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Wang J, Zhu XN, Zhu LL, Chen W, Ma YH, Gan T, Yang JL. Efficacy and safety of endoscopic submucosal tunnel dissection for superficial esophageal squamous cell carcinoma and precancerous lesions. World J Gastroenterol 2018; 24:2878-2885. [PMID: 30018482 PMCID: PMC6048426 DOI: 10.3748/wjg.v24.i26.2878] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/02/2018] [Accepted: 06/09/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the clinical outcomes of patients who underwent endoscopic submucosal tunnel dissection (ESTD) for esophageal squamous cell carcinoma (ESCC) and precancerous lesions.
METHODS ESTD was performed in 289 patients. The clinical outcomes of the patients and pathological features of the lesions were retrospectively reviewed.
RESULTS A total of 311 lesions were included in the analysis. The en bloc rate, complete resection rate, and curative resection rate were 99.04%, 81.28%, and 78.46%, respectively. The ESTD procedure time was 102.4 ± 35.1 min, the mean hospitalization time was 10.3 ± 2.8 d, and the average expenditure was 3766.5 ± 846.5 dollars. The intraoperative bleeding rate was 6.43%, the postoperative bleeding rate was 1.61%, the perforation rate was 1.93%, and the postoperative infection rate was 9.65%. Esophageal stricture and positive margin were severe adverse events, with an incidence rate of 14.79% and 15.76%, respectively. No tumor recurrence occurred during the follow-up period.
CONCLUSION ESTD for ESCC and precancerous lesions is feasible and relatively safe, but for large mucosal lesions, the rate of esophageal stricture and positive margin is high.
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Affiliation(s)
- Jin Wang
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
- State Key Laboratory of Biotherapy and Cancer Center, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xiao-Nan Zhu
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Lin-Lin Zhu
- Department of General Practice, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Wei Chen
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yi-Han Ma
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Tao Gan
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jin-Lin Yang
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
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Clements WD, Johnston LR, McIlwrath E, Spence RA, McGuigan J. Self-Expanding Stents for Malignant Dysphagia. J R Soc Med 2018; 89:454-6. [PMID: 8795499 PMCID: PMC1295887 DOI: 10.1177/014107689608900809] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Self-expanding metallic stents have been employed successfully for vascular, urethral, and biliary strictures. In a prospective study we examined the efficacy of the 16 mm Wallstent for palliation of malignant dysphagia. Eight patients with severe dysphagia due to advanced primary (four) or secondary (four) oesophageal malignant disease were recruited and nine Wallstents were inserted (one patient required two). Dysphagia was reduced in all but one patient, who died after oesophageal perforation; a second patient had a self-limiting bout of haematemesis. Two patients required subsequent treatment for tumour ingrowth but five had no further palliative therapy from stent insertion to time of death. With careful patient selection and skilful application, a 16 mm self-expanding metal endoprosthesis affords effective palliation in malignant oesophageal obstruction.
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Affiliation(s)
- W D Clements
- Department of Thoracic Surgery, Royal Victoria Hospital, Belfast City Hospital, Belfast, Northern Ireland
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3
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Murray LJ, Din OS, Kumar VS, Dixon LM, Wadsley JC. Palliative radiotherapy in patients with esophageal carcinoma: A retrospective review. Pract Radiat Oncol 2012; 2:257-264. [DOI: 10.1016/j.prro.2011.12.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 12/03/2011] [Accepted: 12/17/2011] [Indexed: 10/14/2022]
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4
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Esophagus. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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5
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Blazeby JM, Alderson D, Farndon JR. Quality of life in patients with oesophageal cancer. Recent Results Cancer Res 2000; 155:193-204. [PMID: 10693253 DOI: 10.1007/978-3-642-59600-1_20] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
There is a growing interest in assessing quality of life in patients with oesophageal cancer because it provides detailed information of the patients' perception of the benefits or harms of treatment. Yet few studies have prospectively measured quality of life using validated appropriate instruments. There are now several questionnaires for patients with cancer, although these are not sufficiently sensitive to small but clinically important changes in quality of life. It is therefore recommended that a disease-specific module is used in conjunction with generic measures. The European Organisation into Research and Treatment of Cancer (EORTC) QLQ-OES24 is currently completing an international validation study. It is used with the EORTC QLQ-C30 core instrument and is designed for patients undergoing potentially curative treatment or palliation of malignant dysphagia. Studies that have assessed quality of life after oesophagectomy have generally found that survivors do regain their former health. Little is known about the effect of neoadjuvant chemoradiation on patients' quality of life. Following endoscopic palliation of dysphagia, quality of life can be maintained and improvement of swallowing is seen. A validated appropriate assessment of quality of life should be included in future palliative trials and in studies of new treatments which may marginally influence survival but cause significant side effects.
