Conventional stents versus stents loaded with (125)iodine seeds for the treatment of unresectable oesophageal cancer: a multicentre, randomised phase 3 trial

Transarterial chemoembolization combined with iodine 125 seeds versus transarterial chemoembolization combined with radiofrequency ablation in the treatment of early- and intermediate-stage hepatocellular carcinoma

Background

Transarterial chemoembolization (TACE), radiofrequency ablation (RFA), and iodine 125 seeds implantation are optional treatments for hepatocellular carcinoma (HCC). The aim of this study is to compare the efficacy of the combined treatment of TACE with iodine 125 seeds implantation (TACE-iodine 125) with TACE with RFA (TACE-RFA) in patients with early- and intermediate-stage HCC.

Methods

The study included 112 patients who were diagnosed with early- and intermediate-stage HCC from January 1, 2014, to May 31, 2018. Among them, 38 patients were treated with TACE-Iodine 125, and 74 with TACE-RFA. The efficacy of the two treatment groups was retrospectively analyzed. To reduced the selective bias, a propensity score matching (PSM) analysis and inverse probability of treatment weighting (IPTW) method were used to compare the outcomes between the two groups.

Results

In the absence of PSM and IPTW, the median overall survival (OS) and progression-free survival (PFS) of the TACE-RFA group were slightly longer than those of the TACE-Iodine 125 group (OS: 41 months vs. 36 months; PFS: 18 months vs. 15 months). However, there were no statistically significant differences in the median OS, PFS, and objective response rate (ORR) between the two groups (P > 0.05). After adjusting the age, gender, Child-Pugh class, Barcelona Clinic Liver Cancer (BCLC) stage, and Alpha-fetoprotein (AFP), TACE-Iodine 125 treatment was not associated with a significant increasing the risks of death (HR: 0.763; 95%CI: 0.403,1.345, P = 0.320) and recurrence (HR: 1.020; 95%CI: 0.645,1.611, P = 0.934). After PSM, 35 matched pairs of patients were obtained, and there were no statistically significant differences in the median OS and PFS between the two groups. After IPTW, similar results presented.

Conclusions

The combination of TACE with iodine 125 seeds implantation may represent an effective treatment for patients with early- and intermediate-stage HCC.

Palliation of dysphagia in metastatic oesogastric cancers: An international multidisciplinary position

Malignant dysphagia is the most common symptom in advanced oesogastric cancers patients. Relief of dysphagia allows quality of life improvement, nutritional replenishment and potentially improves prognosis. Chemotherapy alone is effective and should be prioritised in patients with metastatic disease a good performance status, and its impact on dysphagia should be determined before further interventions are planned. Regarding local treatments, the insertion of a covered self-expandable metallic stent is the most commonly used alternative, as it allows for the rapid relief of severe dysphagia. Although several randomised trials have highlighted the role of oesophageal brachytherapy, this technique is often not easily accessible. Contemporary trials are ongoing to better define the role of external radiation therapy. While awaiting these results, external radiation therapy can be considered as a second-best option for patients with a life-expectancy > 3 months. It is important to offer nutritional support and to integrate quality of life measures in the palliative management of dysphagia. This multidisciplinary international position paper aims to propose a decision-making process and highlight randomised trials for the management of malignant dysphagia in metastatic oesogastric cancer patients.

Iodine‑125 seed radiation induces ROS‑mediated apoptosis, autophagy and paraptosis in human esophageal squamous cell carcinoma cells

Iodine-125 (¹²⁵I) seed brachytherapy has been proven to be a safe and effective treatment for advanced esophageal cancer; however, the mechanisms underlying its actions are not completely understood. In the present study, the anti-cancer mechanisms of ¹²⁵I seed radiation in human esophageal squamous cell carcinoma (ESCC) cells (Eca-109 and KYSE-150) were determined, with a particular focus on the mode of cell death. The results showed that ¹²⁵I seed radiation significantly inhibited cell proliferation, and induced DNA damage and G2/M cell cycle arrest in both ESCC cell lines. ¹²⁵I seed radiation induced cell death through both apoptosis and paraptosis. Eca-109 cells were primarily killed by inducing caspase-dependent apoptosis, with 6 Gy radiation resulting in the largest response. KYSE-150 cells were primarily killed by inducing paraptosis, which is characterized by extensive cytoplasmic vacuolation. ¹²⁵I seed radiation induced autophagic flux in both ESCC cell lines, and autophagy inhibition by 3-methyladenine enhanced radiosensitivity. Furthermore ¹²⁵I seed radiation induced increased production of reactive oxygen species (ROS) in both ESCC cell lines. Treatment with an ROS scavenger significantly attenuated the effects of ¹²⁵I seed radiation on endoplasmic reticulum stress, autophagy, apoptosis, paraptotic vacuoles and reduced cell viability. In vivo experiments showed that ¹²⁵I seed brachytherapy induced ROS generation, initiated cell apoptosis and potential paraptosis, and inhibited cell proliferation and tumor growth. In summary, the results demonstrate that in ESCC cells, ¹²⁵I seed radiation induces cell death through both apoptosis and paraptosis; and at the same time initiates protective autophagy. Additionally, ¹²⁵I seed radiation-induced apoptosis, paraptosis and autophagy was considerably mediated by ROS.

PD-1 gene rs10204525 and rs7421861 polymorphisms are associated with increased risk and clinical features of esophageal cancer in a Chinese Han population

Programmed death-1 (PD-1) polymorphisms have been associated with esophageal cancer risk. Here, the aims of this case-control study were to explore whether three PD-1 polymorphisms (rs10204525, rs7421861, and rs36084323) were related with the risk and clinical features of esophageal cancer in Chinese Han subjects (n = 814 cases and 961 controls). We found that rs10204525 and rs7421861, but not rs36084323, conferred increased susceptibility to esophageal cancer. Subgroup analysis revealed that all three loci increased the risk of esophageal cancer among men, and that rs10204525 and rs7421861 correlated with increased risk among patients ≥ 60 years old. The rs10204525 and rs7421861 polymorphisms were associated with higher TNM stage, and rs10204525 was associated with distant metastasis. The combination of smoking and either the rs10204525 or rs7421861 genotype conferred an increased risk to esophageal cancer, which is indicative of potential gene-environment interactions. The rs10204525 and rs7421861 polymorphisms correlated with increased PD-1 gene and protein levels, and Kaplan-Meier survival curves showed higher PD-1 gene expression was related to poorer overall survival. These data indicate the rs10204525 and rs7421861 polymorphisms of PD-1 gene confer an increased risk of esophageal cancer among Chinese Han individuals.

Radioactive feeding tube in the palliation of esophageal malignant obstruction

PURPOSE

A radioactive feeding tube was used to achieve both nutrition and brachytherapy for the treatment for malignant esophageal obstruction. We report the safety and effectiveness of this technique.

METHODS

We conducted a retrospective analysis of 16 consecutive patients who employed this technique from January 2015 to March 2018. The radioactive feeding tube was made by binding the ¹²⁵I seed chain on the feeding tube. Under fluoroscopic guidance, the tube was inserted into the obstructed esophagus, with the seed chain crossing over the segment of malignant esophageal obstruction. Technical success rate, dysphagia score, procedure time and complications were analyzed. Kaplan-Meier analysis was used to analyze the survival time.

RESULTS

The radioactive feeding tube was easy to prepare. The technical success rate was 100%, without serious complications such as bleeding or infection. The median procedure time of tube insertion was 44.0 min. The Kamofsky score and Neuhaus dysphagia grading were significantly improved after tube insertion (p < 0.01). On esophageal radiography, the contrast agent passed through the narrow area smoothly. Complete remission (n = 1) and partial remission (n = 13) of local tumor were obtained in 14 patients, and the local tumor control rate was 87.5% (14/16). During follow-up, four patients survived with no obvious clinical symptom and 10 patients died of cancer. The median survival was 12.0 months.

