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Lancellotta V, Cellini F, Fionda B, De Sanctis V, Vidali C, Fusco V, Barbera F, Gambacorta MA, Corvò R, Magrini SM, Tagliaferri L. The role of palliative interventional radiotherapy (brachytherapy) in esophageal cancer: An AIRO (Italian Association of Radiotherapy and Clinical Oncology) systematic review focused on dysphagia-free survival. Brachytherapy 2019; 19:104-110. [PMID: 31636025 DOI: 10.1016/j.brachy.2019.09.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/16/2019] [Accepted: 09/09/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE The aim of this review was to examine efficacy of palliative interventional radiotherapy (IRT) in esophageal cancer compared with other treatment in terms of dysphagia-free survival (DyFS) and safety. METHODS AND MATERIAL A systematic research using PubMed, Scopus, and Cochrane library was performed to identify full articles evaluating the efficacy of IRT as palliation in patients with esophageal cancer. ClinicalTrials.gov was searched for ongoing or recently completed trials, and PROSPERO was searched for ongoing or recently completed systematic reviews. We analyzed only clinical study as full text of patients with symptomatic esophageal cancer treated with IRT alone or in combination with other treatment. Conference paper, survey, letter, editorial, book chapter, and review were excluded. Time restriction (1990-2018) as concerns the years of the publication was considered. The primary outcome was the duration of dysphagia relief (DyFS) after brachytherapy vs. other treatment (external-beam radiotherapy, photodynamic therapy, argon plasma coagulation, stent, and laser) during followup. Secondary outcomes included overall survival and adverse event rates. RESULTS The literature search resulted in 554 articles. Sixty-six articles were assessed via full text for eligibility. Of these, 59 articles were excluded for various reasons, leaving seven randomized studies. The number of evaluated patients was 905 patients, and median age was 70.5 years. In the IRT group, the median DyFS was 99 days, the most relevant G3-G4 toxicity were fistula development and stenosis reported, respectively, in 8.3% and 12.2%; the overall median survival was 175.5 days. CONCLUSION In conclusion, we provided evidence-based support that IRT is an effective and safe treatment option; therefore, its underuse is no longer justified.
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Affiliation(s)
- Valentina Lancellotta
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
| | - Francesco Cellini
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
| | - Bruno Fionda
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy.
| | - Vitaliana De Sanctis
- Faculty of Medicina e Psicologia, Sant'Andrea Hospital, Department of Radiation Oncology, University of Rome "La Sapienza", Rome, Italy
| | - Cristiana Vidali
- Department of Radiation Oncology, Azienda Sanitaria Universitaria Integrata di Trieste (ASUITS), Trieste, Italy
| | - Vincenzo Fusco
- Department of Radiation Oncology, Centro di Riferimento Oncologico Regionale, Rionero in Vulture, Potenza, Italy
| | - Fernando Barbera
- Brachytherapy Section, Radiation Oncology Department, Ospedali Civili Hospital and Brescia University, Brescia, Italy
| | - Maria Antonietta Gambacorta
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy; Università Cattolica del Sacro Cuore, Istituto di Radiologia, Roma, Italy
| | - Renzo Corvò
- Radiation Oncology, IRCCS Ospedale Policlinico San Martino and Department of Health Science, University of Genoa, Genoa, Italy
| | - Stefano Maria Magrini
- Radiation Oncology Department, Ospedali Civili Hospital and Brescia University, Brescia, Italy
| | - Luca Tagliaferri
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
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Kawamoto T, Nihei K, Sasai K, Karasawa K. Palliative radiotherapy and chemoradiotherapy in stage IVA/B esophageal cancer patients with dysphagia. Int J Clin Oncol 2018; 23:1076-1083. [PMID: 30066207 DOI: 10.1007/s10147-018-1324-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/27/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Palliative therapeutic strategies in esophageal squamous cell carcinoma (ESCC) patients with dysphagia remain controversial. Only few studies have assessed therapeutic effect factors related to improvement in dysphagia score and nutrition-support-free survival (NSFS). OBJECTIVE The present study assessed the efficacy and therapeutic effect factors related to the use of palliative radiotherapy (RT) and chemoradiotherapy (CRT) in ESCC patients with dysphagia. METHODS We retrospectively evaluated 70 patients with stage IVA/B ESCC. Patients received RT of 30 Gy in 10 fractions or concurrent CRT using 5-fluorouracil plus cisplatin of 40 Gy in 20 fractions. The change in the dysphagia score from before to after treatment was assessed, and NSFS was evaluated. RESULTS The median follow-up duration was 6 months (range 1-41 months). The overall rate of improvement in the dysphagia score was 60%. The median NSFS was 7.5 months. Craniocaudal tumor length < 6 cm, tumor circumference < 3/4, and CRT of 40 Gy in 20 fractions were associated with a significant improvement in the dysphagia score (p = 0.0036, p = 0.0069, and p = 0.03, respectively). NSFS was significantly longer with CRT than with RT (p = 0.048). CONCLUSION Palliative RT and CRT are effective treatment options for ESCC patients with dysphagia. Craniocaudal tumor length < 6 cm, tumor circumference < 3/4, and CRT of 40 Gy in 20 fractions may improve dysphagia. CRT of 40 Gy in 20 fractions may improve NSFS.
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Affiliation(s)
- Terufumi Kawamoto
- Division of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 18-22-3 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan. .,Department of Radiation Oncology, Graduate School of Medicine, Juntendo University, Tokyo, Japan.
| | - Keiji Nihei
- Division of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 18-22-3 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Keisuke Sasai
- Department of Radiation Oncology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Katsuyuki Karasawa
- Division of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 18-22-3 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
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Lu YF, Chung CS, Liu CY, Shueng PW, Wu LJ, Hsu CX, Kuo DY, Hou PY, Chou HL, Leong KI, How CH, Chou SF, Wang LY, Hsieh CH. Esophageal Metal Stents with Concurrent Chemoradiation Therapy for Locally Advanced Esophageal Cancer: Safe or Not? Oncologist 2018; 23:1426-1435. [PMID: 29728468 DOI: 10.1634/theoncologist.2017-0646] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/23/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The purpose of this study was to review the risks and benefits of concurrent chemoradiation therapy (CCRT) with esophageal self-expandable metal stents (SEMS) for the treatment of locally advanced esophageal cancer. MATERIALS AND METHODS Between January 2014 and December 2016, the data from 46 locally advanced esophageal cancer patients who received CCRT at our institution were retrospectively reviewed. Eight patients who received CCRT concomitant with SEMS placement (SEMS plus CCRT group) and thirty-eight patients who received CCRT without SEMS placement (CCRT group) were identified. The risk of developing esophageal fistula and the overall survival of the two groups were analyzed. RESULTS The rate of esophageal fistula formation during or after CCRT was 87.5% in the SEMS plus CCRT group and 2.6% in the CCRT group. The median doses of radiotherapy in the SEMS plus CCRT group and the CCRT group were 47.5 Gy and 50 Gy, respectively. SEMS combined with CCRT was associated with a greater risk of esophageal fistula formation than CCRT alone (hazard ratio [HR], 72.30; 95% confidence interval [CI], 8.62-606.12; p < .001). The median overall survival times in the SEMS plus CCRT and CCRT groups were 6 months and 16 months, respectively. Overall survival was significantly worse in the SEMS plus CCRT group than in the CCRT group (HR, 5.72; 95% CI, 2.15-15.21; p < .001). CONCLUSION CCRT concomitant with SEMS for locally advanced esophageal cancer results in earlier life-threatening morbidity and a higher mortality rate than treatment with CCRT alone. Further prospective and randomized studies are warranted to confirm these observations. IMPLICATIONS FOR PRACTICE Patients treated with SEMS placement followed by CCRT had higher risk of esophageal fistula formation and inferior overall survival rate compared with patients treated with CCRT alone. SEMS placement should be performed cautiously in patients who are scheduled to receive CCRT with curative intent.
