Evolving management and outcome of esophageal cancer with airway involvement

Background. Esophageal cancer with airway involvement, including patients with esophagorespiratory fistula (ERF), has been associated with a poor prognosis. Multimodality treatment, self-expanding metal stents, and improved supportive therapy may be impacting outcome in these patients. There is concern for the development of ERF during therapy. Methods. We retrospectively studied 74 consecutive male patients at a single institution presenting between 1/85 to 12/98 with bronchoscopic, endoscopic or radiographic confirmation of airway involvement with esophageal cancer, including 35 patients with ERF. Comparison was made between the first 35 patients (group I) and the last 39 patients (group II) with regard to antineoplastic therapy, stent placement, and survival. Results. Treatment in group I included supportive care in 17 of 35 patients, plastic stent in 7 of 35 patients, and radiation or chemotherapy in 9 of 35 patients. In group II, radiation or chemotherapy was offered to 33 patients, and self-expanding metal stents were placed in 10 of 39 patients. Surgical resection was possible after neoadjuvant therapy in 13 of 39 patients in group II, including 2 initially presenting with ERF. Median survival in group I was 16 weeks and in group II was 37 weeks. Comparison of Kaplan-Meier survival estimates using log rank testing demonstrated improved survival in group II (p = 0.0026). Long-term survival in 4 group II patients initially presenting with ERF and receiving multimodality treatment was observed. Development of ERF during treatment occurred in 3 group II patients. Treatment failure was predominantly local in group I and local and distant in group II. Conclusions. More aggressive treatment may favorably influence outcome in esophageal cancer with airway invasion. Long-term survival and the development of ERF during therapy occurred at similar rates.