CONCLUSION

Preparation of the radioactive feeding tube is simple and easy. The insertion of this kind of tube achieves parenteral nutrition and brachytherapy simultaneously and is safe and effective in dysphagia palliation of malignant esophageal stricture. The radiological-radiotherapeutic procedure could be an alternative tool in the case of refusing other treatments by the patients.

125I Irradiation Stent for Hepatocellular Carcinoma with Main Portal Vein Tumor Thrombosis: A Systematic Review

A systematic review was conducted to provide an overview of the efficacy and safety of ¹²⁵I irradiation stent placement for patients with hepatocellular carcinoma (HCC) and main portal vein tumor thrombosis (MPVTT). Six studies with 406 patients were included in the final analysis. The median overall survival for patients treated with ¹²⁵I irradiation stent placement was 10.3 months. The most common radiation-related adverse event was leukopenia. The stent-related adverse events consisted of fever, abdominal pain, hemorrhage, and anorexia. No stent or seed migration was reported. Overall, the use of an ¹²⁵I irradiation stent has the potential to act as an alternative therapy for patients with HCC with MPVTT.

Factors associated with overall survival and relief of dysphagia in advanced esophageal cancer patients after 125I seed-loaded stent placement: a multicenter retrospective analysis

Iodine-125 (125I) seed-loaded stent placement has served as an effective palliation for malignant esophageal strictures in China. We performed a retrospective study to identify the prognostic factors of this irradiation stent placement in advanced esophageal cancer patients. A total of 201 patients who underwent 125I seed-loaded stent placement were included in this study from June 2012 to March 2016 at five hospitals in China. The Cox regression models adjusted for stratification factors were used, and a stepwise multivariate analysis was performed to predict the overall survival and relief of dysphagia on the basis of pretreatment clinical characteristics, respectively. Three independent prognostic factors were identified for overall survival: histopathological subtype (squamous cell carcinoma vs. adenocarcinoma, hazard ratio [HR] 1.45, 95% confidence interval [CI95%]: 1.01-2.09, P = 0.046), serum total protein (≥66 g/L vs. <66 g/L, HR 0.61, CI95%: 0.48-0.59, P = 0.023), and performance status (<2 vs. ≥2, HR 1.57, CI95%: 1.09-2.08, P = 0.013). Four factors were significantly associated with the relief of dysphagia: T stage (T3 vs. T4, P = 0.003), tumor location (superior vs. inferior, P = 0.049), tumor-node-metastasis classification (IV vs. II, P = 0.025), and age (≥71 years vs. <71 years, P = 0.029). Prognostic factors identified from this analysis can be used to aid clinical decision-making and design future clinical trials.

Comparison of 125 Iodine Seed-Loaded Stents with Different Diameters in Esophageal Cancer: A Multicenter Retrospective Cohort Study

Currently, there are no recommendations or guidelines concerning the preferred diameter of esophageal stents for palliative treatment, owing to the lack of adequate evidence. We therefore conducted a retrospective cohort study to evaluate whether 18 mm stents would achieve a similar function of dysphagia relief with fewer complications and longer survival compared to 20 mm stents. Esophageal cancer patients who underwent 125 iodine seed-loaded stent placement with a diameter of either 18 mm (n = 103) or 20 mm (n = 54) were included at five hospitals in China. The stabilized inverse probability of treatment weighting (IPTW) was used to control potential confounding factors and bias that are inherent in a retrospective study. The primary endpoint was dysphagia relief. Stent-related complications and overall survival were assessed as the secondary endpoints. In the IPTW-adjusted analysis, no significant difference was found in the dysphagia score between the two groups either at 1 week after stent placement or at the last week before death. Despite a comparable rate of overall complications, there was a significantly lower incidence of severe retrosternal pain (15.4% vs. 32.7%, p = 0.013) and a trend toward longer survival (median survival, 176 days [95% confidence interval (CI) 144 to 209] vs. 109 days [92 to 126], p = 0.057) in the 18 mm group. An irradiated stent with a diameter of 18 mm showed a similar outcome of dysphagia relief to that achieved with a 20 mm diameter stent, but halved the incidence of retrosternal pain after stent placement.

Percutaneous stenting and chemotherapy for unresectable pancreatic cancer: Comparison of irradiation stents vs conventional metal stents

OBJECTIVES

Percutaneous stenting is a palliative method to relieve obstructive jaundice caused by unresectable pancreatic carcinoma. In this study, we aimed to compare the safety and efficacy of irradiation stents and conventional metal stents.

METHODS

A total of 32 patients who received irradiation stents or conventional metal stents to treat obstructive jaundice caused by locally advanced pancreatic cancer were included in this retrospective study. Chemotherapy using gemcitabine was performed after jaundice subsided. Stent patency, technical success, survival, and complications were compared between groups.

RESULTS

Seventeen patients were enrolled in the irradiation stent group (ISG), and 15 patients were enrolled in the uncovered stent group (USG). Median and mean stent patency time were 9.8 months (95% CI, 7.682-11.981) and 9.506 months (95% CI, 8.0-11.012) in the ISG, respectively, vs 8.8 months (95% CI, 6.528-11.072) and 7.62 months (95% CI, 5.917-9.323) in the USG, respectively (P = 0.019). Median and mean overall survival were 10.4 months (95% CI, 8.383-12.417) and 9.953 months (95% CI, 8.408-11.498), respectively, in the ISG vs 9.7 months (95% CI, 7.901-11.499) and 8.14 months (95% CI, 6.44-9.84), respectively, in the USG (P = 0.027).

CONCLUSIONS

Irradiation stents extend stent patency and overall survival compared with conventional biliary stents for the treatment of pancreatic carcinoma complicated by obstructive jaundice. Irradiation stents combined with chemotherapy may be a better choice for the treatment of obstructive jaundice caused by unresectable pancreatic carcinoma.

Radiomics Facilitates Candidate Selection for Irradiation Stents Among Patients With Unresectable Pancreatic Cancer

Purpose: To develop a model to select appropriate candidates for irradiation stent placement among patients with unresectable pancreatic cancer with malignant biliary obstruction (UPC-MBO). Methods: This retrospective study included 106 patients treated with an irradiation stent for UPC-MBO. These patients were randomly divided into a training group (74 patients) and a validation group (32 patients). A clinical model for predicting restenosis-free survival (RFS) was developed with clinical predictors selected by univariate and multivariate analyses. After integrating the radiomics signature, a combined model was constructed to predict RFS. The predictive performance was evaluated with the concordance index (C-index) in both the training and validation groups. The median risk score of progression in the training group was used to divide patients into high- and low-risk subgroups. Results: Radiomics features were integrated with clinical predictors to develop a combined model. The predictive performance was better in the combined model (C-index, 0.791 and 0.779 in the training and validation groups, respectively) than in the clinical model (C-index, 0.673 and 0.667 in the training and validation groups, respectively). According to the median risk score of 1.264, the RFS was significantly different between the high- and low-risk groups (p < 0.001 for the training group, and p = 0.016 for the validation group). Conclusions: The radiomics-based model had good performance for RFS prediction in patients with UPC-MBO who received an irradiation stent. Patients with slow progression should consider undergoing irradiation stent placement for a longer RFS.

Dose perturbation and inhomogeneity of multi-arrays of 125I seed-loaded stent for treatment of portal vein tumor thrombosis

PURPOSE

To investigate the dosimetry of ¹²⁵I seed-loaded stent system currently used for an adjuvant treatment of portal vein tumor thrombosis (PVTT).