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Affiliation(s)
- Yueh-Feng Lu
- Division of Radiation Oncology, Department of Radiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Chen-Shuan Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chao-Yu Liu
- Division of Thoracic Surgery, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Pei-Wei Shueng
- Division of Radiation Oncology, Department of Radiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Radiation Oncology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Le-Jung Wu
- Division of Radiation Oncology, Department of Radiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Chen-Xiong Hsu
- Division of Radiation Oncology, Department of Radiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Deng-Yu Kuo
- Division of Radiation Oncology, Department of Radiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Pei-Yu Hou
- Division of Radiation Oncology, Department of Radiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Hsiu-Ling Chou
- Department of Nursing, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- School of Nursing, National Yang-Ming University, Taipei, Taiwan
- Department of Nursing, Oriental Institute of Technology, New Taipei City, Taiwan
| | - Ka-I Leong
- Division of Thoracic Surgery, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Cheng-Hung How
- Division of Thoracic Surgery, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - San-Fang Chou
- Department of Medical Research, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Li-Ying Wang
- Physical Therapy Center, National Taiwan University Hospital, Taipei, Taiwan
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chen-Hsi Hsieh
- Division of Radiation Oncology, Department of Radiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Institute of Traditional Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Singh P, Singh A, Singh A, Sharma G, Bhatia PK, Grover AS. Long Term Outcome in Patients with Esophageal Stenting for Cancer Esophagus - Our Experience at a Rural Hospital of Punjab, India. J Clin Diagn Res 2016; 10:PC06-PC09. [PMID: 28208923 DOI: 10.7860/jcdr/2016/22950.8994] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 10/14/2016] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Cancer of the esophagus is among the leading cause of cancer deaths in Punjab, India. Patients generally present with dysphagia as their first symptom and more often they have advanced disease at the time of presentation to a tertiary care centre. Palliative procedures have important roles in this setting. Stenting is the best option to palliate the symptoms of dysphagia, from which patient is suffering the most. AIM To know the success rate, early and long term complications and mortality in esophageal stenting, when it was done in malignant esophageal stricture patients. MATERIALS AND METHODS One hundred patients, who had undergone esophageal stenting from January 2012 to January 2015, were included in the study. We retrospectively analysed the data for patient characteristics, causes of non-operability, early and long term complications, re-interventions, efficacy and mortality. RESULTS Out of 100 patients, indications for stenting were locally advanced disease not amenable to surgery (52%), metastatic disease (35%), CVA (1%), cardiac and respiratory problem (8%), un-willing for surgery in 5% of patients. Majority of patients (94%) had squamous cell carcinoma, while only 6% had adenocarcinoma. 84% of patients presented with dysphagia with or without chest pain and recurrent cough while 16% had recurrent vomiting. 58% had dysphagia to liquids and solids and 17% had complete dysphagia. After stenting 93% had significant improvement in dysphagia score from median of 3 to 1. Post procedure stay was 3.61±1.0 days. One patient had procedure related major complication in the form of post procedural bleed (after 16 days of stenting) leading to death of that patient. Minor complications were present in 52 patients treated conservatively not affecting the efficacy of procedure. These include pain after stenting (38%), stent obstruction (23%) and stent migration (6%). All the minor complications were treated conservatively except in six patients in whom re-stenting was done. CONCLUSION Esophageal stenting is relatively safe procedure with short stay of the patient in the hospital. Although, it helps in alleviating patients' morbidity very effectively and reliably, there are many technical glitches, which needs to be kept into account and patient should be properly counseled before the procedure to prevent and manage post procedure complications and medico legal aspects.
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Affiliation(s)
- Parvinder Singh
- Assistant Professor, Department of Surgery, Gian Sagar Medical College , Ram Nagar, Rajpura, Patiala, Punjab, India
| | - Abhitesh Singh
- Junior Resident, Department of Surgery, Gian Sagar Medical College , Ram Nagar, Rajpura, Patiala, Punjab, India
| | - Anantbir Singh
- Junior Resident, Department of Surgery, Gian Sagar Medical College , Ram Nagar, Rajpura, Patiala, Punjab, India
| | - Ghansham Sharma
- Assistant Professor, Department of Biostatistics, ESIC Medical College and PGIMSR , Banglore, Karnatka, India
| | - Parmod Kumar Bhatia
- Professor, Department of Surgery, Gian Sagar Medical College , Ram Nagar, Rajpura, Patiala, Punjab, India
| | - Amarjeet Singh Grover
- Professor, Department of Surgery, Gian Sagar Medical College , Ram Nagar, Rajpura, Patiala, Punjab, India
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Welsch J, Kup PG, Nieder C, Khosrawipour V, Bühler H, Adamietz IA, Fakhrian K. Survival and Symptom Relief after Palliative Radiotherapy for Esophageal Cancer. J Cancer 2016; 7:125-30. [PMID: 26819634 PMCID: PMC4716843 DOI: 10.7150/jca.13655] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 11/01/2015] [Indexed: 12/17/2022] Open
Abstract
Purpose: The aim of this study was to assess the 6-months dysphagia-free survival, improvement in swallowing function, complication rate, and overall survival in patients with incurable esophageal cancer treated with palliative radiotherapy. Methods: We retrospectively reviewed data from 139 patients (median age 72 years) with advanced/recurrent incurable esophageal cancer, who were referred to 3 German radiation oncology centers for palliative radiotherapy between 1994 and 2014. Radiotherapy consisted of external beam radiotherapy (EBRT) with 30 - 40.5 Gy/2.5 - 3 Gy per fraction, brachytherapy alone (BT) with 15 - 25 Gy/5 - 7Gy per fraction/weekly and EBRT + BT (30 - 40.5 Gy plus 10 - 14 Gy with BT) in 65, 46, and 28 patients, respectively. Dysphagia-free survival (Dy-PFS) was defined as the time to worsening of dysphagia for at least one point, a new loco-regional failure or death of any cause. Results: Median follow-up time was 6 months (range 1-6 months). Subjective symptom relief was achieved in 72 % of patients with median response duration of 5 months. The 1-year survival rate was 30%. The 6-months Dy-PFS time for the whole group was 73 ± 4%. The 6-months Dy-PFS was 90 ± 4% after EBRT, 92 ± 5% after EBRT + BT and 37 ± 7% after BT, respectively (p<0.001). Five patients lived for more than 2 years, all of them were treated with EBRT ± BT. Ulceration, fistula and stricture developed in 3, 6 and 7 patients, respectively. Conclusions: Radiotherapy leads to symptom improvement in the majority of patients with advanced incurable esophageal cancer. The present results favor EBRT ± BT over BT alone. Due to the retrospective nature of this study, imbalances in baseline characteristics might have contributed to this finding, and further trials appear necessary.
