Irradiation of carcinoma of the esophagus containing a tracheoesophageal fistula.

Abstract

For patients with locally advanced esophageal carcinoma, tracheal involvement is common, and the formation of a tracheoesophageal fistula is a frequent complication of the disease, with or without treatment. However, the presence of a tracheoesophageal fistula has historically been considered a relative contraindication to radiation therapy. Therefore, we are presenting a case report whereby irradiation was continued despite the presence of such a fistula. A 60-year-old white man diagnosed with Stage III, T4N0M0, moderately well-differentiated invasive squamous cell carcinoma of the esophagus was initially treated with four courses of chemotherapy (5-fluorouracil and cisplatin) and had an excellent tumor response. He was then referred for consolidative radiation therapy (XRT). At 600 cGy, he had symptoms consistent with a tracheoesophageal fistula (TEF), which was documented by barium swallow at 3000 cGy. Radiation treatments were continued, but at a reduced fraction size that was gradually increased over several days. Upon completion of the radiation therapy, the TEF persisted but had completely disappeared 2 months post-XRT. However, at 4 months post-XRT, the fistula recurred due to tumor recurrence. At 6 months post-XRT, he died with metastatic disease, 16 months after initial diagnosis and 8.5 months after the first TEF occurred. The presence of a TEF may not be an absolute contraindication to radiation therapy. Radiation therapy may be initiated or continued in the presence of a TEF, and eventual resolution of the fistula may occur. Recurrence of a healed TEF may indicate recurrence of a tumor.