METHODS

The stent system consisted of an inner metallic stent and outer seed-loaded capsules. Four arrays of ¹²⁵I seeds were attached longitudinally to the outer surface of the stent at 90° separation. 145 Gy was prescribed at 5 mm from the axes of seed-arrays. For the geometries of the 4-array, and potential 6- and 8-array configurations, treatment planning system (TPS) and Monte Carlo (MC) calculations were performed to evaluate 3D dose distributions and dosimetric impact of the metallic stent.

RESULTS

The MC simulations indicated the metallic stent reduced a dose to the prescription points by over 10%, compared to the water-based TPS results. The total activity calculated by the water-based TPS to deliver the prescription dose should compensate for this amount of reduction. The MC- and TPS-calculated doses normalized to the prescription points for the current configuration were in agreements within 4.3% on a cylindrical surface along 5 mm from the axes of seed-arrays. The longitudinal underdosage worsened as approaching the edge of arrays, and ranged from 2.8% to 25.5%. The angular underdosage between neighboring arrays was 2.1%-8.9%.

CONCLUSIONS

With this compensation and a special care of near-edge underdosage, the current 4-array system can provide adequate dose coverage for treatment of PVTT. Further dosimetric homogeneity can be achieved using 6-or 8-array configurations.

A New Fully Covered Irradiation Stent Versus a Partially Covered Irradiation Stent for Unresectable Malignant Dysphagia: A Single-Center Experience

PURPOSE

To assess the efficacy and safety of a newly developed fully covered irradiation stent (FCIS) compared with a partially covered irradiation stent (PCIS) in patients with unresectable malignant dysphagia.

MATERIALS AND METHODS

Data of 195 patients [158 (81.0%) males, median age of 75 years (range 49-89 years)] who underwent FCIS or PCIS placement for unresectable malignant dysphagia from January 2012 to November 2017 were retrospectively analyzed. The median follow-up time was 181 days (range 4-547 days). Outcomes were measured in terms of recurrent dysphagia (primary), technical success, clinical success, overall survival, and adverse events. Recurrent dysphagia was analyzed by Fine-Gray regression model.

RESULTS

The technical success rate was 97.8% (87/89) in the FCIS group and 99.1% (105/106) in the PCIS group (P = 0.59). The clinical success rate was 100.0% in both groups. There was no statistically significant difference in the recurrent dysphagia rate between the FCIS and PCIS groups (21.8% vs. 28.6%; P = 0.12). Compared with PCISs, FCISs were associated with a decrease in tissue/tumor growth rate (11.5% vs. 21.9%; P = 0.01), while stent migration rates were statistically comparable (11.5% vs. 5.7%; P = 0.23). The median overall survivals were comparable between the FCIS and PCIS groups (164 days vs. 162 days; P = 0.70). A dysphagia score of 4 and metastasis were risk factors for survival. No significant differences were observed in the rates of adverse events, including chest pain, fistula formation, hemorrhage, and aspiration pneumonia (P > 0.05).

CONCLUSION

For patients with unresectable malignant dysphagia, this newly developed FCIS can provide efficacy and safety comparable to those of a PCIS. Compared with PCIS, this FCIS is more successful in preventing tissue/tumor growth, with a comparable stent migration rate.

Esophageal Cancer: Should Gender Be Considered as an Influential Factor for Patient Safety in Drug Treatment?

Aim

Analyze the gender difference of esophageal cancer patients in response to drug treatment.

Methods

All publications on clinical trials were collected from PubMed, Scopus, and PMC. Each publication was examined to determine whether the publication is a clinical trial and whether data on gender difference were reported.

Results

Selected from a total of 191 publications, data from 7 trials with a total of 2041 patients were evaluated for gender differences. These clinical trials involve different drugs and disease phenotype. A significant difference was obtained between male and female groups from Student's t-test. There is no conclusive result on age, ethnicity, tumor size, and drug influence.

Conclusions

Gender difference in response to treatment potentially most likely exists in esophageal cancer patients, regardless of age, race, and drugs.

Palliation of dysphagia

Palliation of dysphagia is the cornerstone of palliative treatment in patients with incurable oesophageal cancer. Available palliative options for dysphagia are oesophageal stent placement and radiotherapy. In general, oesophageal stent placement is the preferred therapeutic option in patients with a relatively poor prognosis because of its rapid relief of dysphagia. Regardless of ongoing technical developments, recurrence of dysphagia and stent-related complications are still occurring. For patients with a relatively good prognosis, intra-luminal brachytherapy is advised because of its sustained palliation of dysphagia. Due to limited availability of intra-luminal brachytherapy in clinical practice, fractionated external beam radiation therapy is commonly applied as an alternative. Selection of the optimal palliative approach for patients remains however challenging as conclusive high-quality evidence is limited. Moreover, with the introduction of new palliative treatment options (e.g. palliative chemotherapeutic and radiotherapeutic options) and the concurrent change of patient characteristics, supporting evidence from large randomised studies is warranted.

Profiles of genomic alterations in primary esophageal follicular dendritic cell sarcoma: A case report

RATIONALE

Follicular dendritic cell (FDC) sarcoma is a rare tumor with FDC differentiation that typically arises within lymph nodes but can also occur extranodally. To date, the primary esophageal FDC sarcoma has not been reported in the English literature.

PATIENT CONCERNS

We described a 67-year-old female who foremostly presented with dysphagia, and the patient was readmitted due to a dry cough and pain of his right shoulder 2 years after initial treatment.

DIAGNOSES

Primary esophageal FDC sarcoma with the right superior mediastinal lymph node metastasis.

INTERVENTIONS

The esophageal tumor was removed by endoscopic submucosal dissection at the first hospitalization. At the second hospitalization 2 years after the initial visit, the tracheal stent loaded with (125) iodine radioactive seeds was placed. The profiles of genetic variations and immunotherapeutic biomarkers were also explored by next-generation sequencing protocol from the patient's blood, esophageal primary, and mediastinal metastatic tumor samples.

OUTCOMES

The patient's symptom transitorily relieved, but she gave up further treatment and died 2 months after the tracheal stent was placed. As for the genomic alterations, we found 9 gene mutations in all the samples, including checkpoint kinase 2(CHEK2), FAT atypical cadherin 1 (FAT1), tumor protein 53 (TP53), DPYD, ERBB2 interacting protein (ERBB2IP), FBXW7, KMT2D, PPP2R1A, TSC2, whereas amplification of MYC was only in the metastatic example. The analysis of clonal evolution and phylogenetic tree showed the propagation and replay of polyclonal esophageal FDC sarcoma. At the same time, the detection of biomarkers for immunotherapy revealed microsatellite stable and mismatch repair-proficient (pMMR), which predicted a relatively poor anti-programmed death (PD-1)/programmed death ligand (PD-L1) immunotherapy outcome. On the contrary, the tumor mutational burdens were 10 mutations per 1 million bases in both the primary and metastatic tumor sample, which ranked the top 23.3% in solid tumors mutational burdens database of Geneseeq and might be a good predictor of the efficacy of anti-PD-1/PD-L1 immunotherapy.

LESSONS

To the best of our knowledge, this case report announced the first case of extranodal primary esophageal FDC sarcoma in the world, and firstly revealed its unique genetic alterations profiles, which might contribute to further in-depth study of this rare disease.

Endoscopic Full-Thickness Defects and Closure Techniques

PURPOSE OF REVIEW

Gastrointestinal transmural defects are defined as total rupture of the gastrointestinal wall and can be divided into three main categories: perforations, leaks, and fistulas. Due to an increase in the number of therapeutic endoscopic procedures including full-thickness resections and the increase incidence of complications related to bariatric surgeries, there has been an increase in the number of transmural defects seen in clinical practice and the number of non-invasive endoscopic treatment procedures used to treat these defects.

