Treatment patterns and prognostic factors of radiation-associated esophageal fistula in patients with esophageal squamous cell carcinoma: a retrospective cohort study.

Abstract

Background: Most previous studies have focused on exploring the formation mechanism of esophageal fistula (EF) and predicting its risk of occurrence. However, few studies have reported the treatment and prognosis of EF after radiotherapy (RT) in patients with esophageal cancer (EC). This study aimed to explore treatment patterns and prognostic factors of radiation-associated esophageal fistula (RAEF) in esophageal squamous cell carcinoma (ESCC).

Methods: A total of 91 EF patients were retrospectively enrolled from January 2016 to July 2023. Based on the fistula type, 39 patients presented with tracheoesophageal fistula (TEF) and 52 with esophagomediastinal fistula (EMF). Survival analyses utilized the Kaplan-Meier method. Multivariable Cox regression analysis was employed to ascertain prognosis.

Results: By the last follow-up date on June 30, 2025, all patients had died. The cohort had a median post-fistula survival time of 3.1 months, and their 3-month, 6-month, and 12-month survival rates were 51.6%, 18.7%, and 5.5%, respectively. All patients received nutritional support therapy, including nasal feeding (n=61), esophageal stenting (n=10), gastrostomy/jejunostomy (n=12), and simple fluid infusion therapy (n=8). Gastrostomy/jejunostomy was associated with the highest post-fistula survival rates (3-month: 83.3%, 6-month: 41.7%, 12-month: 25.0%). In TEF, esophageal stenting provided comparable 3-month post-fistula survival rates to gastrostomy/jejunostomy (71.4% vs. 75.0%). Among 21 patients who had EF during primary RT, those completing the planned RT after receiving nutritional support therapy achieved superior fistula closure rates compared to treatment discontinuation (77.8% vs. 25.0%). Multivariable Cox analysis identified reirradiation, simple fluid infusion therapy, persistent fistula, and hemoglobin <120 g/L as independent unfavorable prognostic factors.

Conclusions: Gastrostomy/jejunostomy is associated with improved survival in patients with RAEF. Esophageal stenting represents a viable short-term palliative option for TEF patients. Completing planned RT may promote fistula healing for EF during primary RT. Hemoglobin level serves as an accessible prognostic biomarker.