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Affiliation(s)
- J M Blazeby
- University Department of Surgery, Bristol Royal Infirmary, UK
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6
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Kubba AK, Krasner N. An update in the palliative management of malignant dysphagia. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2000; 26:116-29. [PMID: 10744928 DOI: 10.1053/ejso.1999.0754] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Oesophageal cancer is generally associated with late presentation and poor prognosis. Therefore palliative surgery has been largely superseded by less invasive non-surgical techniques. Once palliation is indicated, the aims of the management should be: the maintenance of oral intake, minimizing hospital stay, relief of pain, elimination of reflux and regurgitation and the prevention of aspiration. METHODS This study was a review of all published English language data on the palliation of malignant dysphagia between 1994-1999. The Medline and Bids databases were searched and other references were derived from the material perused. RESULTS AND CONCLUSIONS Palliative treatment for oesophageal cancer should be individualized and relate to tumour stage, size and location, the patient's medical condition and his/her personal wishes. The palliative treatment largely includes self-expanding metal stents (SEMS), laser (including photodynamic therapy (PDT)) or a combination of the two to relieve symptoms, this may be employed with or without other treatments such as radiotherapy/chemotherapy (RT/CT) with the aim of reducing tumour bulk and possibly prolonging survival. A multi-disciplinary approach is vital in patients with advanced oesophageal cancer.
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Affiliation(s)
- A K Kubba
- Dept of Surgery, University of Nottingham, Liverpool, UK
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7
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Moghissi K, Dixon K, Thorpe JA, Stringer M, Moore PJ. The role of photodynamic therapy (PDT) in inoperable oesophageal cancer. Eur J Cardiothorac Surg 2000; 17:95-100. [PMID: 10731642 DOI: 10.1016/s1010-7940(99)00350-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate the role of PDT in palliation of patients with inoperable oesophageal cancer and to identify subgroups in which this role is of particular significance. METHODS Sixty-five patients (37 male, 28 female) aged 42-89 (mean 65.6) with advanced and inoperable oesophageal cancer were the subjects of this study. Inoperability was due to advanced stage of the disease in 61 and because of general condition in 4. Fifty-eight (89%) had previous treatments, other than PDT. All patients had dysphagia of whom 20 could not swallow fluid. Pre-PDT clinical, radiological and endoscopic examinations were carried out. Performance status (PS) and clinical staging was assessed. PDT protocol consisted of: intravenous injection of 2 mg/kg; photofrin (or equivalent polyhaematoporphyrin) followed 24-72 h later by endoscopic illumination using 630 nm laser light. MAIN OUTCOME MEASUREMENTS (1) Relief of dysphagia generally and specifically in those with cervical and post-cricoid carcinoma who were previously treated by external beam radiotherapy (EBR) (n=6) and those with previous intubation or stent (n=9); (2) Survival. RESULTS There was no PDT related mortality. Three patients (4.6%) developed a mild skin photosensitivity reaction. Dysphagia was relieved in all patients. The mean and median survival of the 58 patients who have died was 7. 7 and 6 months respectively. Seven patients are alive from 2-30 months (mean 16). Survival was not significantly influenced by tumour histology, location in the oesophagus, severity of dysphagia on admission, or by previous therapy. Survival was significantly influenced by Performance Status prior to treatment (P=0.03 log rank, for PS < or =2 vs. PS=3), an most significantly by the stage of the disease (P=0.0001 log rank, for Stage III vs. Stage IV). CONCLUSIONS (1) PDT is safe and effective for palliation of dysphagia in inoperable oesophageal cancer. This is particularly important in post-cricoid and cervical oesophageal cancer previously treated by other methods and for patients with recurrent malignant obstruction who previously had intubation or stent placement. (2) Survival is influenced by better PS (< or =2) and in those with disease Stage III rather than patients in Stage IV. This study has not been able to determine the influence of complete tumour staging on survival because, apart from four patients, all others were Stages III and IV cancer.
