Palliation of oesophageal carcinoma using the argon beam coagulator

Randomized comparison of three palliative regimens including brachytherapy, photodynamic therapy, and APC in patients with malignant dysphagia (CONSORT 1a) (Revised II)

OBJECTIVES

Because most esophageal cancers are diagnosed at an advanced stage, a majority of patients require palliative dysphagia treatment. Dysphagia severity and the need for repeated re-canalization procedures significantly affect patients' quality of life (QoL). The aim of this study was to establish whether combining argon plasma coagulation (APC) of the neoplastic esophageal tissue with another re-canalization method results in a longer dysphagia-free period compared with APC alone.

METHODS

We conducted a randomized trial in 93 patients with malignant dysphagia. Patients were followed until death. We compared three regimens of esophageal re-canalization; APC combined with high dose rate (HDR) brachytherapy, APC combined with photodynamic therapy (PDT), and APC alone. The primary outcome measure was the dysphagia-free period following randomization. Secondary measures were survival, QoL, treatment-associated complications, and treatment tolerance. A per-protocol analysis was carried out.

RESULTS

The time to first dysphagia recurrence was significantly different between each combination treatment group and the control group (overall test: P=0.006; HDR vs. control, log-rank P=0.002, PDT vs. control, log-rank P=0.036), but not different between the combination groups (HDR vs. PDT, log-rank P=0.36). The median time to first dysphagia recurrence was 88, 59, and 35 days in the HDR, PDT, and control groups, respectively. There was no difference in overall survival between the study groups (P=0.27). No deaths, perforations, hemorrhages, or fistula formations were attributed to treatment. The only major complication was fever, occurring in three PDT patients. Minor complications were observed significantly more often in the combination treatment groups and included pain in both groups, transient dysphagia worsening, and skin sensitivity in the PDT group. The QoL 30 days after treatment in the HDR group was significantly better than in the other groups.

CONCLUSIONS

In patients with inoperable esophageal cancer, palliative combination treatment of dysphagia with APC and HDR or PDT was significantly more efficient than APC alone, and was safe and well tolerated. APC combined with HDR resulted in fewer complications and better QoL than APC with PDT or APC alone (CONSORT 1b).

Investigation of the thermal tissue effects of the argon plasma coagulation modes "pulsed" and "precise" on the porcine esophagus, ex vivo and in vivo

BACKGROUND

Argon plasma coagulation (APC) is a monopolar, noncontact, thermal procedure that is widely used in therapeutic endoscopy. Systematic investigations of the tissue damage ex vivo and in vivo with the new, second-generation APC modes are lacking.

OBJECTIVE

The aim of this study is to compare the tissue effects of the pulsed effect 2 and precise APC modes.

DESIGN AND SETTING

Ex vivo and in vivo animal model.

SUBJECTS

This study involved 3 explanted porcine esophagi and 8 pigs under general anesthesia.

INTERVENTION

APC application on 3 explanted esophagi and during esophagoscopy.

MAIN OUTCOME MEASUREMENTS

The tissue effect was subjected to histological and statistical investigation.

RESULTS

In vivo, a well known type of superficial tissue damage (type A) of the tunica mucosa and a new injury pattern (type B) limited to the tunica muscularis, were found. Ex vivo, only type A injuries were seen. Thermal injury of the tunica muscularis was significantly lower with precise APC compared with pulsed APC in vivo. The pulsed effect 2 shows a positive correlation between the penetration depth and the power (r = 0.38, P < .0002) or application time for the highest power setting used (40 W, r = 0.77, P < .0001). This correlation could not be detected with precise APC because of its very superficial tissue effect.

LIMITATIONS

This was an animal study. The distance of the APC probe to the esophagus may have varied between applications in vivo.

CONCLUSION

Thermal damage by APC of the esophageal tunica muscularis seems to be underestimated ex vivo. The extent of tissue injury was significantly lower with precise APC than with pulsed APC, indicating that precise APC may be suitable for the treatment of particularly thermosensitive, thin-wall anatomy.