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Affiliation(s)
- Julia Welsch
- 1. Department of Radiation Oncology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Philipp Günther Kup
- 1. Department of Radiation Oncology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Carsten Nieder
- 2. Department of Oncology and Palliative Medicine, Nordland Hospital Bodø, Norway; 3. Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Norway
| | - Veria Khosrawipour
- 4. Department of Surgery, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Helmut Bühler
- 1. Department of Radiation Oncology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Irenäus A Adamietz
- 1. Department of Radiation Oncology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany.; 5. Department of Radiation Oncology, Sankt Josef Hospital Bochum, Ruhr-University Bochum, Bochum, Germany.; 6. Department of Radiation Oncology, Ev-Krankenhaus Witten, Academic Hospital of the Witten/Herdecke University, Witten, Germany
| | - Khashayar Fakhrian
- 1. Department of Radiation Oncology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany.; 5. Department of Radiation Oncology, Sankt Josef Hospital Bochum, Ruhr-University Bochum, Bochum, Germany
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Hou PY, Teng CJ, Chung CS, Liu CY, Huang CC, Chang MH, Shueng PW, Hsieh CH. Aortic pseudoaneurysm formation following concurrent chemoradiotherapy and metallic stent insertion in a patient with esophageal cancer. Medicine (Baltimore) 2015; 94:e862. [PMID: 25997064 PMCID: PMC4602863 DOI: 10.1097/md.0000000000000862] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Aortic pseudoaneurysm formation subsequent to concurrent chemoradiotherapy (CCRT) for esophageal cancer patient with esophageal metallic stent insertion is a rare condition.A 52-year-old man with esophageal cancer, cT4N1M0, stage IIIC, was treated with concurrent weekly cisplatin (30 mg/m) and 5-Fluorouracil (500 mg/m) as well as radiotherapy (50.4 Gy in 28 fractions) for 6 weeks. An esophageal metallic stent was inserted for dysphagia 1 week after initiation of CCRT. During the treatment regimen, the platelet count dropped to less than 200 × 10 /μL. One month after the completion of CCRT, chest CT revealed the presence of an aortic pseudoaneurysm as well as aortoesophageal fistulas. A thoracic aortic endografting was performed and the patient responded well to surgery. However, the patient died 2 months later due to a nosocomial infection.Multimodality treatment for esophageal cancer comprising cisplatin-based CCRT and esophageal metallic stent placement near a great vessel may increase the risk of pseudoaneurysm formation.
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Affiliation(s)
- Pei-Yu Hou
- From the Division of Radiation Oncology, Department of Radiology, Far Eastern Memorial Hospital, New Taipei City (P-YH, P-WS, C-HH); Department of Medicine (C-JT, C-HH); Institute of Traditional Medicine, School of Medicine, National Yang-Ming University, Taipei (C-HH); Division of Oncology and Hematology, Department of Medicine, Far Eastern Memorial Hospital, New Taipei City (C-JT); Institute of Public Health, National Yang-Ming University, Taipei (C-JT); Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City (C-SC); College of Medicine, Fu Jen Catholic University, New Taipei City (C-SC); Department of Thoracic surgery, Far Eastern Memorial Hospital, New Taipei City (C-YL); Department of Medical Imaging, Far Eastern Memorial Hospital, New Taipei City (C-CH); Department of Anatomical Pathology, Far Eastern Memorial Hospital, New Taipei City (M-HC); Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (P-WS)
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Dai Y, Li C, Xie Y, Liu X, Zhang J, Zhou J, Pan X, Yang S. Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev 2014; 2014:CD005048. [PMID: 25354795 PMCID: PMC8106614 DOI: 10.1002/14651858.cd005048.pub4] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Most patients with oesophageal and gastro-oesophageal carcinoma are diagnosed at an advanced stage and require palliative intervention. Although there are many kinds of interventions, the optimal one for the palliation of dysphagia remains unclear. This review updates the previous version published in 2009. OBJECTIVES The aim of this review was to systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal and gastro-oesophageal carcinoma. SEARCH METHODS To find new studies for this updated review, in January 2014 we searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL; and major conference proceedings (up to January 2014). SELECTION CRITERIA Only randomised controlled trials (RCTs) were included in which patients with inoperable or unresectable primary oesophageal cancer underwent palliative treatment. Different interventions like rigid plastic intubation, self-expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head-to-head or in combination, were included. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30-day mortality, adverse effects and quality of life. DATA COLLECTION AND ANALYSIS Data collection and analysis were performed in accordance with the methods of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group. MAIN RESULTS We included 3684 patients from 53 studies. SEMS insertion was safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provided comparable dysphagia palliation but had an increased requirement for re-interventions and for adverse effects. Anti-reflux stents provided comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might have reduced gastro-oesophageal reflux and complications. Newly-designed double-layered nitinol (Niti-S) stents were preferable due to longer survival time and fewer complications compared to simple Niti-S stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life, and might provide better results when combined with argon plasma coagulation or external beam radiation therapy. AUTHORS' CONCLUSIONS Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Some anti-reflux stents and newly-designed stents lead to longer survival and fewer complications compared to conventional stents. Combinations of brachytherapy with self-expanding metal stent insertion or radiotherapy are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, and chemotherapy alone are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.
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Affiliation(s)
- Yingxue Dai
- Department of Child, Adolescent and Maternal Health, Hua Xi School of Public Health, Sichuan University, 17 Ren min nan lu san duan, Chengdu, Sichuan, China, 610041
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Abstract
The most commonly used treatments for maliganat dysphagia are stenting and radiotherapy (RT). A prospective data of 91 patients with locally advanced or metastatic esophageal cancer who has been treated with either palliative RT, stent or both. Group I had RT only, Group II had stent only and group III had both RT and stent. The median overall survival was 169, 119 and 237 in the three groups respectively. The difference between GI & III was statistically significant (P=0.01). Combinations of stent and RT may provide survival benefit in patients with malignant dysphagia. A randomized clinical trial is recommended.