RECENT FINDINGS

The variety of endoscopic approaches and devices, including closure techniques using clips, endoloop, and endoscopic sutures; covering techniques such as the cardiac septal occluder device, luminal stents, and tissue sealants; and drainage techniques including endoscopic vacuum therapy, pigtail, and septotomy with balloon dilation are transforming endoscopy as the first-line approach for therapy of these conditions. In this review, we describe the various transmural defects and the endoscopic techniques and devices used in their closure.

Combined local immunostimulatory radioisotope therapy and systemic immune checkpoint blockade imparts potent antitumour responses

Radiation therapy for cancer can lead to off-target toxicity and can be ineffective against hypoxic solid tumours and distant metastases. Here, we show that intratumoral injection, in mouse and rabbit xenografts and in patient-derived mouse xenografts, of a sodium alginate formulation containing catalase (Cat) labelled with the therapeutic ¹³¹I radioisotope enables long-term relief of tumour hypoxia and complete tumour elimination at low radioactivity doses. On injection, the soluble polysaccharide rapidly transforms into a hydrogel in the presence of endogenous Ca²⁺, fixing ¹³¹I-Cat within the tumours. We also show that local radiotherapy with a formulation that includes the immunostimulatory CpG oligonucleotide combined with systemic checkpoint-blockade therapy using an anti-CTLA-4 antibody leads to metastasis inhibition and protection against tumour rechallenge. The local therapy, which uses only biocompatible components, might enable new strategies for local tumour treatments that can be combined with systemic therapeutic responses, for the inhibition of tumour metastasis and the prevention of tumour recurrence in patients with advanced-stage cancer.

A Novel Tracheobronchial Stent Loaded with 125I Seeds in Patients with Malignant Airway Obstruction Compared to a Conventional Stent: A Prospective Randomized Controlled Study

Background

To evaluate the safety and efficacy of a novel radioactive bare metal stent (RBMS) compared with a conventional bare metal stent (CBMS) in patients with inoperable malignant airway obstruction.

Methods

This prospective study was approved by the Institutional Ethics Committee, and informed consent was obtained from each participant. Patients with malignant airway obstruction who had dyspnea were randomly assigned to receive RBMS or CBMS placement. The primary endpoint was stenosis grade, while the secondary endpoints were technical success, overall survival, and complications. A p value of <0·05 was considered statistically significant.

Results

Between September 2013 and July 2015, 66 patients with inoperable malignant airway obstruction received stent placement fluoroscopically (33 in either group). The median follow-up time was 154 days (range, 15–335 days). The baseline stenosis was immediately relieved in both groups after stent placement, and the stenosis grades in the RBMS group were significantly lower than that in the CBMS group since the second month (p < 0·05). The technical success rates of stent placement were 100% in both groups. The median survival in the RBMS group was significantly longer than that in the CBMS group (170 days vs. 123 days, p < 0·05). There was no significant difference in the incidence of complications between the two groups (p < 0·05).

Conclusions

The placement of RBMS in patients with inoperable malignant airway obstruction is feasible and safe, and it significantly reduces restenosis and improves overall survival compared with the placement of CBMS.

•

The baseline stenosis was immediately relieved in both groups after stent placement.

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The stenosis grades in the RBMS group were significantly lower than that in the CBMS group since the second month.

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The technical success rates of stent placement were 100% in both groups.

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The median survival in the RBMS group was significantly longer than that in the CBMS group.

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There was no significant difference of the incidence of complications between the two groups.

Malignant airway obstruction (MAO) is a serious situation of 20-30% cases of lung cancer, resulting in dyspnea, decreased functional status, and asphyxiation risk. Conventional stent placement provides immediate palliation of dyspnea. However, stent restenosis occurs during the follow up. A novel radioactive bare metal stent (RBMS) loaded with ¹²⁵I seed was developed for preventing such restenosis. Our study showed that placement of RBMS in patients with inoperable malignant airway obstruction is feasible and safe, and it significantly reduces the restenosis and improves overall survival compared with placement of conventional stent.

Stenting of the Portal Vein Combined with Different Numbers of Iodine-125 Seed Strands: Dosimetric Analyses

Background:

Portal-vein stent combined with one iodine-125 (¹²⁵I) seed strand has become a new treatment for portal vein tumor thrombosis. However, dosimetric aspects of this irradiation stent have not been reported. Therefore, we aimed to undertake dosimetric analyses comparing portal-vein stents combined with different numbers of ¹²⁵I seed strands.

Methods:

A water cylinder was created by a treatment-planning system to simulate a portal-vein stent. The stent was combined with one, two, or three ¹²⁵I seed strands (Groups I, II, and III, respectively). At different prescribed doses (PDs), ¹²⁵I seeds of identical activities were loaded on Groups I–III. Conformation number (CN), external volume index, and homogeneity index were calculated. Linear regression analyses were used to evaluate the obtained data.

Results:

For identical ¹²⁵I seed activity, when the ¹²⁵I seed strand increased from one chain to two, D₉₀ (dose delivered to 90% of the target volume) increased by ≥184%; when it increased from two chains to three, D₉₀ increased by ≥63%. When the PD was 105 Gy and ¹²⁵I seed strands increased from one chain to two, V₁₀₀ (percentage of the target volume receiving ≥90% of the PD) increased by 158–249%; when it increased from two chains to three, V₁₀₀ increased by 7–175%. CN was correlated positively with ¹²⁵I seed activity (B = 0.479, P < 0.001) and number of ¹²⁵I seed strands (B = 0.201, P < 0.001) and was independent of PD (B = −0.002, P = 0.078).

Conclusions:

A portal-vein stent combined with a single ¹²⁵I seed strand could not meet dosimetry requirements. For a stent combined with two ¹²⁵I seed strands, when the PD was 105 Gy and seed activity was 0.7 mCi, the dose distribution could satisfy dosimetry requirements. For a stent combined with three ¹²⁵I seed strands, if the PD was 105, 125, or 145 Gy, the recommended seed activities were 0.5, 0.5, and 0.6 mCi, respectively.

Malignant obstructive jaundice treated with intraluminal placement of Iodine-125 seed strands and metal stents: An analysis of long-term outcomes and prognostic features

PURPOSE

The purpose of this study was to analyze the long-term outcomes, including safety, efficacy, and prognostic features, of intraluminal brachytherapy with Iodine-125 (¹²⁵I) seed strand and stent placement for treatment of patients with malignant obstructive jaundice (MOJ).

METHODS AND MATERIALS

From January 2009 to December 2013, 107 consecutive patients with MOJ were treated with intraluminal placement of ¹²⁵I seed strands and metal stents. A retrospective evaluation of therapeutic outcomes, including overall survival (OS), stent patency rate, complications, and prognostic features, was conducted in 101 patients.

RESULTS

¹²⁵I seed strands and stents were all successfully implanted. The median followup time was 231 (45-1015) days, and the median OS was 394.0 (95% confidence interval: 319.1-468.9) days. The cumulative OS rates at 3, 6, 12, and 24 months were 95%, 77%, 53%, and 20%, respectively. The median stent patency period was 278.0 (95% confidence interval: 164.1-391.9) days, and cumulative patency rates at 3, 6, 12, and 24 months were 92%, 69%, 45%, and 13%, respectively. Multivariate analysis indicated that the serum conjugated/total bilirubin ≥88% before procedure (p = 0.032) and whether the patient receiving further treatment (p = 0.041) appear to be the prognostic factors of OS. There is no statistical prognostic factor for stent patency.

CONCLUSIONS

The intraluminal placement of ¹²⁵I seed strands and stents appears to be a safe and efficient therapy on MOJ. The patient with serum conjugated/total bilirubin ≥88% before procedure and receiving further treatment seems to live longer.