A regional audit of iatrogenic perforation of tumours of the oesophagus and cardia

INTRODUCTION

With the rising incidence of oesophageal cancer, palliative treatment has an increasingly important role. With median survival unlikely to exceed 6 months, in advanced disease the palliative therapy chosen must not hasten patient's demise.

AIM

To establish the outcome of both modern and historical palliative treatment in oesophageal tumours, with emphasis on the aetiology and outcome of iatrogenic perforation.

METHODS

Patients with oesophageal or cardia carcinoma treated within the West Midlands between 1992 and 1996 were identified retrospectively. Information was gathered from hospital case notes and the regional cancer intelligence unit with hospitals visited to capture data. All episodes were entered into a dedicated database.

RESULTS

Of the 3660 patients who were treated, 2529 received palliation as primary treatment, with 5259 palliative procedures performed; 164 iatrogenic perforations were recorded; 83 were due to diagnostic endoscopy (endoscopic perforation) with the reminder due to interventional palliative procedures. Median survival from all forms of palliation was 138 days. Following perforation survival was 95 days after interventional palliative procedure and 58 days after endoscopic perforation (P > 0.05). Thirty-day mortality after emergency surgery was 11.8% with mean survival of 7.5 months.

CONCLUSION

Perforation at diagnostic endoscopy is associated with substantial mortality despite rapid intervention. Patients with suspected cancer must be investigated with extreme care to reduce iatrogenic complications.

Best palliation in esophageal cancer: surgery, stenting, radiation, or what?

Palliation of patients with obstructing or fistulizing esophageal cancer is not easy. Median survival cannot be expected to be longer than 3-6 months, regardless of which therapy is carried out. Self-expandable metal stents have revolutionized the treatment of these patients because of easy insertion, relatively low complication rates and reasonably good functional results. Plastic tubes are mainly indicated in situations in which removal may be needed. The palliative effect of external beam radiation is well established, endoesophageal brachytherapy having the advantage of delivering a high dose in a short time. More recently, there has been increasing interest in locally destructive therapies, mostly in combination with palliative radiation or radiochemotherapy. Obviously, a single best palliation for every situation does not exist. The most appropriate method to alleviate symptoms must be worked out for each individual patient depending on the specific patient situation and the specific expertise of the physician.

Efficacy and complications of argon plasma coagulation for hematochezia related to radiation proctopathy

BACKGROUND

Endoscopic treatments effectively control bleeding caused by radiation proctopathy. The aims of this study were to determine the efficacy and side effects of argon plasma coagulation in the treatment of this type of bleeding.

METHODS

Records of 21 consecutive patients in whom argon plasma coagulation was used to treat hemorrhagic radiation proctopathy were reviewed.

RESULTS

Pharmacologic measures had been unsuccessful in 12 patients. Endoscopic treatment had been unsuccessful in 5 patients. All patients were anemic and 4 had received blood transfusions. The mean number of treatment sessions was 1.7, and 10 patients were successfully treated in single session. Rectal bleeding resolved within 1 month of the last treatment in 19 patients, usually on the day of the last procedure. Bleeding resolved 2 months after cessation of therapy in another patient. Short-term side effects occurred in 3 (14%) patients (rectal pain, tenesmus, and/or abdominal distention); long-term complications (rectal pain, tenesmus, diarrhea) developed in 4 patients (19%).

CONCLUSIONS

Hematochezia caused by radiation proctopathy is effectively controlled by argon plasma coagulation, in some cases after a single treatment session. Treatment may result in protracted bowel symptoms.

A randomized trial of thermal ablative therapy versus expandable metal stents in the palliative treatment of patients with esophageal carcinoma

BACKGROUND

Expandable metal stent insertion and thermal tumor ablation (TTA) both improve dysphagia in patients with advanced esophageal cancer, but no direct comparison study of their efficacy on health-related quality of life has been published. The aim of this study was to compare survival, relief of dysphagia, quality of life, and cost in patients treated by thermal ablation or stent insertion.

METHODS

Sixty-five patients with histologically proven, inoperable esophageal and esophagogastric cancer were initially assessed by endoscopy, barium contrast radiography, and CT of the thorax and abdomen. Dysphagia and quality of life were serially assessed at monthly intervals. Patients were randomized to either repeated TTA or insertion of an expandable metal stent.