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Hanna WC, Sudarshan M, Roberge D, David M, Waschke KA, Mayrand S, Alcindor T, Ferri LE. What is the optimal management of dysphagia in metastatic esophageal cancer? ACTA ACUST UNITED AC 2012; 19:e60-6. [PMID: 22514498 DOI: 10.3747/co.19.892] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The palliation of dysphagia in metastatic esophageal cancer remains a challenge, and the optimal approach for this difficult clinical scenario is not clear. We therefore sought to define and determine the efficacy of various treatment options used at our institution for this condition. METHODS We reviewed a prospective database for all patients managed in an esophageal cancer referral centre over a 5-year period. All patients receiving palliation of malignant dysphagia were reviewed for demographics, palliative treatment modalities, complications, and dysphagia scores (0 = none to 4 = complete). The Wilcoxon signed rank test was used to determine significance (p < 0.05). RESULTS During 2004-2009, 63 patients with inoperable esophageal cancer were treated for palliation of dysphagia. The primary treatment was radiotherapy in 79% (brachytherapy in 18 of 50; external-beam in 10 of 50; both types in 22 of 50), and stenting in 21%. Mean wait time from diagnosis to treatment was 22 days in the stent group and 54 days in the radiotherapy group (p = 0.003). Mean duration of treatment was 1 day in the stent group and 40 days in the radiotherapy group (p = 0.001). In patients treated initially by stenting, dysphagia improved within 2 weeks of treatment in 85% of patients (dysphagia score of 0 or 1). However, 20% of patients presented with recurrence of dysphagia at 10 weeks of treatment. In the radiotherapy group, the onset of palliation was slower, with only 50% of patients palliated at 2 weeks (dysphagia score of 0 or 1). However, long-term palliation was more satisfactory, with 90% of patients remaining palliated after 10 weeks of treatment. CONCLUSIONS In inoperable esophageal cancer at our centre, radiation treatment provided durable long-term relief, but came at a high price of a long wait time for initiation of treatment and a long lag time between initiation of treatment and relief of symptoms. On the other hand, endoluminal stenting provided more rapid and effective early relief from symptoms, but was affected by recurrence of dysphagia in the long-term. It is now time for a prospective randomized trial to assess the safety and efficacy of combined-modality treatment with both endoluminal stenting and radiation therapy compared with either treatment alone.
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Affiliation(s)
- W C Hanna
- Division of Thoracic Surgery, McGill University, The Montreal General Hospital, Montreal, QC
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Lindenmann J, Matzi V, Neuboeck N, Anegg U, Baumgartner E, Maier A, Smolle J, Smolle-Juettner FM. Individualized, multimodal palliative treatment of inoperable esophageal cancer: clinical impact of photodynamic therapy resulting in prolonged survival. Lasers Surg Med 2012; 44:189-98. [PMID: 22334351 DOI: 10.1002/lsm.22006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2012] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVE In esophageal carcinoma palliative treatment is often required due to advanced tumor stage or patient-related factors. The main goal of our retrospective single center study was to evaluate the effect of an individualized multimodal palliative treatment, focusing on the efficacy of different treatment options. MATERIALS AND METHODS Between 1999 and 2009, 640 patients suffering from esophageal carcinoma were referred to our division. Two hundred fifty out of those (39.1%) were treated with palliative intention by using a individualized, multimodal concept including endoscopic dilatation, photodynamic therapy (PDT), endoluminal brachytherapy, external radiation, chemotherapy, stenting, feeding tube, and palliative resection. RESULTS There were 37 women (14.9%) and 211 men (85.1%). The treatment included PDT in 171 cases (in 118 as first measure), stenting in 124 (38), dilatation in 83 (24), endoluminal brachytherapy in 92 (20), feeding enterostomy in 40 (14), external radiation in 67 (23), chemotherapy in 57 (29), and palliative resection in 3 patients. The mean number of palliative treatments per patient was 2.6. Mean survival time for the collective was 34 months. Distant metastases and nodal positivity were connected with a significantly reduced survival. If PDT was used in the first place, median survival was 50.9 months compared to 17.3 months if other options were used as initial modality (P = 0.012). CONCLUSION By using an individualized multimodal approach, an acceptable mean survival time can be achieved in advanced esophageal cancer treated with palliative intention. PDT, if used as initial endoluminal treatment in patients without gross tumor infiltration into the mediastinum, the great vessels or the tracheo-bronchial tree, enables a considerable beneficial effect in the palliative setting.
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Affiliation(s)
- Joerg Lindenmann
- Division of Thoracic and Hyperbaric Surgery, Department of Surgery, Medical University Graz, Graz, Austria.
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11
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Martinez JC, Puc MM, Quiros RM. Esophageal stenting in the setting of malignancy. ISRN GASTROENTEROLOGY 2011; 2011:719575. [PMID: 21991527 PMCID: PMC3168502 DOI: 10.5402/2011/719575] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 06/15/2011] [Indexed: 12/28/2022]
Abstract
Esophageal cancer is often diagnosed at an advanced stage, with many patients
found to have locoregional or metastatic disease at time of diagnosis. Because
of this, cure may be unlikely, leading treatment efforts to focus more on
symptom palliation and improving patient quality of life. The majority of
patients with advanced disease suffer from some degree of dysphagia. Palliative
efforts are therefore directed at relieving dysphagia, allowing patients to
manage their oropharyngeal secretions, reduce aspiration risk, and maintain
caloric intake orally. A variety of endoscopic treatment modalities have been
utilized with these objectives in mind, with options determined by the location
and size of the tumor, as well as the patient's expected prognosis. In this
article, we review the use of endoscopically-placed stents for palliation in
patients with advanced esophageal cancer. We discuss the history of stent use in
such cases, as well as more recent developments in stent technology. We give an
overview of some of the more commonly used stents in practice, discuss the
technique of insertion, and survey the short- and long-term outcomes of stent
placement.
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12
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Palmes D, Brüwer M, Bader FG, Betzler M, Becker H, Bruch HP, Büchler M, Buhr H, Ghadimi BM, Hopt UT, Konopke R, Ott K, Post S, Ritz JP, Ronellenfitsch U, Saeger HD, Senninger N. Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group. Langenbecks Arch Surg 2011; 396:857-66. [PMID: 21713594 DOI: 10.1007/s00423-011-0818-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 06/07/2011] [Indexed: 12/16/2022]
Abstract
PURPOSE Correct diagnosis, surgical treatment, and perioperative management of patients with esophageal carcinoma remain crucial for prognosis within multimodal treatment procedures. This study aims to achieve a consensus regarding current management strategies in esophageal cancer by questioning a panel of experts from the German Advanced Surgical Treatment Study (GAST) group, comprised of 9 centers specialized in esophageal surgery, with a combined total of >220 esophagectomies per year. MATERIALS AND METHODS The Delphi method, a systematic and interactive, evidence-based approach, was used to obtain consensus statements from the GAST group regarding ambiguities and disparities in diagnosis, patient selection, surgical technique, and perioperative management of patients with esophageal carcinoma. After four rounds of surveys, agreement was measured by Likert scales and defined as full (100% agreement), near (≥66.6% agreement), or no consensus (<66.6% agreement). RESULTS Full or near consensus was obtained for essential aspects of esophageal cancer staging, proper surgical technique, perioperative management and indication for primary surgery, and neoadjuvant treatment or palliative treatment. No consensus was achieved regarding acceptability of minimally invasive technique and postoperative nutrition after esophagectomy. CONCLUSION The GAST consensus statement represents a position paper for treatment of patients with esophageal carcinoma which both contributes to the development of clinical treatment guidelines and outlines topics in need of further clinical studies.