Irradiation stents vs. conventional metal stents for unresectable malignant biliary obstruction: A multicenter trial

BACKGROUND & AIMS

Placement of an irradiation stent has been demonstrated to offer longer patency and survival than an uncovered self-expandable metallic stent (SEMS) in patients with unresectable malignant biliary obstruction (MBO). We aim to further assess the efficacy of an irradiation stent compared to an uncovered SEMS in those patients.

METHODS

We performed a randomized, open-label trial of participants with unresectable MBO at 20 centers in China. A total of 328 participants were allocated in parallel to the irradiation stent group (ISG) or the uncovered SEMS group (USG). Endpoints included stent patency (primary), technical success, relief of jaundice, overall survival, and complications.

RESULTS

The first quartile stent patency time (when 25% of the patients experienced stent restenosis) was 212 days for the ISG and 104 days for the USG. Irradiation stents were significantly associated with a decrease in the rate of stent restenosis (9% vs. 15% at 90 days; 16% vs. 27% at 180 days; 21% vs. 33% at 360 days; p = 0.010). Patients in the ISG obtained longer survival time (median 202 days vs. 140 days; p = 0.020). No significant results were observed in technical success rate (93% vs. 95%; p = 0.499), relief of jaundice (85% vs. 80%; p = 0.308), and the incidence of grade 3 and 4 complications (8.5% vs. 7.9%; p = 0.841).

CONCLUSIONS

Insertion of irradiation stents instead of uncovered SEMS could improve patency and overall survival in patients with unresectable MBO.

LAY SUMMARY

For patients with unresectable malignant biliary obstruction (MBO), placement of a self-expandable metallic stent (SEMS) is a recommended palliative modality to relieve pruritus, cholangitis, pain, and jaundice. However, restenosis is a main pitfall after stent placement. Data from this first multicenter randomized controlled trial showed that insertion of an irradiation stent provided longer patency and better survival than a conventional metal stent. ClinicalTrials.gov ID: NCT02001779.

Intraluminal Brachytherapy Using a Self-Expandable Stent Loaded With Linear Iodine-125 Seeds in a Patient With Reiterative Recurrence of Cancer-Associated Vein Obstruction: A Case Report With 3 Months of Follow-Up

Cancer-associated vein obstruction (CAVO) is a common complication in oncological patients, but the effective therapeutic options are scant. We report a patient with reiterative recurrent CAVO who was successfully treated with intraluminal brachytherapy using a self-expandable stent loaded with linear radioactive iodine-125 seeds (RIS) strand. During follow-up, her clinical symptoms were well improved. Three-month imaging follow-up revealed satisfactory patency of the iliofemoral vein, and the stents combined with RIS strands performed well. No serious complications associated with the implantation of stent and RIS strands were documented in any of the sessions. Intraluminal brachytherapy using a self-expandable stent loaded with linear RIS may be a safe and effective option for CAVO as long as it includes not only blood flow restoration but also brachytherapy administration for cancer.

Treatment for unresectable or metastatic oesophageal cancer: current evidence and trends

Approximately half of the patients diagnosed with oesophageal cancer present with unresectable or metastatic disease. Treatment for these patients aims to control dysphagia and other cancer-related symptoms, improve quality of life and prolong survival. In the past 25 years, modestly improved outcomes have been achieved in the treatment of patients with inoperable non-metastatic cancer who are medically not fit for surgery or have unresectable, locally advanced disease. Concurrent chemoradiotherapy offers the best outcomes in these patients. In distant metastatic oesophageal cancer, several double-agent or triple-agent chemotherapy regimens have been established as first-line treatment options. In addition, long-term results of multiple large randomized phase III trials using additional targeted therapies have been published in the past few years, affecting contemporary clinical practice and future research directions. For the local treatment of malignant dysphagia, various treatment options have emerged, and self-expandable metal stent (SEMS) placement is currently the most widely applied method. Besides the continuous search for improved SEMS designs to minimize the risk of associated complications, efforts have been made to develop and evaluate the efficacy of antireflux stents and irradiation stents. This Review outlines the current evidence and ongoing trends in the different modern-day, multidisciplinary interventions for patients with unresectable or metastatic oesophageal cancer with an emphasis on key randomized trials.

Role of Esophageal Metal Stents Placement and Combination Therapy in Inoperable Esophageal Carcinoma: A Systematic Review and Meta-analysis

INTRODUCTION

More than 50% of patients with esophageal cancer already have inoperable disease at the time of diagnosis. Controversy surrounds the outcomes of patients with advanced esophageal cancer who receive palliative care by either stent alone or stent plus an additional modality. We set out to perform a systematic review and meta-analysis of studies assessing the use of metal stents as treatment options for symptomatic improvement, survival, and adverse events.

METHODS

We searched Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception until January 14, 2016, as well as other databases for randomized controlled trials (RCTs) comparing esophageal stent versus either esophageal stent plus brachytherapy, radiotherapy, or chemotherapy. For quality assurance purposes throughout the systematic review, multiple independent extractions were performed, and the process was executed as per the standards of the Cochrane collaboration. Primary outcomes were mean change in dysphagia score, overall survival, and quality of life. Secondary outcomes were adverse events including fever, severe pain, aspiration, fistula, stent migration, perforation, and restenosis.

RESULTS

Eight RCTs enrolling 732 patients were included with three distinct comparisons: stents combination therapy vs stents alone (5 studies, n = 417), stents alone versus brachytherapy alone (2 studies, n = 274), and stents + brachytherapy vs brachytherapy alone (1 study, n = 41). Stents combination therapy was defined as stents plus radiotherapy, chemotherapy, or both. Mean change in dysphagia scores favored stents combination therapy versus stents alone, and the effect was seen in patients surviving longer than 3 months. Stents combination therapy was also associated with a more favorable overall survival. The risks of stent migration, aspiration pneumonia, and restenosis were lower in the stents combination group compared to stents alone, while the risks of severe pain, hemorrhage, and fistula formation were higher. Changes in dysphagia scores and overall survival did not differ significantly in the brachytherapy-alone vs stents-alone comparison. The risk of fistula formation and hemorrhage were higher in the stents-alone group, while the risk of perforation was lower, compared to brachytherapy alone. Quality of life improvements were seen in all treatment groups, but were not pooled in analysis due to differing methods of measurement.

DISCUSSION

While there appears to be no immediate short-term differences, those who live longer than 3 months experience a significant improvement in dysphagia score using a stents combination therapy approach vs stents alone. The combination therapy significantly improves the overall survival as well as showed improvements in quality of life scores. Larger randomized controlled trials are needed to assess improvements in dysphagia score, overall survival, quality of life, and adverse events.

In vitro Dosimetric Study of Biliary Stent Loaded with Radioactive 125I Seeds

Background:

A novel radioactive ¹²⁵I seed-loaded biliary stent has been used for patients with malignant biliary obstruction. However, the dosimetric characteristics of the stents remain unclear. Therefore, we aimed to describe the dosimetry of the stents of different lengths — with different number as well as activities of ¹²⁵I seeds.

Methods:

The radiation dosimetry of three representative radioactive stent models was evaluated using a treatment planning system (TPS), thermoluminescent dosimeter (TLD) measurements, and Monte Carlo (MC) simulations. In the process of TPS calculation and TLD measurement, two different water-equivalent phantoms were designed to obtain cumulative radial dose distribution. Calibration procedures using TLD in the designed phantom were also conducted. MC simulations were performed using the Monte Carlo N-Particle eXtended version 2.5 general purpose code to calculate the radioactive stent's three-dimensional dose rate distribution in liquid water. Analysis of covariance was used to examine the factors influencing radial dose distribution of the radioactive stent.