RESULTS

Median survival was significantly longer for patients who underwent TTA; 125 days (17-546) versus 68 days (8-602) for those in whom a stent was inserted (p < 0.05), although relief of dysphagia was disappointing in both groups. Several patients in both groups had serious treatment-related complications and required further therapy. Median length of hospital stay and cost were greater for patients treated by TTA. Health-related quality of life was globally impaired in both groups at randomization and deteriorated significantly in the stent group. Pain was reported more commonly by patients with stents.

CONCLUSIONS

The palliation of patients with advanced esophageal and esophagogastric cancer remains unsatisfactory. Health-related quality of life deteriorated in the stent group but not in the TTA group. Patients treated by TTA live longer than patients treated by stent insertion, but the cost of TTA is higher.

Near-infrared photo-excited emission from tissues treated at different temperature levels

BACKGROUND AND OBJECTIVE

There is a lack of methods to evaluate the extent of thermal treatment of biological tissue. The intensity of the near-infrared (NIR) emission photo-excitation was investigated from tissue undergoing different levels of heat treatment.

STUDY DESIGN/MATERIALS AND METHODS

Chicken muscle was heated in an oven at different temperature levels ranging from 40 degrees C until burn-off. The spectral emission intensity from these heat-treated tissues was measured with a CCD camera and the intensity was calculated.

RESULTS

The emission intensity increased proportionally with respect to the extent of treatment temperature until burning. Linear relationships between treatment temperature and the emission intensity from tissue samples were found in three temperature ranges: from 40 to 160 degrees C, from 165 to 220 degrees C, and from 225 to 250 degrees C.

CONCLUSIONS

The change in tissue damage after heat treatment could be detected by measuring the NIR emission intensity from the thermally damaged tissues.

Argon beam coagulation for treatment of symptomatic radiation-induced proctitis

BACKGROUND

Radiation proctitis is a complication of radiotherapy for malignant pelvic disease. Argon beam coagulation is a new and rapidly evolving technology that permits a "no-touch" electrocoagulation of diseased tissue.

METHODS

We analyzed retrospectively the records of 7 patients with prostatic and endometrial cancers treated with irrradiation (median radiation dose was 6840 cGy, range 2400 to 7200 cGy). The median time to onset of symptoms after the conclusion of radiotherapy was 20 months (range 16 to 48 months); symptoms consisted of rectal bleeding and tenesmus in all patients. The patients underwent argon beam coagulation after colonoscopic evaluation. The usual treatment interval was 3 weeks (range 1 to 3 weeks).

RESULTS

A median of 2 treatment sessions (range 2 to 4) was necessary for complete symptom relief. All interventions were well tolerated without complications. During follow-up (median 24 months, range 18 to 24 months), there was no recurrence of symptoms (bleeding, tenesmus).

CONCLUSIONS

Argon beam coagulation is a safe, well tolerated, and effective treatment option in symptomatic radiation proctitis.

Endoscopic palliation of inoperable cancer of the oesophagus or cardia by argon electrocoagulation

BACKGROUND

Cancer of the oesophagus and the cardia tends to present late. Palliation of dysphagia is the prospect of most of the patients. This paper reports the use of argon electrocoagulation in 83 patients with inoperable cancer strictures in the oesophagus and cardia.

METHODS

The argon electrocoagulation was done by a fibre conducting electricity and argon air to the site of coagulation. After treatment the patients were allowed to take fluids and normal food the same evening or the next morning. After recanalization the patients were treated regularly every 3-4 weeks.

RESULTS

Recanalization enabling passage for normal food was achieved with 1 treatment in 48 patients (58%), whereas 22 (26%) needed more than 1 treatment. In 13 patients (16%) the ability to eat normal food was not achieved. In these patients dysphagia improved at least one grade. Perforation was seen in seven patients (8%) and in 1% of treatments. Perforations were successfully treated conservatively in six of the seven patients. Sixty-three patients (76%) died during the investigation period, on average 146 days (range, 43-397 days) after diagnosis.

CONCLUSION

Argon electrocoagulation offers an easy, cheap, and safe alternative to treatment with laser photocoagulation and expandable metal stents.