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Affiliation(s)
- Daniel Palmes
- Department of General and Visceral Surgery, University of Münster, Waldeyerstrasse 1, 48149 Münster, Germany.
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13
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Sreedharan A, Harris K, Crellin A, Forman D, Everett SM. WITHDRAWN: Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev 2011:CD005048. [PMID: 21328271 DOI: 10.1002/14651858.cd005048.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The majority of oesophageal and gastro-oesophageal cancers are diagnosed at an advanced stage and palliative treatment is the realistic management option for most patients. The optimal intervention for the palliation of dysphagia in these patients has not been established. OBJECTIVES To systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal carcinoma. SEARCH STRATEGY We undertook a search according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL and major conference proceedings up to August 2005. The literature search was re-run in August 2006 and March 2007. SELECTION CRITERIA Randomised controlled trials (RCTs) in patients with inoperable or unresectable primary oesophageal cancer who underwent palliative treatment. We included rigid plastic intubation, self-expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head-to-head or in combination. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30-day mortality, adverse effects and quality of life. DATA COLLECTION AND ANALYSIS One author assessed the eligibility criteria of each study and extracted data regarding outcomes and factors affecting risk of bias. MAIN RESULTS We included 2542 patients from 40 studies. SEMS insertion is safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provide comparable dysphagia palliation but have an increased requirement for re-interventions and adverse effects. Anti-reflux stents provide comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might reduce gastro-oesophageal reflux compared to conventional metal stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life. AUTHORS' CONCLUSIONS Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Self-expanding metal stent insertion and brachytherapy provide comparable palliation to endoscopic ablative therapy but are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, chemotherapy alone, combination chemoradiotherapy and bypass surgery are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.
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Affiliation(s)
- Aravamuthan Sreedharan
- Department of Gastroenterology, United Lincolnshire Hospitals NHS Trust, Lincoln County Hospital, Greetwell Road, Lincoln, Lincolnshire, UK, LN2 2YE
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14
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Diamantis G, Scarpa M, Bocus P, Realdon S, Castoro C, Ancona E, Battaglia G. Quality of life in patients with esophageal stenting for the palliation of malignant dysphagia. World J Gastroenterol 2011; 17:144-50. [PMID: 21245986 PMCID: PMC3020367 DOI: 10.3748/wjg.v17.i2.144] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 10/16/2010] [Accepted: 10/23/2010] [Indexed: 02/06/2023] Open
Abstract
Incidence of esophageal cancer (EC) is rising more rapidly in the Western world than that of any other cancer. Despite advances in therapy, more than 50% of patients have incurable disease at the time of presentation. This precludes curative treatment and makes palliative treatment a more realistic option for most of these patients. Dysphagia is the predominant symptom in more than 70% of patients with EC and although several management options have been developed in recent years to palliate this symptom, the optimum management is not established. Self-expanding metal stents (SEMS) are a well-established palliation modality for dysphagia in such patients. Health-related quality of life (HRQoL) is becoming a major issue in the evaluation of any therapeutic or palliative intervention. To date, only a few published studies can be found on Medline examining HRQoL in patients with advanced EC treated with SEMS implantation. The aim of this study was to review the impact on HRQoL of SEMS implantation as palliative treatment in patients with EC. All Medline articles regarding HRQoL in patients with advanced EC, particularly those related to SEMS, were reviewed. In most studies, relief of dysphagia was the only aspect of HRQoL being measured and SEMS implantation was compared with other palliative treatments such as brachytherapy and laser therapy. SEMS insertion provides a swift palliation of dysphagia compared to brachytherapy and no evidence was found to suggest that stent implantation is different to laser treatment in terms of improving dysphagia, recurrent dysphagia and better HRQoL, although SEMS insertion has a better technical success rate and also reduces the number of repeat interventions.
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15
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Affiliation(s)
- Matthew J Schuchert
- Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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16
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Sreedharan A, Harris K, Crellin A, Forman D, Everett SM. Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev 2009:CD005048. [PMID: 19821338 DOI: 10.1002/14651858.cd005048.pub2] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The majority of oesophageal and gastro-oesophageal cancers are diagnosed at an advanced stage and palliative treatment is the realistic management option for most patients. The optimal intervention for the palliation of dysphagia in these patients has not been established. OBJECTIVES To systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal carcinoma. SEARCH STRATEGY We undertook a search according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL and major conference proceedings up to August 2005. The literature search was re-run in August 2006 and March 2007. SELECTION CRITERIA Randomised controlled trials (RCTs) in patients with inoperable or unresectable primary oesophageal cancer who underwent palliative treatment. We included rigid plastic intubation, self-expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head-to-head or in combination. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30-day mortality, adverse effects and quality of life. DATA COLLECTION AND ANALYSIS One author assessed the eligibility criteria of each study and extracted data regarding outcomes and factors affecting risk of bias. MAIN RESULTS We included 2542 patients from 40 studies. SEMS insertion is safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provide comparable dysphagia palliation but have an increased requirement for re-interventions and adverse effects. Anti-reflux stents provide comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might reduce gastro-oesophageal reflux compared to conventional metal stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life. AUTHORS' CONCLUSIONS Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Self-expanding metal stent insertion and brachytherapy provide comparable palliation to endoscopic ablative therapy but are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, chemotherapy alone, combination chemoradiotherapy and bypass surgery are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.