Results:

The maximum reduction in cumulative radial dose was 26% when the seed activity changed from 0.5 mCi to 0.4 mCi for the same length of radioactive stents. The TLD's dose response in the range of 0–10 mGy irradiation by ¹³⁷Cs γ-ray was linear: y = 182225x − 6651.9 (R²= 0.99152; y is the irradiation dose in mGy, x is the TLDs’ reading in nC). When TLDs were irradiated by different energy radiation sources to a dose of 1 mGy, reading of TLDs was different. Doses at a distance of 0.1 cm from the three stents’ surface simulated by MC were 79, 93, and 97 Gy.

Conclusions:

TPS calculation, TLD measurement, and MC simulation were performed and were found to be in good agreement. Although the whole experiment was conducted in water-equivalent phantom, data in our evaluation may provide a theoretical basis for dosimetry for the clinical application.

Endovascular implantation of 125I seed combined with transcatheter arterial chemoembolization for unresectable hepatocellular carcinoma

AIM

The purpose of this study was to evaluate the efficacy and safety of the endovascular implantation of ¹²⁵I seed under ultrasound and x-ray guidance combined with transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT).

PATIENTS & METHODS

The study included 134 pathologically proven or clinically confirmed primary HCC patients with PVTT in our hospital from January 2013 to June 2015.

RESULTS & CONCLUSION

Compared with the TACE treatment alone, the combination therapy of ¹²⁵I seed implantation with TACE significantly prolonged the median survival time and improved the 6-, 12- and 18-month survival rates for HCC patients with PVTT. In addition, the type III PVTT and tumor size were independent predictors for poor prognosis of HCC patients with PVTT.

Oesophageal cancer

Oesophageal cancer is a clinically challenging disease that requires a multidisciplinary approach. Extensive treatment might be associated with a considerable decline in health-related quality of life and yet still a poor prognosis. In recent decades, prognosis has gradually improved in many countries. Endoscopic procedures have increasingly been used in the treatment of premalignant and early oesophageal tumours. Neoadjuvant therapy with chemotherapy or chemoradiotherapy has supplemented surgery as standard treatment of locally advanced oesophageal cancer. Surgery has become more standardised and centralised. Several therapeutic alternatives are available for palliative treatment. This Seminar aims to provide insights into the current clinical management, ongoing controversies, and future needs in oesophageal cancer.

Complications of stent placement in patients with esophageal cancer: A systematic review and network meta-analysis

Background

Palliative treatments and stents are necessary for relieving dysphagia in patients with esophageal cancer. The aim of this study was to simultaneously compare available treatments in terms of complications.

Methods

Web of Science, Medline, Scopus, Cochrane Library and Embase were searched. Statistical heterogeneity was assessed using the Chi² test and was quantified by I². The results of this study were summarized in terms of Risk Ratio (RR). The random effects model was used to report the results. The rank probability for each treatment was calculated using the p-score.

Results

Out of 17855 references, 24 RCTs reported complications including treatment related death (TRD), bleeding, stent migration, aspiration, severe pain and fistula formation. In the ranking of treatments, thermal ablative therapy (p-score = 0.82), covered Evolution® stent (p-score = 0.70), brachytherapy (p-score = 0.72) and antireflux stent (p-score = 0.74) were better treatments in the network of TRD. Thermal ablative therapy (p-score = 0.86), the conventional stent (p-score = 0.62), covered Evolution® stent (p-score = 0.96) and brachytherapy (p-score = 0.82) were better treatments in the network of bleeding complications. Covered Evolution® (p-score = 0.78), uncovered (p-score = 0.88) and irradiation stents (p-score = 0.65) were better treatments in network of stent migration complications. In the network of severe pain, Conventional self-expandable nitinol alloy covered stent (p-score = 0.73), polyflex (p-score = 0.79), latex prosthesis (p-score = 0.96) and brachytherapy (p-score = 0.65) were better treatments.

Conclusion

According to our results, thermal ablative therapy, covered Evolution® stents, brachytherapy, and antireflux stents are associated with a lower risk of TRD. Moreover, thermal ablative therapy, conventional, covered Evolution® and brachytherapy had lower risks of bleeding. Overall, fewer complications were associated with covered Evolution® stent and brachytherapy.

Factors That Affect Stent-Related Complications in Patients with Malignant Obstruction of the Esophagus or Gastric Cardia

Background/Aims

Self-expandable metallic stent (SEMS) placement is effective for dysphagia that results from malignant obstruction of the esophagus or gastric cardia; however, stent-related complications may be life-threatening. Thus, the goal of this study was to identify risk factors associated with complications following esophageal stenting.

Methods

Of the 71 patients who underwent SEMS placement for dysphagia as a result of malignant stricture of the esophagus or gastric cardia, 53 patients with squamous cell carcinoma or adenocarcinoma, without previous SEMS placement, without a fistula, and without recurrent tumor after surgery were retrospectively identified. The occurrence of stent-related complications was used as an endpoint.

Results

Stent-related complications were identified in 26 patients (49.1%), and major complications occurred in 14 patients (26.4%). The use of an Ultraflex stent (odds ratio [OR], 6.81; 95% confidence interval [CI], 1.54 to 30.00; p=0.011) and prior chemotherapy (OR, 6.13; 95% CI, 1.46 to 25.70; p=0.013) were significantly associated with stent-related complications. Moreover, the use of an Ultraflex stent (OR, 19.60; 95% CI, 2.26 to 170.00; p=0.007) and prior radiation (OR, 25.70; 95% CI, 2.37 to 280.00; p=0.008) significantly increased the risk of major complications.

Conclusions

The use of an Ultraflex stent and prior radiation and/or chemotherapy may represent risk factors for complications following esophageal SEMS placement.

Self-Expandable Metallic Stent Placement for the Palliation of Esophageal Cancer

Esophageal stents have been used to palliate patients with dysphagia caused by esophageal cancer. Early rigid plastic prostheses have been associated with a high risk of complications. However, with the development of self-expanding stents, it has developed into a widely accepted method for treating malignant esophageal strictures and esophagorespiratory fistulas (ERFs). The present review covers various aspects of self-expanding metallic stent placement for palliating esophageal cancer, including its types, placement procedures, indications, contraindications, complications, and some of innovations that will become available in the future.

Prognostic value of PAX9 in patients with esophageal squamous cell carcinoma and its prediction value to radiation sensitivity

Abnormal paired box 9 (PAX9) expression is associated with tumorigenesis, cancer development, invasion and metastasis. The present study investigated the prognostic significance of PAX9 in esophageal squamous cell carcinoma (ESCC) and its role in predicting radiation sensitivity. A total of 52.8% (121/229) ESCC tissues were positive for PAX9. The 1-, 3- and 5-year disease-free survival (DFS) rates were 72.2, 35.2 and 5.6%, respectively, and the overall survival (OS) rates were and 86.1, 44.4, and 23.1%, respectively, in PAX9-positive tumors. In PAX9-negative tumors, the one-, three- and five-year DFS rates were 76.9, 47.9 and 24.0%, and the OS rates were 90.9, 57.9 and 38.8%, respectively. Univariate analysis revealed that PAX9, differentiation, T stage, lymph node metastasis, and tumor-node-metastasis stage were associated with OS. Multivariate analysis of DFS and OS revealed that the hazard ratios for PAX9 were 0.624 (95% CI: 0.472–0.869, P=0.004) and 0.673 (95% CI: 0.491–0.922, P=0.014), respectively. Patients that received adjuvant therapy exhibited significant differences in the 5-year DFS (P<0.001) and OS (P<0.001). PAX9-positive ESCC patients who received post-surgery radiotherapy had a significantly greater 5-year DFS (P=0.011) and OS (P=0.009) than patients who received surgery only. Thus, PAX9 may be an independent prognostic factor for the surgical treatment of ESCC and a possible predictor of radiation sensitivity.

