Airway interventions for tracheobronchial involvement in esophageal carcinoma: a retrospective cohort outcome study and algorithmic approach

Abstract

Background: In advanced esophageal carcinoma (EC), there is limited data on risk factors predicting tracheobronchoesophageal fistula (TEF) formation and survival among patients who required airway interventions.

Methods: A retrospective analysis of consecutive patients with EC, who had airway involvement requiring intervention, was conducted from 1998 to 2018. Demographics, clinical progress, disease stage, treatment and survival outcomes were recorded. Patients were followed up till death or until completion of the study. Survival was estimated with the Kaplan-Meier method and curves compared by log-rank test. Multivariate analyses of risk factors were performed using Cox proportional hazard regression.

Results: A total of 122 patients were included. The median (IQR) survival from time of airway intervention was 3.30 (1.57-6.88) months, while the median (IQR) survival from time of histological diagnosis was 8.90 (4.91-14.45) months. Tumour location within 20 mm of the carina, prior radiotherapy and/or esophageal stenting were significantly associated with formation of TEF. Mid EC [adjusted hazard ratio (HR) 1.9; 95% confidence interval (CI): 1.1-3.2] or presence of TEF (adjusted HR 1.8; 95% CI: 1.0-3.2) were associated with lower survival. Patients receiving chemotherapy (adjusted HR 0.46; 95% CI: 0.25-0.84), or esophageal stenting whether before or after airway intervention (adjusted HR 0.32; 95% CI: 0.15-0.68 and adjusted HR 0.51; 95% CI: 0.29-0.90) were associated with increased survival.

Conclusions: Factors associated with TEF formation include airway location, radiotherapy and prior esophageal stenting, and the development of TEF was associated with poorer survival. An algorithmic approach towards tracheobronchial involvement in EC is proposed based on these findings and a review of the literature.

Keywords: Esophageal carcinoma (EC); airway obstruction; stent; tracheoesophageal fistula (TEF).

Figure 1

Mucosal tumour invasion seen within 20 mm of carina. (A) Bronchoscopic evaluation revealing tumour invasion of the distal trachea, carina and left main bronchus. (B) The area of mucosal invasion is covered with a silicone Y stent, with the proximal end of Y stent at the mid trachea.

Figure 2

Evaluation and treatment of extrinsic airway obstruction of the carina. (A,B) Computed tomography showing airway obstruction by mid esophageal tumour and adjacent lymphadenopathy causing collapse, as well as consolidation of the right lower lobe. (C) Bronchoscopic evaluation showing complete occlusion of the left main bronchus from the level of the carina. There is no visible tumour invasion of the airway mucosa. (D) Post 15/12/12 mm × 30/30/15 mm (trachea/left main stem bronchus/right main stem bronchus diameter and length) silicone Y-stent deployment with good patency of the airways

Figure 3

Treatment of a stent associated esophago-respiratory fistula. (A) Bronchoscopic evaluation showing the proximal end of an esophageal stent. There is no evidence of tumour invasion of the airway mucosa. (B) The stent associated esophago-respiratory fistula is covered with a self-expanding metallic airway stent.

Video 1

Esophageal carcinoma with tracheobronchoesophageal fistula and silicone straight stent insertion.

Video 2

Esophageal carcinoma with tracheobronchoesophageal fistula due to esophageal stent, and self-expanding metallic stent insertion.

Figure 4

Kaplan-Meier plots of overall survival of patients with and without TEF at time of airway intervention. Median survival from the time of airway intervention was 1.98 (IQR: 0.94–3.02) and 4.52 (IQR: 3.56–5.47) months for patients with TEF and without TEF, respectively (P<0.001). TEF, tracheobronchoesophageal fistula.

Figure 5

Algorithm for the management of tracheobronchial involvement secondary to esophageal carcinoma. *, we propose close airway surveillance for non-critical (≤50%) stenosis, and surgery in appropriate candidates in the absence of mural invasion; **, radial endobronchial ultrasonography may be useful to assess extent of airway wall invasion (35,36); ***, stenting should be considered in the presence of dyspnea; ∆, esophageal stenting should proceed after evaluation of the likelihood of further compromise to airway patency; ^, external beam radiotherapy to the esophagus after stenting should be used with caution. Brachytherapy may be an alternative or addition to esophageal stenting for malignant dysphagia (1). TEF, tracheobronchoesophageal fistula.

Figure 6

Algorithm for the management of TEF secondary to esophageal carcinoma. *, surgery may considered in patients with appropriate performance status and surgical indication; ∆, esophageal stenting should proceed after evaluation of the likelihood of further compromise to airway patency; ^, external beam radiotherapy to the esophagus after stenting should be used with caution. Brachytherapy may be an alternative or addition to esophageal stenting for malignant dysphagia (1). TEF, tracheobronchoesophageal fistula; RT, radiation therapy.