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Affiliation(s)
- Aravamuthan Sreedharan
- Department of Gastroenterology, United Lincolnshire Hospitals NHS Trust, Lincoln County Hospital, Greetwell Road, Lincoln, Lincolnshire, UK, LN2 2YE
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17
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Sreedharan A, Harris K, Crellin A, Forman D, Everett SM. Interventions for dysphagia in oesophageal cancer. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [PMID: 19821338 DOI: 10.1002/14651858.cd005048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The majority of oesophageal and gastro-oesophageal cancers are diagnosed at an advanced stage and palliative treatment is the realistic management option for most patients. The optimal intervention for the palliation of dysphagia in these patients has not been established. OBJECTIVES To systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal carcinoma. SEARCH STRATEGY We undertook a search according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL and major conference proceedings up to August 2005. The literature search was re-run in August 2006 and March 2007. SELECTION CRITERIA Randomised controlled trials (RCTs) in patients with inoperable or unresectable primary oesophageal cancer who underwent palliative treatment. We included rigid plastic intubation, self-expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head-to-head or in combination. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30-day mortality, adverse effects and quality of life. DATA COLLECTION AND ANALYSIS One author assessed the eligibility criteria of each study and extracted data regarding outcomes and factors affecting risk of bias. MAIN RESULTS We included 2542 patients from 40 studies. SEMS insertion is safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provide comparable dysphagia palliation but have an increased requirement for re-interventions and adverse effects. Anti-reflux stents provide comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might reduce gastro-oesophageal reflux compared to conventional metal stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life. AUTHORS' CONCLUSIONS Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Self-expanding metal stent insertion and brachytherapy provide comparable palliation to endoscopic ablative therapy but are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, chemotherapy alone, combination chemoradiotherapy and bypass surgery are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.
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Affiliation(s)
- Aravamuthan Sreedharan
- Department of Gastroenterology, United Lincolnshire Hospitals NHS Trust, Lincoln County Hospital, Greetwell Road, Lincoln, Lincolnshire, UK, LN2 2YE
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18
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Madhusudhan C, Saluja SS, Pal S, Ahuja V, Saran P, Dash NR, Sahni P, Chattopadhyay TK. Palliative stenting for relief of dysphagia in patients with inoperable esophageal cancer: impact on quality of life. Dis Esophagus 2009; 22:331-6. [PMID: 19473211 DOI: 10.1111/j.1442-2050.2008.00906.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The aim of palliation in patients with inoperable esophageal cancer is to relieve dysphagia with minimal morbidity and mortality, and thus improve quality of life (QOL). The use of a self-expanding metal stent (SEMS) is a well-established modality for palliation of dysphagia in such patients. We assessed the QOL after palliative stenting in patients with inoperable esophageal cancer. Thirty-three patients with dysphagia due to inoperable esophageal cancer underwent SEMS insertion between October 2004 and December 2006. All patients had grade III/IV dysphagia and locally advanced unresectable cancer (n = 13), distant metastasis (n = 14), or comorbid conditions/poor general health status precluding a major surgical procedure (n = 6). Patients with grade I/II dysphagia and those with carcinoma of the cervical esophagus were excluded. The QOL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 (version 3) and EORTC QLQ-Esophagus (OES) 18 questionnaire (a QOL scale specifically designed for esophageal diseases) before and at 1, 4, and 8 weeks after placement of the stent. The mean age of the patients was 56 (range 34-78) years, and 22 were men. A covered SEMS was used in all patients. The most common site of malignancy was the lower third of the esophagus (n = 18, 55%). In 23 (77%) patients, the stent crossed the gastroesophageal junction. Seven patients required a reintervention for stent block (n = 5) and stent migration (n = 2). Dysphagia improved significantly immediately after stenting, and this improvement persisted until 8 weeks (16.5 vs. 90.6; P < 0.01). The global health status (5.8 vs. 71.7; P < 0.01) and all functional scores improved significantly after stenting from baseline until 8 weeks. Except pain (14.1 vs. 17.7; P = 0.67), there was significant improvement in deglutition (22.7 vs. 2.0; P < 0.01), eating (48 vs. 12.6; P < 0.01), and other symptom scales (19.7 vs. 12.1; P = 0.04) following stenting. The median survival was 4 months (3-7 months). Palliative stenting using SEMS resulted in significant improvement in all scales of QOL without any mortality and acceptable morbidity.
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Affiliation(s)
- Chinthakandhi Madhusudhan
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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Abstract
Oesophageal and gastric cancers are amongst the most frequent and lethal of cancers worldwide. In the US alone, some 13 000 individuals are affected each year, and mortality is particularly high in elderly patients with advanced stage disease and multiple co-morbidities. Patients usually do not present until later in the disease when symptoms occur, once the tumour is sufficiently large to cause obstruction or invasion of adjacent structures. Oesophageal cancer can metastasize to almost any organ, and widespread distant metastases are almost always present at the time of death. Overall mortality from this cancer is around 80-90%. Curative treatment of oesophageal cancer must achieve local control of the primary lesion as well as control and/or prevention of metastases. These are important contributors to overall results when therapy is undertaken in elderly patients, as are the significant risks of adverse effects such as morbidity from chemoradiation and the morbidity and mortality of oesophagectomy. Surgical resection affords the best chance for local control and the best means of palliation of dysphagia for most patients with localized disease, although both local and systemic recurrence of disease are common when surgery is used alone. Because of the low cure rates associated with the use of surgery alone, other modalities have been added to the treatment regimen. Elderly patients with significant cardiac and pulmonary co-morbidity are candidates for nonoperative therapy, even at an early disease stage. There are few data to support a survival advantage from adjuvant radiotherapy or chemotherapy following complete resection, in the absence of documented metastatic disease. Chemotherapy and radiotherapy have both been reported to improve survival when administered preoperatively in patients with oesophageal cancer, while current data using trimodal therapy show a trend towards increased treatment-related mortality with only a slight increase in overall survival. There is currently no completely reliable preoperative method for restaging patients following neoadjuvant chemoradiation in order to assess pathological complete response. Novel restaging techniques are therefore required, in addition to further study of the risks and benefits of neoadjuvant chemoradiotherapy for this disease.
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Affiliation(s)
- Mark J Krasna
- Saint Joseph Cancer Institute, St Joseph Medical Center, Towson, Maryland 21204, USA.
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20
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da Silveira EB, Artifon EL. Cost-effectiveness of palliation of unresectable esophageal cancer. Dig Dis Sci 2008; 53:3103-11. [PMID: 18523886 DOI: 10.1007/s10620-008-0302-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Accepted: 04/10/2008] [Indexed: 12/09/2022]
Abstract
INTRODUCTION Different modalities of palliation for obstructive symptoms in patients with unresectable esophageal cancer (EC) exist. However, these therapeutic alternatives have significant differences in costs and effectiveness. METHODS A Markov model was designed to compare the cost-effectiveness (CE) of self-expandable stent (SES), brachytherapy and laser in the palliation of unresectable EC. Patients were assigned to one of the strategies, and the improvement in swallowing function was compared given the treatment efficacy, probability of survival, and risks of complications associated to each strategy. Probabilities and parameters for distribution were based on a 9-month time frame. RESULTS Under the base-case scenario, laser has the lowest CE ratio, followed by brachytherapy at an incremental cost-effectiveness ratio (ICER) of $4,400.00, and SES is a dominated strategy. In the probabilistic analysis, laser is the strategy with the highest probability of cost-effectiveness for willingness to pay (WTP) values lower than $3,201 and brachytherapy for all WTP yielding a positive net health benefit (NHB) (threshold $4,440). The highest probability of cost-effectiveness for brachytherapy is 96%, and consequently, selection of suboptimal strategies can lead to opportunity losses for the US health system, ranging from US$ 4.32 to US$ 38.09 million dollars over the next 5-20 years. CONCLUSION Conditional to the WTP and current US Medicare costs, palliation of unresectable esophageal cancers with brachytherapy provides the largest amount of NHB and is the strategy with the highest probability of CE. However, some level of uncertainly remains, and wrong decisions will be made until further knowledge is acquired.