Radioactive self-expanding stents for palliative management of unresectable esophageal cancer: a systematic review and meta-analysis

Stent insertion is a feasible and safe palliative management for advanced unresectable esophageal cancer. The aim of this study is to assess the efficacy of radioactive stent for unresectable esophageal cancer compared with conventional stent. Systematic searches of the PubMed and Web of science are dated from their beginning to January 25, 2016. Studies that compared radioactive stent with conventional stent for unresectable esophageal cancer were included. The outcomes were postimplantation survival, relief of dysphagia, and complications related to stent implant. Six studies with 539 patients were included. All of them used stent equipped with radioactive iodine beads as a radioactive stent. The pooled weighted mean difference for median survival was 2.734 months (95% CI 1.710-3.775; Z = 5.21, P = 0.000) between two groups. The 1,3,6 month survival rates were higher in radioactive stents than conventional stent, with the pooled ORs 3.216 (95% CI 1.293-7.999; Z = 2.51, P = 0.012), 3.095 (95% CI 1.908-5.020; Z = 4.58, P = 0.000), and 7.503 (95% CI 2.206- 25.516; Z = 3.23, P = 0.001, respectively). The pooled hazard ratio was 0.464 (95% CI 0.328-0.655; Z = 4.35, P = 0.000) between two groups. For relief of dysphagia, two stents all have good relief of the dysphagia effect, but radioactive stent showed a better effect at 3, 6 months follow-up after implantation. For complications related to stent implant, no significant differences were found between two stents in terms of severe chest pain (30.0% vs. 35.7%, OR 0.765, 95% CI 0.490-1.196), gastroesophageal reflux (18.6% vs. 16.1%, OR 1.188, 95% CI 0.453-3.115), fever (12.1% vs. 12.1%, OR 1.014, 95% CI 0.332-3.097), bleeding (16.7% vs. 14.2%, OR 1.201, 95% CI 0.645-2.236), perforation or fistula (6.1% vs. 9.0%, OR 0.658, 95% CI 0.291-1.486), pneumonia (10.7% vs. 14.1%, OR 0.724, 95% CI 0.343-1.526), stent migration (7.0% vs. 10.2%, OR 0.651, 95% CI 0.220-1.924), and restenosis (24.2% vs. 20.6%, OR 1.228, 95% CI 0.674-2.239). Radioactive stent insertion had potential benefits for palliative management for patients with unresectable esophageal cancer. This method prolonged survival and dysphagia relief period without more complications. However, this conclusion should be confirmed by more trials.

Volume-outcome relation in palliative systemic treatment of metastatic oesophagogastric cancer

INTRODUCTION

Palliative systemic therapy has been shown to improve survival in metastatic oesophagogastric cancer. Administration of palliative systemic therapy in metastatic oesophagogastric cancer varies between hospitals. We aimed to explore the association between the annual hospital volume of oesophagogastric cancer patients and survival.

METHODS

Patients diagnosed in the Netherlands between 2005 and 2013 with metastatic oesophagogastric cancer were identified in the Netherlands Cancer Registry. Patients were attributed according to three definitions of high volume: (1) high-volume incidence centre, (2) high-volume treatment centre and (3) high-volume surgical centre. Independent predictors for administration of palliative chemotherapy were evaluated by means of multivariable logistic regression analysis, and multivariable Cox proportional hazard regression analysis was performed to assess the impact of high-volume centres on survival.

RESULTS

Our data set comprised 4078 patients with metastatic oesophageal cancer, and 5425 patients with metastatic gastric cancer, with a median overall survival of 20 weeks (95% confidence interval [CI] 19-21 weeks) and 16 weeks (95% CI 15-17 weeks), respectively. Patients with oesophageal cancer treated in a high-volume surgical centre (adjusted hazard ratio [HR] 0.80, 95% CI 0.70-0.91) and a high-volume treatment centre (adjusted HR 0.88, 95% CI 0.78-0.99) exhibited a decreased risk of death. For gastric cancer, patients treated in a high-volume surgical centre (adjusted HR 0.83, 95% CI 0.74-0.92) had a superior outcome.

CONCLUSION

Improved survival in patients undergoing palliative systemic therapy for oesophagogastric cancer was associated with treatment in high-volume treatment and surgical centres. Further research should be implemented to explore which specific factors of high-volume centres are associated with improved outcomes.

Autologous hematopoietic stem cell transplantation following high-dose chemotherapy for nonrhabdomyosarcoma soft tissue sarcomas

BACKGROUND

Soft tissue sarcomas (STS) are a highly heterogeneous group of rare malignant solid tumors. Nonrhabdomyosarcoma soft tissue sarcomas (NRSTS) comprise all STS except rhabdomyosarcoma. In people with advanced local or metastatic disease, autologous hematopoietic stem cell transplantation (HSCT) applied after high-dose chemotherapy (HDCT) is a planned rescue therapy for HDCT-related severe hematologic toxicity. The rationale for this update is to determine whether any randomized controlled trials (RCTs) have been conducted and to clarify whether HDCT followed by autologous HSCT has a survival advantage.

OBJECTIVES

To assess the efficacy and safety of high-dose chemotherapy (HDCT) followed by autologous hematopoietic stem cell transplantation (HSCT) for all stages of nonrhabdomyosarcoma soft tissue sarcomas (NRSTS) in children and adults.

SEARCH METHODS

For this update, we revised the search strategy to improve the precision and reduce the number of irrelevant hits. We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8), PubMed from 2012 to 6 September 2016, and Embase from 2012 to 26 September 2016. We searched online trial registries and congress proceedings from 2012 to 26 September 2016.

SELECTION CRITERIA

Terms representing STS and autologous HSCT were required in the title or abstract. We restricted the study design to RCTs. We included studies if at least 80% of participants had a diagnosis listed in any version of the World Health Organization (WHO) classification and classified as malignant. The search included children and adults with no age limits.

DATA COLLECTION AND ANALYSIS

We used standard methodologic procedures expected by Cochrane. The primary outcomes were overall survival and treatment-related mortality.

MAIN RESULTS

We identified 1549 records; 85 items from electronic databases, 45 from study registries, and 1419 from congress proceedings. The revised search strategy did not identify any additional RCTs. In the previous version of the review, we identified one RCT comparing HDCT followed by autologous HSCT versus standard-dose chemotherapy (SDCT). The trial randomized 87 participants who were considerably heterogeneous with respect to 19 different tumor entities. The data from 83 participants were available for analysis.In the single included trial, overall survival at three years was 32.7% in the HDCT arm versus 49.4% in the SDCT arm and there was no difference between the treatment groups (hazard ratio (HR) 1.26, 95% confidence interval (CI) 0.70 to 2.29, P = 0.44; 1 study, 83 participants; high quality evidence). In a subgroup of participants who had a complete response before HDCT, overall survival was higher in both treatment groups and overall survival at three years was 42.8% in the HDCT arm versus 83.9% in the SDCT arm and favored the SDCT group (HR 2.92, 95% CI 1.1 to 7.6, P = 0.028; 1 study, 39 participants).In the single included trial, the authors reported one treatment-related leukemia death two years after HDCT. They also evaluated severe adverse events WHO grade 3 to 4 in 22 participants in the HDCT arm and in 51 participants in the SDCT arm. The authors reported 11 events concerning digestive-, infection-, pain-, or asthenia-related toxicity in the HDCT arm and one event in the SDCT arm (moderate quality evidence). The development of secondary neoplasia was not addressed. We judged the study to have an overall unclear risk of bias as three of seven items had unclear and four items had low risk of bias. For GRADE, we judged three items as high quality and three items were not reported.

AUTHORS' CONCLUSIONS

The limited data of a single RCT with an unclear risk of bias and moderate to high quality evidence showed no survival advantage for HDCT. If this treatment is offered it should only be given after careful consideration on an individual person basis and possibly only as part of a well-designed RCT.

