Irradiation of carcinoma of the esophagus containing a tracheoesophageal fistula

Background . 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. Methods . A 60‐year‐old white man diagnosed with Stage III, T4NOMO, 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. Results . 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. Conclusions . 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.