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Affiliation(s)
- Eduardo B da Silveira
- Division of Gastroenterology, Portland VA Medical Center, Oregon Health and Science University, 3710 SW US Veterans Hospital Road, P3GI, Portland, OR, 97239, USA.
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21
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Palliative endoscopic therapy for cancer patients with esophageal fistula. Chin J Cancer Res 2008. [DOI: 10.1007/s11670-008-0053-9] [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] Open
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Katsoulis IE, Karoon A, Mylvaganam S, Livingstone JI. Endoscopic palliation of malignant dysphagia: a challenging task in inoperable oesophageal cancer. World J Surg Oncol 2006; 4:38. [PMID: 16820062 PMCID: PMC1540418 DOI: 10.1186/1477-7819-4-38] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Accepted: 07/04/2006] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The main goal when managing patients with inoperable oesophageal cancer is to restore and maintain their oral nutrition. The aim of the present study was to assess the value of endoscopic palliation of dysphagia in patients with oesophageal cancer, who either due to advanced stage of the disease or co-morbidity are not suitable for surgery. PATIENTS AND METHODS All the endoscopic palliative procedures performed over a 5-year period in our unit were retrospectively reviewed. Dilatation and insertion of self-expandable metal stents (SEMS) were mainly used for tight circumferential strictures whilst ablation with Nd-YAG laser was used for exophytic lesions. All procedures were performed under sedation. RESULTS Overall 249 palliative procedures were performed in 59 men and 40 women, with a median age of 73 years (range 35-93). The median number of sessions per patient was 2 (range 1-13 sessions). Palliation involved laser ablation alone in 24%, stent insertion alone in 22% and dilatation alone in 13% of the patients. In 41% of the patients, a combination of the above palliative techniques was applied. A total of 45 SEMS were inserted. One third of the patients did not receive any other palliative treatment, whilst the rest received chemotherapy, radiotherapy or chemoradiotherapy. Swallowing was maintained in all patients up to death. Four oesophageal perforations were encountered; two were fatal whilst the other two were successfully treated with covered stent insertion and conservative treatment. The median survival from diagnosis was 10.5 months (range 0.5-83 months) and the median survival from 1st palliation was 5 months (range 0.5-68.5 months). CONCLUSION Endoscopic interventions are effective and relatively safe palliative modalities for patients with oesophageal cancer. It is possible to adequately palliate almost all cases of malignant dysphagia. This is achieved by expertise in combination treatment.
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Affiliation(s)
- IE Katsoulis
- Upper Gastrointestinal Surgery Unit, Watford General Hospital and Mount Vernon Centre for Cancer, Northwood, London, UK
| | - A Karoon
- Upper Gastrointestinal Surgery Unit, Watford General Hospital and Mount Vernon Centre for Cancer, Northwood, London, UK
| | - S Mylvaganam
- Upper Gastrointestinal Surgery Unit, Watford General Hospital and Mount Vernon Centre for Cancer, Northwood, London, UK
| | - JI Livingstone
- Upper Gastrointestinal Surgery Unit, Watford General Hospital and Mount Vernon Centre for Cancer, Northwood, London, UK
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Jin AQ, Huang XJ, Wang X, Fan H. Clinical application of self-expandable medical memorial metallic stent with iodine-125 seeds in treatment of esophageal carcinoma. Shijie Huaren Xiaohua Zazhi 2006; 14:814-818. [DOI: 10.11569/wcjd.v14.i8.814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the curative effect of self-expan-dable medical memorial metallic stent with iodine-125 seeds in the treatment of esophageal carcinoma at advanced stage.
METHODS: Forty-five patients with esophageal carcinoma at advanced stage were divided into group A and B. The patients in group A were treated with normal self-expandable stents, while those in group B received the stents with iodine-125 seeds. After the operation, the patients were followed up and their complications and survival time were analyzed.
RESULTS: The stents were successfully implanted in all the 45 patients. The patients were obviously relieved from their difficulties in swallowing. The survival time of patients in group A were 90-300 d, with an average of 171 ± 56 d, and those in group B were 120-450 d, with an average of 316 ± 116 d. There was significant difference between them (t = -3.385, P < 0.05).
CONCLUSION: Self-expandable stent with iodine-125 seeds can obviously alleviate the symptoms of difficulty in swallowing, improve the patients' life quality and survival time.
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Bergquist H, Wenger U, Johnsson E, Nyman J, Ejnell H, Hammerlid E, Lundell L, Ruth M. Stent insertion or endoluminal brachytherapy as palliation of patients with advanced cancer of the esophagus and gastroesophageal junction. Results of a randomized, controlled clinical trial. Dis Esophagus 2005; 18:131-9. [PMID: 16045572 DOI: 10.1111/j.1442-2050.2005.00467.x] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal cancer often presents as advanced stage disease with a dismal prognosis, with only 10-15% of patients surviving 5 years. Therefore, in a large proportion of patients, palliative treatment is the only option available. The aim of this study was to prospectively compare the palliative effect of self-expandable stent placement with that of endoluminal brachytherapy regarding the effect on quality of life and on specific symptoms. Sixty-five patients with advanced cancer of the esophagus or gastroesophageal junction were randomized to treatment with either an Ultraflex expandable stent or high-dose-rate endoluminal brachytherapy with 7 Gy x 3 given in 2-4 weeks. Clinical assessment and health-related quality of life (HRQL) were measured at inclusion and 1, 3, 6, 9 and 12 months later. The HRQL was measured with standardized questionnaires (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Oesophageal Module and Hospital Anxiety and Depression Scale). Twenty-eight patients completed the stent treatment and 24 patients the brachytherapy. The group of patients treated with stent reported significantly better HRQL scores for dysphagia (P < 0.05) at the 1-month follow-up, but most other HRQL scores, including functioning and symptom scales, deteriorated. Among brachytherapy-treated patients, improvement was found for the dysphagia-related scores at the 3-months follow-up, whereas other significant changes of scores were few. The median survival time was comparable in the two groups (around 120 days). In conclusion, insertion of self-expandable metal stents offered a more instant relief of dysphagia compared to endoluminal brachytherapy, but HRQL was more stable in the brachytherapy group.
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Affiliation(s)
- H Bergquist
- Department of Otorhinolaryngology, Sahlgrenska University Hospital, Göteborg, Sweden.