History of the Use of Esophageal Stent in Management of Dysphagia and Its Improvement Over the Years

The art and science of using stents to treat dysphagia and seal fistula, leaks and perforations has been evolving. Lessons learnt from the deficiencies of previous models led to several improvements making stent deployment easier, and with some designs, it was also possible to remove the stents if needed. With these improvements, besides malignant dysphagia, newer indications for using stents emerged. Unfortunately, despite several decades of evolution, as yet, there is no perfect stent that "fits all." This article is an overview of how this evolution process happened and where we are currently with using stents to manage patients with dysphagia and with other esophageal disorders.

Brachytherapy for the palliation of dysphagia owing to esophageal cancer: A systematic review and meta-analysis of prospective studies

BACKGROUND

The management of dysphagia owing to esophageal cancer is challenging. Brachytherapy has been proposed as an alternative option to stent placement. We performed a systematic review to examine its efficacy and safety in the resolution of dysphagia.

METHODS

Prospective studies recruiting at least 20 patients with malignant dysphagia and published up to April 2016 were eligible. The dysphagia-free survival (DFS) and adverse event rates were pooled by means of a random effect model.

RESULTS

Six studies for a total of 9 treatment arms (623 patients) were eligible for inclusion. After 1month since treatment, the DFS rate was 86.9% [95%CI: 76.0-93.3%]; after 3months, it was 67.2% [95%CI: 56.1-76.7%]; after 6months, it was 47.4% [95%CI: 38.5-56.5%]; after 9months, it was 37.6% [95%CI:30.0-45.9%]; and, finally, after 12months, it was 29.4% [95%CI: 21.6-38.7%]. The heterogeneity between studies was high at 1-, 3- and 6-month assessment; the values of I² were 86.3%, 80.0% and 57.8%, respectively. The meta-regression analysis showed total radiation dose and number of fractions as the only positively influencing factors. Severe adverse event rate was 22.6% (95%CI 19.4-26.3). The main reported adverse events were brachytherapy-related stenosis (12.2%) and fistula development (8.3%). Two cases (0.3%) of deaths were reported due to esophageal perforation.

CONCLUSION

Brachytherapy is a highly effective and relatively safe treatment option therefore its underuse is no longer justified. Further studies should investigate the optimal radiation dose and number of fractions able to achieve the highest DFS rates.

Immunotherapy for esophageal cancer: Current studies and future perspectives

Esophageal cancer is one of the most common malignant tumors of the digestive system, and China has the highest morbidity and mortality rates of esophageal cancer in the world. Currently, main therapies for esophageal cancer include endoscopy, surgery, chemotherapy, and radiotherapy. These traditional treatments have appreciated clinical effects, but the prognosis of this malignancy is still poor. There is accumulating evidence that tumor immune microenvironment plays a key role in the development and progression of esophageal cancer. Recent clinical investigations and ongoing studies indicate that immunotherapy might have a great potential in the treatment of patients with esophageal cancer. Future studies will identify treatment strategies that can maximize therapeutic benefits by combining immunotherapies with existing and novel treatment modalities.

Second- and third-line systemic therapy in patients with advanced esophagogastric cancer: a systematic review of the literature

The optimal second- and third-line chemotherapy and targeted therapy for patients with advanced esophagogastric cancer is still a matter of debate. Therefore, a literature search was carried out in Medline, EMBASE, CENTRAL, and oncology conferences until January 2016 for randomized controlled trials that compared second- or third-line therapy. We included 28 studies with 4810 patients. Second-line, single-agent taxane/irinotecan showed increased survival compared to best supportive care (BSC) (hazard ratio 0.65, 95 % confidence interval 0.53-0.79). Median survival gain ranged from 1.4 to 2.7 months among individual studies. Taxane- and irinotecan-based regimens showed equal survival benefit. Doublet chemotherapy taxane/irinotecan plus platinum and fluoropyrimidine was not different in survival, but showed increased toxicity vs. taxane/irinotecan monotherapy. Compared to BSC, second-line ramucirumab and second- or third-line everolimus and regorafenib showed limited median survival gain ranging from 1.1 to 1.4 months, and progression-free survival gain, ranging from 0.3 to 1.6 months. Third- or later-line apatinib showed increased survival benefit over BSC (HR 0.50, 0.32-0.79). Median survival gain ranged from 1.8 to 2.3 months. Compared to taxane-alone, survival was superior for second-line ramucirumab plus taxane (HR 0.81, 0.68-0.96), and olaparib plus taxane (HR 0.56, 0.35-0.87), with median survival gains of 2.2 and 4.8 months respectively. Targeted agents, either in monotherapy or combined with chemotherapy showed increased toxicity compared to BSC and chemotherapy-alone. This review indicates that, given the survival benefit in a phase III study setting, ramucirumab plus taxane is the preferred second-line treatment. Taxane or irinotecan monotherapy are alternatives, although the absolute survival benefit was limited. In third-line setting, apatinib monotherapy is preferred.

Interventional Therapy of Esophageal Cancer

Esophageal cancer (EC) is the fourth leading cause of cancer death in China. Despite a lot of advances in diagnosis and therapy, the survival rate of patients with EC is low. There is urgent need for a variety of methods and techniques to improve the survival time and alleviate the lesions of EC. Nowadays, alternative and less invasive approaches to the treatment of ECs are being identified. Here, we review several main interventional methods at different stages of EC, including endoscopic resection, stent placement, arterial infusion, photodynamic therapy, and radiofrequency ablation. This review will focus on the indications, methods, clinical outcomes, and complications of these methods, which may help guide the way forward.

Antireflux versus conventional self-expanding metallic Stents (SEMS) for distal esophageal cancer: results of a multicenter randomized trial

INTRODUCTION

Self-expanding metal stents (SEMS) are commonly used in the palliation of dysphagia in patients with inoperable esophageal carcinoma. However, they predispose to gastroesophageal reflux when deployed across the gastroesophageal junction. The aims of this study were to: 1) assess the influence of the antireflux valve on trans-prosthetic reflux (primary outcome); and 2) compare the results of SEMS with and without antireflux valve in terms of reflux symptoms, quality of life (QOL), improvement of dysphagia and adverse events (secondary outcomes).

PATIENTS AND METHODS

Thirty-eight patients were enrolled in nine centers. Carcinomas were locally advanced (47 %) or metastatic. After randomization, patients received either a covered SEMS with antireflux valve (n = 20) or a similar type of SEMS with no antireflux device but assigned to standard proton pump inhibitor therapy and postural advice (n = 18). Trans-prosthetic reflux was assessed at day 2 using a radiological score based on barium esophagography performed after Trendelenburg maneuver and graded from 0 (no reflux) to 12 (maximum). Monthly telephone interviews were conducted for Organisation Mondiale de la Santé (OMS) scoring from 0 (excellent) to 5 (poor), QOL assessment (based on the Reflux-Qual Simplifié scoring system) from 0 (poor) to 100 (excellent), dysphagia scoring from 0 (no dysphagia) to 5 (complete dysphagia) and regurgitation scoring from 0 (no regurgitation) to 16 (maximum).

RESULTS

No difference was noted in terms of age, sex, size of lesion, prosthesis length or need for dilation prior to SEMS placement. No difficulty in placing SEMS nor complications were noted. Radiological scores of reflux were found to be significantly lower in patients with an antireflux stent compared to the conventional stent and associated measures. The regurgitation scores were significantly decreased in patients with antireflux stents during the first 2 months after stent placement and thereafter, they were similar in the two groups. QOL and dysphagia were improved in both groups. Survival rates were comparable in the two groups.

CONCLUSIONS

No difference was observed between the two types of SEMS regarding the palliation of dysphagia and improvement of QOL. However, SEMS with an antireflux valve were more effective in preventing trans-prosthetic gastroesophageal reflux but at the cost of an increased likehood of minor adverse events (migrations and/or obstruction of the SEMS).