Endoscopic palliation of malignancies of the upper gastrointestinal tract using Nd:YAG laser: results and survival in 308 treated patients

Evaluation of Quality of Life in Patients with Malignant Dysphagia

Background

In the last 10 years of clinical research there has been increasing interest in the evaluation of quality of life. Several generic and specific instruments have been developed for this purpose. EORTC QLQ C-30 is a cancer-specific questionnaire translated into various languages and validated in several European countries including Italy, where the impact of malignant disease on different areas of quality of life is poorly documented.

Methods

The EORTC QLQ C-30 was administered to 109 patients referred to the endoscopy division of the Istituto Nazionale Tumori, Milan, for endoscopic palliative treatment of malignant dysphagia to test its characteristics in terms of acceptability and clinical validity.

Results

In this group of patients the impact of advanced esophageal cancer was highly evident for Emotional and Physical Functioning, Fatigue and Global QoL scales. Dysphagia is a serious problem for many patients; there is a correlation between grade of dysphagia and four QoL dimensions.

Conclusions

QoL assessment is an important tool to evaluate the adequate management of patients with esophageal cancer. The EORTC QLQ-C30 questionnaire proved to be valid and reliable also in this population.

Palliation of Dysphagia of Esophageal Cancer by Endoscopic Lumen Restoration Techniques

BACKGROUND: Cure of patients with esophageal cancer has remained rare over the past four decades. The overall five-year survival rate for squamous cell and adenocarcinoma of the esophagus currently is reported as 12% in whites and 8% in blacks. The five-year survival rate for localized disease at initial staging is only 26% for whites and 13% for blacks. With regional involvement, these rates are 11% and 7%, respectively. METHODS: The author reviews the literature on optimal endoscopic lumen restoration techniques, including dilation, thermal laser and chemical ablation, photodynamic therapy, and stents. Procedures for pain relief and nutritional support are also presented. RESULTS: Lumen restoration to relieve dysphagia and provide the opportunity for sustaining reasonable peroral nutrition is an essential element in the overall management. Nonsurgical lumen restoration procedures have much to offer for dysphagia palliation and are briefly reviewed in this presentation. The major options include ablation of intraluminal tumor mass by thermal laser, photodynamic laser, chemical ablation, peroral dilation, and placement of esophageal stents. Most patients require more than one palliative method to sustain lumen patency during the course of their disease. CONCLUSIONS: Most patients with esophageal cancer will require palliation for the multiple problems that develop during their limited life span. The responsibility of the palliation therapist is to provide the patient with safe and cost-effective treatments that provide the best possible dysphagia relief.

Palliation of oesophageal carcinoma using the argon beam coagulator

Oesophageal intubation occasionally fails to palliate inoperable carcinoma: some tumours are unsuitable for this procedure and others overgrow the tube. This study reports a series of nine patients (median age 79 (range 55-87) years) in whom the argon beam monopolar coagulator via a flexible endoscopic probe was used to ablate such tumours. Fourteen ablation procedures were performed. The endoscope was passed to the stomach at the end of each procedure. There were no complications; the median hospital stay was 2 (range 1-13) days. Thirteen procedures rendered the patients completely asymptomatic for a median of 6 (range 4-12) weeks. Six patients died a median of 14 (range 4-38) weeks after the first ablation, reflecting their limited life expectancy. The argon beam coagulator provides an effective alternative to laser ablation, being considerably cheaper and safer, while maintaining the minimally invasive nature of the palliation.

Comparison of different treatments for unresectable esophageal cancer

Many patient with esophageal cancer have advanced disease that in not amenable to curative treatment. For these individuals the relief of dysphagia is of utmost importance to the quality of their remaining survival time. This article reviews and compares the methods of palliation with focus on indications and contraindications, advantages as well as disadvantages of each technique, success rates, and complications. Tumor characteristics, the physician's experience, the institution's capabilities, cost, and patient preference will influence choice of palliation. Methods are often complementary rather than competitive.

Photodynamic therapy for obstructing esophageal cancer: light dosimetry and randomized comparison with Nd:YAG laser therapy

BACKGROUND & AIMS

Light dosimetry analysis to achieve predictable tumor necrosis has not been performed for photodynamic therapy (PDT) in the gastrointestinal tract. We evaluated dihematoporphyrin ethers for sensitizing esophageal carcinomas to 630 nm light and compared PDT with neodymium:yttrium-aluminum-garnet (Nd:YAG) laser therapy in a randomized trial.

METHODS

Of 52 patients with dysphagia, 32 received palliative PDT. Ten patients treated with PDT participated in a preliminary trial using various doses of 630-nm light, and 22 patients treated with PDT participated in a randomized trial using a derived standardized light dose for comparison with 20 patients treated with the Nd:YAG laser.

RESULTS

Light dosimetry correlated with depth of tumor necrosis (r = 0.664; P < 0.001). PDT activity was similar for squamous cell and adenocarcinoma. Among randomized patients, both PDT and Nd:YAG therapy relieved dysphagia, but PDT resulted in improved Karnofsky performance status at 1 month (+7 vs. -7; P < 0.001) and longer duration of response (84 vs. 57 days; P = 0.008). Skin photoreactions were unique to PDT.

CONCLUSIONS

The extent of PDT tumor ablation correlates with light dosimetry, enabling selection of a standardized light dose. PDT can relieve esophageal obstruction from squamous cell and adenocarcinoma and is an alternative to Nd:YAG thermal necrosis with a longer duration of response. However, PDT requires patient precautions to minimize skin photoreactions.