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Pazurek M, Malecka-Panas E. Photodynamic therapy in the palliative treatment of esophageal cancer. Photodiagnosis Photodyn Ther 2005; 2:73-7. [DOI: 10.1016/s1572-1000(05)00013-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2004] [Revised: 02/28/2005] [Accepted: 02/28/2005] [Indexed: 10/25/2022]
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Wai CT, Sutedja DS, Lee YM. Remember to Crush the Tablets After Esophageal Stent Insertion. Surg Laparosc Endosc Percutan Tech 2005; 15:22-3. [PMID: 15714151 DOI: 10.1097/01.sle.0000153735.55356.d8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The main mode of palliation for inoperable esophageal cancer is by insertion of expandable metallic stents. While major complications include occlusion by tumor ingrowth and migration, impaction by food has been reported in as many as 10% of cases. Although patients are routinely instructed to follow a soft and finely minced diet after insertion of esophageal stents, stent blockage can still occur if patients swallow large-sized tablets. We report a case of stent blockage by 2 large-sized tablets, about which the endoscopist did not forewarn the patient or his family. The tablets were eventually dislodged easily through a repeat endoscopy. We caution about the possibility of such complication after esophageal stenting. We recommend inspection of patients' medication before the stenting procedure as well as instructing patients, their family, and care providers to crush their large-sized tablets before consumption.
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Affiliation(s)
- Chun-Tao Wai
- Division of Gastroenterology, Department of Medicine, National University Hospital, Singapore 119074.
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Pungpapong S, Raimondo M, Wallace MB, Woodward TA. Problematic esophageal stricture: an emerging indication for self-expandable silicone stents. Gastrointest Endosc 2004; 60:842-5. [PMID: 15557974 DOI: 10.1016/s0016-5107(04)02035-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Surakit Pungpapong
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Jacksonville, Florida 32224, USA
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28
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Abstract
Primary and metastatic thoracic malignancies are often incurable. Surgeons caring for these patients must be familiar with the options,indications, techniques, and limitations of interventions for palliative treatments in these patients. This article is an overview of the current practices for palliation of a broad spectrum of complaints relating to patients with carcinomas of the lung, esophagus,and mesothelium. The information can be used for treatment of patients with complaints secondary to less common malignancies and metastatic disease of the thorax.
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Affiliation(s)
- Adam Berger
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
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29
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Litle VR, Luketich JD, Christie NA, Buenaventura PO, Alvelo-Rivera M, McCaughan JS, Nguyen NT, Fernando HC. Photodynamic therapy as palliation for esophageal cancer: experience in 215 patients. Ann Thorac Surg 2003; 76:1687-92; discussion 1692-3. [PMID: 14602313 DOI: 10.1016/s0003-4975(03)01299-2] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Photodynamic therapy (PDT) utilizes a photosensitizing agent, light, and oxygen to endoscopically ablate cancer cells. This review summarizes our experience with PDT for the palliation of bleeding or obstructing esophageal cancer (EC). METHODS All patients with bleeding or obstructing EC treated with PDT from November 1996 through June 2002, were reviewed. After Photofrin II injection, nonthermal light treatment was delivered endoscopically. Dysphagia scores, duration of palliation, reinterventions, complications, and survival after treatment were reviewed. RESULTS A total of 215 patients underwent 318 courses of PDT for bleeding (n = 15), obstruction (n = 277), bleeding and obstruction (n = 18), or other indications (n = 8). Tumor histology included 179 adenocarcinomas, 33 squamous cell carcinomas, and 3 undifferentiated. Seventy-five percent of EC were in the distal esophagus. In 85% of courses for obstruction, mean dysphagia scores improved pre- and post-PDT. The mean dysphagia-free interval was 66 days. Supplemental nutrition was discontinued after PDT in 8 of 27 patients (30%). Thirty-five patients required stent placement after PDT with a mean interval to reintervention of 58.5 days. PDT complications included perforation (2% of treatment courses), stricture (2%), Candida esophagitis (2%), pleural effusions (4%), and sunburn (6%). The procedure-related mortality rate was 1.8%, and median survival was 4.8 months. CONCLUSIONS PDT offers effective palliation for patients with obstructing EC in 85% of treatment courses. The ideal EC patient for PDT palliation has an obstructing endoluminal cancer. Patients living more than 2 months may require reintervention to maintain palliation of malignant dysphagia, and a multimodality treatment approach is common.
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Affiliation(s)
- Virginia R Litle
- Division of Thoracic and Foregut Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Zhang PB, Zhao XY, Li YH, Da SP. Self-expandable metal stents for dysphagia in 26 patients with advanced esophageal cancer. Shijie Huaren Xiaohua Zazhi 2003; 11:1528-1530. [DOI: 10.11569/wcjd.v11.i10.1528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the therapeutic effect of self-expandable metal stents for dysphagia in 26 patients with advanced esophageal cancer.
METHODS Twenty-six patients with inoperable esophageal cancer had dysphagia and were treated with self-expandable stents. After esophageal dilation, a covered self-expandable metal stent was inserted and released on the site of stenosis.
RESULTS The stent was placed successfully in all of the 26 patients. Immediate relief of dysphagia was observed, the dysphagia score decreased from 3.08 to 1.38 (P<0.01).The main complications of this procedure were chest pain, gastroesophageal reflux and obstruction of the stent.
CONCLUSION Self-expandable mental stent is a safe and effective method to palliate the dysphagia in inoperable esophageal cancer.
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Affiliation(s)
- Peng-Bin Zhang
- Department of Gastroenterology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Xiao-Yan Zhao
- Department of Gastroenterology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Yi-Hui Li
- Department of Gastroenterology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Si-Ping Da
- Department of Gastroenterology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
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Abstract
In the absence of medical contraindications to surgery, resection is the mainstay of treatment for localised oesophageal cancer. Advancements in preoperative staging and imaging, anaesthesia delivery, surgical technique, and postoperative care, now enable the surgeon to safely operate on patients with oesophageal tumours and to tailor the procedure on the basis of performance status, tumour location, and extent of disease. During the past 10 years, several "minimally invasive" techniques, which aim to limit the extent of resection, have been introduced; these procedures are currently being investigated for use in both staging and treatment of oesophageal malignant diseases. Despite these accomplishments however, overall 5-year survival remains disappointing: less than 25% of patients live for 5 years after oesophagectomy. For patients with locally or regionally advanced disease (stage IIa, IIb, III, and IVa), combining several treatment approaches, either with or without surgery, can result in good objective responses and, in some patients, durable survival. The role of surgery in such combined modality approaches is still evolving and some investigators have challenged its worth. To provide a definitive review of the issues involved, we outline the types of surgery used to treat cancer of the oesophagus and summarise the available data about their effectiveness. Clinical outcomes, the value of preoperative chemoradiotherapy, and the use of surgery are all considered.
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Affiliation(s)
- Peter C Wu
- Department of Surgery, University of Chicago, IL 60637, USA
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