title: Concurrent chemoradiotherapy combined with enteral nutrition support: a radical treatment strategy for esophageal squamous cell carcinoma patients with malignant fistulae.
abstract: BACKGROUND
  Concurrent chemoradiotherapy (CCRT) significantly increases the survival rate of esophageal squamous cell carcinoma (ESCC) patients with malignant fistulae. Recent clinical evidence has shown the benefits of enteral nutrition for malnourished cancer patients. In this study, we aimed to validate that, with the support of enteral nutrition, ESCC patients who develop malignant fistulae might be able to complete CCRT and achieve long-term survival.
  
  
  METHODS
  We reviewed the medical records of 652 patients with ESCC who received definitive CCRT at Sun Yat-sen University Cancer Center between January 2010 and December 2012. Treatment outcome and toxicity were retrospectively evaluated in 40 ESCC patients with malignant fistulae. All the 40 patients were treated with CCRT and evaluated by clinical nutritionists using nutrition risk screening (NRS) before, during, and after treatment. Twenty-two patients received a nasogastric tube, and 18 underwent percutaneous endoscopic gastrostomy feeding. The median energy intake was 2166 kcal/day. Treatment response was evaluated at 3 months after the completion of CCRT.
  
  
  RESULTS
  With a median follow-up of 18 months (range, 3-39 months), patients' 1-year overall survival (OS) rate was 62.5%, and the estimated OS time was 25.5 months. Univariate analysis showed that the NRS score (P = 0.003), increase in NRS score (P = 0.024), fistula closure (P = 0.011), and response to treatment (P < 0.001) were significantly associated with OS. Multivariate analysis showed that tumor response (P = 0.044) and increase in NRS score (P = 0.044) were independent predictors of OS. Grade 3 vomiting was observed in 8 patients (20.0%), grade 3 neutropenia was observed in 11 patients (27.5%), and grade 3 cough was observed in 13 patients (32.5%); 2 patients (5.0%) died of massive bleeding during treatment.
  
  
  CONCLUSIONS
  CCRT combined with enteral nutrition support is effective for ESCC patients with malignant fistulae. Patients have an increased potential to be cured, especially those who experience complete response and have an increase in NRS score. Careful observation and nutrition support are required for patients with advanced T-category ESCC who undergo CCRT.
authors.affiliation: Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China.|Guangdong Esophageal Cancer Research Institute, Guangzhou, 510060, Guangdong, P. R. China.|Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, Guangdong, P. R. China.
authors.forename: Li
authors.initials: L
authors.lastname: Ma
authors.affiliation: Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China.|Guangdong Esophageal Cancer Research Institute, Guangzhou, 510060, Guangdong, P. R. China.|Department of Endoscopy, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.
authors.forename: Guang-Yu
authors.initials: GY
authors.lastname: Luo
authors.affiliation: Department of Radiation Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, Guangdong, P. R. China.
authors.forename: Yu-Feng
authors.initials: YF
authors.lastname: Ren
authors.affiliation: Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China.|Guangdong Esophageal Cancer Research Institute, Guangzhou, 510060, Guangdong, P. R. China.|Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, Guangdong, P. R. China.
authors.forename: Bo
authors.initials: B
authors.lastname: Qiu
authors.affiliation: Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China.|Guangdong Esophageal Cancer Research Institute, Guangzhou, 510060, Guangdong, P. R. China.|Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.
authors.forename: Hong
authors.initials: H
authors.lastname: Yang
authors.affiliation: Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China.|Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, Guangdong, P. R. China.
authors.forename: Chun-Xia
authors.initials: CX
authors.lastname: Xie
authors.affiliation: Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China.|Guangdong Esophageal Cancer Research Institute, Guangzhou, 510060, Guangdong, P. R. China.|Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, Guangdong, P. R. China.
authors.forename: Song-Ran
authors.initials: SR
authors.lastname: Liu
authors.affiliation: Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China.|Guangdong Esophageal Cancer Research Institute, Guangzhou, 510060, Guangdong, P. R. China.|Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, Guangdong, P. R. China.
authors.forename: Shi-Liang
authors.initials: SL
authors.lastname: Liu
authors.affiliation: Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China.|Guangdong Esophageal Cancer Research Institute, Guangzhou, 510060, Guangdong, P. R. China.|Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, Guangdong, P. R. China.
authors.forename: Zhao-Lin
authors.initials: ZL
authors.lastname: Chen
authors.affiliation: Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China.|Guangdong Esophageal Cancer Research Institute, Guangzhou, 510060, Guangdong, P. R. China.|Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, Guangdong, P. R. China.
authors.forename: Qun
authors.initials: Q
authors.lastname: Li
authors.affiliation: Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China.|Guangdong Esophageal Cancer Research Institute, Guangzhou, 510060, Guangdong, P. R. China.|Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.
authors.forename: Jian-Hua
authors.initials: JH
authors.lastname: Fu
authors.affiliation: Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China.|Guangdong Esophageal Cancer Research Institute, Guangzhou, 510060, Guangdong, P. R. China.|Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, Guangdong, P. R. China.
authors.forename: Meng-Zhong
authors.initials: MZ
authors.lastname: Liu
authors.affiliation: Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China. huyh@sysucc.org.cn.|Guangdong Esophageal Cancer Research Institute, Guangzhou, 510060, Guangdong, P. R. China. huyh@sysucc.org.cn.|Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, Guangdong, P. R. China. huyh@sysucc.org.cn.
authors.forename: Yong-Hong
authors.initials: YH
authors.lastname: Hu
authors.affiliation: Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China. yewf@sysucc.org.cn.|Guangdong Esophageal Cancer Research Institute, Guangzhou, 510060, Guangdong, P. R. China. yewf@sysucc.org.cn.|Department of Clinical Nutrition, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, Guangdong, P. R. China. yewf@sysucc.org.cn.
authors.forename: Wen-Feng
authors.initials: WF
authors.lastname: Ye
authors.affiliation: Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China. liuhui@sysucc.org.cn.|Guangdong Esophageal Cancer Research Institute, Guangzhou, 510060, Guangdong, P. R. China. liuhui@sysucc.org.cn.|Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, Guangdong, P. R. China. liuhui@sysucc.org.cn.
authors.forename: Hui
authors.initials: H
authors.lastname: Liu
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002294:Carcinoma, Squamous Cell / Q000628:therapy*; D059248:Chemoradiotherapy / Q000009:adverse effects; D004750:Enteral Nutrition; D004937:Esophageal Fistula / Q000628:therapy*; D004938:Esophageal Neoplasms / Q000628:therapy*; D000077277:Esophageal Squamous Cell Carcinoma; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged
keywords: Concurrent chemotherapy; Enteral nutrition support; Esophageal squamous cell carcinoma; Malignant fistula; Radiotherapy