The modern face of esophageal candidiasis in an oncology center: Correlating clinical manifestations, endoscopic grade, and pathological data in 323 contemporary cancer patients

Objectives Clinical presentation and outcomes of esophageal candidiasis (EC) in cancer patients are scarcely studied in the azole era, as is the correlation between clinical, endoscopic, and histopathological EC manifestations. Methods We retrospectively reviewed the risk factors, clinical features, and outcomes of pathology-documented EC cases at MD Anderson Cancer Center. We further assessed associations between presence of symptoms, standardized 4-stage endoscopic grade (Kodsi classification), histopathological data, and fluconazole treatment failure. Results Among 323 cancer patients with EC, 89% had solid tumors, most commonly esophageal cancer (29%). Thirty-three percent of EC patients were asymptomatic. The proportion of symptomatic EC patients significantly increased with endoscopic grade (P=0.005). Among 202 patients receiving oral fluconazole, 27 (13%) had treatment failure. Underlying esophageal disease was the only independent predictor of fluconazole treatment failure (odds ratio: 3.88, P=0.005). Endoscopic grade correlated significantly with Candida organism burden (Correlation coefficient [ρ]=0.21, P<0.01) and neutrophilic inflammation (ρ=0.18, P<0.01). Candida invasion of the squamous mucosal layer was associated with treatment failure (P=0.049). Conclusions EC was predominantly encountered in patients with solid tumors. One third of EC patients were asymptomatic, challenging traditional symptom-based diagnosis. Development of integrated clinicopathological scoring systems could further guide therapeutic management of cancer patients with EC.