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Affiliation(s)
- K Moghissi
- The Yorkshire Laser Centre, Goole and District Hospital, Woodland Avenue, Goole, UK
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8
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Boyce HW. Palliation of Dysphagia of Esophageal Cancer by Endoscopic Lumen Restoration Techniques. Cancer Control 1999; 6:73-83. [PMID: 10758537 DOI: 10.1177/107327489900600107] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- HW Boyce
- Department of Internal Medicine, University of South Florida College of Medicine, Tampa, Florida 33612, USA
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Balducci L, Trotti A. Organ Preservation: An Effective and Safe Form of Cancer Treatment. Clin Geriatr Med 1997. [DOI: 10.1016/s0749-0690(18)30189-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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10
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Spencer GM, Thorpe SM, Sargeant IR, Blackman GM, Solano J, Tobias JS, Bown SG. Laser and brachytherapy in the palliation of adenocarcinoma of the oesophagus and cardia. Gut 1996; 39:726-31. [PMID: 9014774 PMCID: PMC1383399 DOI: 10.1136/gut.39.5.726] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Palliation of malignant dysphagia is possible by a variety of methods although all have significant drawbacks. Laser therapy is an effective and safe treatment but has to be repeated at four to five weekly intervals to maintain palliation. A means of augmenting the benefits while reducing the need for repeat treatments would be highly beneficial to these patients. AIMS To prospectively explore the safety and efficacy of intraluminal radiotherapy (brachytherapy) when used to augment laser recanalisation for malignant dysphagia. PATIENTS Nineteen patients with dysphagia due to advanced adenocarcinoma of the oesophagus or cardia were recruited. METHODS All patients received laser recanalisation until able to swallow a soft diet or better, before the application of a single dose of brachytherapy (10 Gy at 1 cm from the source). Patients were followed up and treated promptly by further endoscopic means in the event of their dysphagia worsening. RESULTS Six patients (32%) required no further treatment until death at a median of 10 weeks (range 1-20 weeks). Further therapy was required at a median of 11 weeks (range 4-37 weeks) after brachytherapy for those 13 patients with recurrent dysphagia. Subsequent symptom control required endoscopic intervention at an average of once every nine weeks. There was no mortality associated with laser or brachytherapy. Median survival from initial treatment and including the one survivor was 36 weeks (range 5-132 weeks). CONCLUSIONS Laser plus brachytherapy offers a safe and effective means of palliating malignant dysphagia due to adenocarcinoma, with a longer dysphagia free interval than historical controls treated with laser alone.
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Affiliation(s)
- G M Spencer
- National Medical Laser Centre, University College London Medical School, London
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11
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Shmueli E, Srivastava E, Dawes PJ, Clague M, Matthewson K, Record CO. Combination of laser treatment and intraluminal radiotherapy for malignant dysphagia. Gut 1996; 38:803-5. [PMID: 8984013 PMCID: PMC1383182 DOI: 10.1136/gut.38.6.803] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Laser treatment for malignant dysphagia is limited by recurrent intraluminal tumour requiring repeated treatment at four to eight week intervals. AIMS To reduce the need for follow up treatment and to improve survival, patients successfully palliated by laser were treated with intraluminal radiotherapy. PATIENTS 32 patients with inoperable oesophageal carcinoma (18 adeno and 14 squamous cell carcinoma). METHODS The patients were initially palliated by a median of three laser treatments. They were then treated with intraluminal radiotherapy, receiving 10-15 Gy at 1 cm from the source as a single treatment with the Selectron system. Patients with squamous cell carcinoma also received external radiotherapy (30 to 50 Gy). RESULTS After the radiotherapy nine patients survived a median of 22 (range 4-40) weeks without requiring any further endoscopic treatment. The remaining patients survived a median of 40 (range 4-102) weeks and required a median of three follow up endoscopic treatments over that time. Eleven patients developed fibrous strictures with no intraluminal tumour and were treated by dilatation. Twelve patients required dilatation and repeat laser therapy for a combination of fibrous stricture and recurrent intraluminal tumour. Six patients eventually required Atkinson tubes. CONCLUSIONS The combination of laser treatment with intraluminal radiotherapy provides good palliation and may reduce the need for repeated endoscopic treatment. Fibrous stricture formation is a common complication.
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Affiliation(s)
- E Shmueli
- Department of Gastroenterology, Royal Victoria Infirmary, Newcastle Upon Tyne
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12
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13
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Abstract
The use of self-expanding metal stents can markedly improve the care of patients with inoperable oesophageal malignancy. The stents can be easily introduced without the need for general anaesthesia. They have fewer complications during insertion than rigid stents and fewer complications than laser therapy. With these stents lumens of up to 2.5 cm are easily obtainable. The article considers the type of patient who may be suitable for stenting, the technique of insertion, benefits and complications of their use.
