esophageal metal stents and development and testing of new delivery method and covered stents. Gastrointest Endosc. 1995; 41 ([abstract]): 358 Abstract Full Text PDF Google Scholar , 6 May A Hahn E Ell C. Self-expanding metal stents for palliation of malignant obstruction in the upper gastrointestinal tract. J Clin Gastroenterol. 1996; 22: 261-266 Crossref PubMed Scopus (107) Google Scholar , 7 Kozarek RA Ball TJ Brandabur JJ Patterson DJ Low D Hill L et al. Expandable versus conventional esophageal prostheses: easier insertion may not preclude subsequent stent-related problems. Gastrointest Endosc. 1996; 43: 204-208 Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar Stent migration and food impaction occur frequently, necessitating endoscopic reintervention in more than 10% to 15% of patients within 3 months. 6 May A Hahn E Ell C. Self-expanding metal stents for palliation of malignant obstruction in the upper gastrointestinal tract. J Clin Gastroenterol. 1996; 22: 261-266 Crossref PubMed Scopus (107) Google Scholar Other therapeutic options, in selected cases, are the use of tissue glue, with success in about 50% of patients, 8 Hirao M Shimada M Kaneko T Mizunoya S Okagawa K. Two cases of esophageal fistula, in which a fibrin glue preparation was effective. J Jpn Assoc Thor Surg. 1994; 42: 2144-2149 Google Scholar , 9 Cellier C Landi B Faye A Wind P Frileux P Cugnenc P-H et al. Upper gastrointestinal tract fistulae: endoscopic obliteration with fibrin sealant. Gastrointest Endosc. 1996; 4: 731-733 Abstract Full Text Full Text PDF Scopus (59) Google Scholar or surgery, which has high morbidity (30%) and mortality (10%) rates even in specialized centers. 3 Spivak H Katariya K Lo AY Harvey JC. Malignant tracheo-esophageal fistula: use of esophageal endoprosthesis. J Surg Oncol. 1996; 63: 65-70 Crossref PubMed Scopus (21) Google Scholar , 10 Fernando HC Benfield JR. Surgical management and treatment of esophageal fistula. Surg Clin North Am. 1996; 76: 1123-1135 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar

Malignant esophageal fistulas and perforations: management with plastic-covered metallic endoprostheses.

To evaluate prospectively the efficacy of plastic-covered metallic endoprostheses in patients with malignant esophageal fistulas and perforations. Thirty-nine patients with incurable esophageal carcinoma who developed esophagorespiratory fistulas (n = 20) or perforations (n = 19) were treated with plastic-covered metallic stents. Covered Wallstent endoprostheses were placed in 36 patients and covered Gianturco stents in three. All 19 perforations and 18 of 20 fistulas were successfully closed (clinical success rate, 95%). Symptoms of aspiration or dysphagia improved in all successfully treated patients. Mean survival was 81.8 days (range, 1-370 days). One patient with a closed perforation developed a fistula 16 weeks later and was treated with a second, overlapping stent; three patients with recurrent fistulas were treated with additional esophageal stents (one patient) or tracheal stents (two patients). In four patients, stent migration (two Gianturco and two Wallstent endoprostheses) necessitated placement of an additional stent. Covered metallic stents offer effective treatment for perforations and fistulas in patients with esophageal malignancy. Patients with recurrent fistulas can be treated with additional stents. Fistulas close to the upper esophageal sphincter may be closed with placement of parallel covered metallic stents in the esophagus and trachea.

Management of Malignant Esophageal Strictures Complicated by Fistula

Malignant esophageal fistula is a devastating complication presenting a challenging problem in terms of occluding the fistula and restoring esophageal patency. Among 29 patients with unresectable esophageal tumors, there were 7 males and 2 females (mean age 63.2 years) who presented with esophageal fistulae: 2 bronchoesophageal, 3 esophagomediastinal, 3 esophagopleural and 1 esophagomediastinopleural. The main presenting symptoms were dysphagia, fever and cough. Intubation was carried out under general anesthesia in 8 and under sedation in 1 patient. A cuffed Wilson-Cook prosthesis was used in 4 patients and self-expanding Strecker stents in 5. Intubation was effective in initially relieving dysphagia and controlling sepsis in all cases. However, fistula recurred in 3 cases and surgical intervention was required by means of retrosternal esophageal bypass. Successful palliation was eventually achieved in all patients. There was no mortality and the mean survival was 7 months. We conclude that malignant esophageal fistulae are difficult to manage and may require a combination of prosthesis placement and bypass surgery should a late failure occur.