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Affiliation(s)
- G J Murphy
- Halton General Hospital, Runcorn, Cheshire, UK
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14
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Abstract
Management of squamous carcinoma of the esophagus remains a dilemma for the clinician. Current treatments produce significant morbidity and mortality, yet most patients still die of their disease. Given the limitations, survival alone is insufficient to assess the various options; quality of life (QOL) must also be addressed. This paper reviews the topic of QOL, the various instruments available to measure it, and methods to evaluate such instruments. A 16-year review of the literature was performed to assess the extent to which QOL has been addressed in patients with esophageal carcinoma. Only 51 of 7569 references on esophageal neoplasms considered QOL. Only 3 used documented QOL instruments with appropriate statistical testing. Currently there is no well validated instrument for measurement of QOL in patients with esophageal carcinoma.
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Affiliation(s)
- G A Gelfand
- Department of Surgery, Vancouver General Hospital, University of British Columbia, Canada
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16
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Knyrim K, Wagner HJ, Bethge N, Keymling M, Vakil N. A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med 1993; 329:1302-7. [PMID: 7692297 DOI: 10.1056/nejm199310283291803] [Citation(s) in RCA: 491] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Esophageal obstruction due to cancer can produce debilitating dysphagia. Rapid palliation is usually possible with endoscopic placement of a plastic esophageal prosthesis, but this device has a high rate of complications. A new alternative is a metal-mesh stent that collapses to 3 mm in diameter at placement but can then expand up to 16 mm. METHODS Patients with esophageal carcinoma (39 patients) or malignant extrinsic obstruction (3 patients) were randomly assigned to treatment with either a plastic prosthesis (16 mm in diameter) or an expansile metal-mesh stent. The patients were evaluated every six weeks until death. The degree of palliation was expressed as a dysphagia score and a Karnofsky performance score. RESULTS Complications were significantly less frequent with the metal stents than with the plastic prostheses (no complications vs. nine; P < 0.001). The dysphagia and Karnofsky scores improved significantly and to a similar degree in both treatment groups. The most common causes of recurrent dysphagia were migration of the plastic prostheses (five patients) and ingrowth or overgrowth of the metal stents by tumor (five patients). The rates of reintervention were similar in both treatment groups, as were the 30-day mortality rates. The period of hospitalization after placement of a prosthesis was significantly longer in the group given plastic prostheses than in the group given metal stents (mean +/- SE, 12.5 +/- 2.1 vs. 5.4 +/- 1.0 days; P = 0.005). Despite their higher initial cost, the metal stents were cost effective because of the absence of fatal complications and the decrease in the hospital stay. CONCLUSIONS Expansile metal stents are a safe and cost-effective alternative to conventional plastic endoprostheses in the treatment of esophageal obstruction due to inoperable cancer.
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Affiliation(s)
- K Knyrim
- Medizinische Klinik I, Städtische Kliniken, Kassel, Germany
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Sargeant IR, Loizou LA, Tobias JS, Blackman G, Thorpe S, Bown SG. Radiation enhancement of laser palliation for malignant dysphagia: a pilot study. Gut 1992; 33:1597-601. [PMID: 1283143 PMCID: PMC1379567 DOI: 10.1136/gut.33.12.1597] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Laser therapy offers rapid relief of dysphagia for patients with cancers of the oesophagus and gastric cardia but repeat treatments are required approximately every five weeks to maintain good swallowing. To try to prolong the treatment interval, 22 elderly patients were given additional external beam radiotherapy. Nine had squamous cell carcinoma and 13 adenocarcinoma: five had documented metastases. Six received 40 Gy and 16,30 Gy in 10-20 fractions. A 'check' endoscopy was performed three weeks after external beam radiotherapy. Dysphagia was graded from 0-4 (0 = normal; 4 = dysphagia for liquids). The median dysphagia grade improved from 3 to 1 after laser treatment. This improvement was maintained in the 30 Gy group but there was a noticeable deterioration in three of those who had received the higher radiation dose. A lifelong dysphagia grade of 2 or better was enjoyed by 14 of 16 patients in the 30 Gy group but only two of six in the 40 Gy group. The dysphagia controlled interval was 9 weeks (median) after check endoscopy and subsequent endoscopic procedures were required every 13 weeks to maintain good swallowing. There were no endoscopy related complications. Combined treatment is a promising approach for reducing the frequency of endoscopic treatments. The 30 Gy dose seems more appropriate and may prolong survival. A randomised study to test these conclusions is in progress.
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Affiliation(s)
- I R Sargeant
- National Medical Laser Centre, University College Hospital, London
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Naveau S, Chaput JC. Laser therapy: first treatment for the palliation of malignant dysphagia. Gastroenterology 1992; 102:1442. [PMID: 1372577 DOI: 10.1016/0016-5085(92)90804-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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20
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Affiliation(s)
- S G Bown
- National Medical Laser Centre, Rayne Institute, London, UK
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