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Brisson-McKenna M, Jefferson GD, Siddiqui SH, Adams S, Afanasieva Sonia S, Chérid A, Burns J, Di Gironimo C, Mady LJ. Swallowing Function After Treatment of Laryngeal Cancer. Otolaryngol Clin North Am 2023; 56:371-388. [PMID: 37030949 DOI: 10.1016/j.otc.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Dysphagia is a common functional outcome following treatment of laryngeal cancer. Despite curative advances in both nonsurgical and surgical approaches, preserving and optimizing swallowing function is critical. Understanding the nature and severity of dysphagia depending on initial tumor staging and treatment modality and intensity is crucial. This chapter explores current evidence on the acute and chronic impacts of treatments for laryngeal cancer on swallow function, as well as the medical and nonmedical management of dysphagia in this population.
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Affiliation(s)
- Maude Brisson-McKenna
- Department of Speech-Language Pathology, McGill University Health Centre, Glen site, D04.7510-1001 boul. Décarie, Montréal, QC, H4A 3J1, Canada.
| | - Gina D Jefferson
- Department of Otolaryngology-Head and Neck Surgery, University of Mississippi Medical Center, 2500 N. State St.Jackson, MS 39216-4505, USA
| | - Sana H Siddiqui
- Head & Neck Surgery, Thomas Jefferson University Hospitals, 925 Chestnut Street, 6th Floor, Philadelphia, PA 19107, USA
| | - Sarah Adams
- Voice and Swallowing Center, Thomas Jefferson University Hospitals, 925 Chestnut Street, 6th Floor, Philadelphia, PA 19107, USA
| | - Sofia Afanasieva Sonia
- Department of Speech-Language Pathology, McGill University Health Centre, Glen site, D04.7510-1001 boul. Décarie, Montréal, QC, H4A 3J1, Canada
| | - Aïda Chérid
- Department of Speech-Language Pathology, McGill University Health Centre, Glen site, D04.7510-1001 boul. Décarie, Montréal, QC, H4A 3J1, Canada
| | - Jesse Burns
- Department of Speech-Language Pathology, McGill University Health Centre, Glen site, D04.7510-1001 boul. Décarie, Montréal, QC, H4A 3J1, Canada
| | - Carla Di Gironimo
- Department of Speech-Language Pathology, McGill University Health Centre, Glen site, D04.7510-1001 boul. Décarie, Montréal, QC, H4A 3J1, Canada
| | - Leila J Mady
- Head & Neck Surgery, Thomas Jefferson University Hospitals, 925 Chestnut Street, 6th Floor, Philadelphia, PA 19107, USA; Cancer Risk and Control Program of Excellence, Sidney Kimmel Cancer Center, 233 S 10th Street, Philadelphia, PA 19107, USA
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Therapeutic strategies, oncologic and swallowing outcomes and their predictive factors in patients with locally advanced hypopharyngeal cancer. Eur Arch Otorhinolaryngol 2022; 279:3629-3637. [DOI: 10.1007/s00405-021-07196-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/20/2021] [Indexed: 12/17/2022]
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El-Asmar KM, Youssef AA. Retrograde endoscopic dilatation for difficult caustic esophageal strictures: Feasibility and effectiveness. J Pediatr Surg 2019; 54:1953-1957. [PMID: 30773393 DOI: 10.1016/j.jpedsurg.2018.12.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 11/20/2018] [Accepted: 12/08/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Difficult caustic esophageal strictures may need a more sophisticated dilatation technique before referring for esophageal replacement surgery. PATIENTS & METHOD Retrospective review of caustic esophageal strictures managed at our center between January 2010 and June 2018 was done. Twenty two patients labeled as undilatable strictures were enrolled. These patients had another trial for endoscopic dilatation using retrograde approach. RESULTS Among these 22 patients, 5 patients could be dilated by antegrade approach. Seventeen patients had a trial of retrograde dilatation after failed antegrade endoscopy. Retrograde dilatation was successful in 14 patients (82%). Nasogastric tube was left following dilatation in 4 patients to facilitate next sessions. Collectively, 19 out of the 22 patients could have their esophagus dilated in the first instance (86%). Among retrograde dilated patients; eight patients succeeded to retain their native esophagus (57%), two patients are still on dilatation with marked improvement (14%), and three patients underwent colon interposition owing to refractory stricture despite frequent dilatations. CONCLUSION Every attempt should be tried to preserve the native esophagus. Retrograde endoscopic dilatation is a valuable alternative for undilatable stricture before referring the patient for replacement surgery. LEVEL OF EVIDENCE This is a case series with no comparison group (level IV).
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Abu-Ghanem S, Sung CK, Junlapan A, Kearney A, DiRenzo E, Dewan K, Damrose EJ. Endoscopic Management of Postradiation Dysphagia in Head and Neck Cancer Patients: A Systematic Review. Ann Otol Rhinol Laryngol 2019; 128:767-773. [PMID: 30895823 DOI: 10.1177/0003489419837565] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To systematically review the success rate and safety profile of the available endoscopic surgical options for radiation-induced dysphagia in head and neck cancer patients following organ preservation treatment, including upper esophageal sphincter (UES) dilation, cricopharyngeus (CP) myotomy (CPM), and CP intramuscular botulinum toxin (Botox) injection. METHODS A search of MEDLINE, Scopus, Google Scholar, and Cochrane databases was done to identify articles published between January 1980 and December 2017. Pediatric series, foreign language articles, series with Zenker's diverticulum or following primary surgical treatment including laryngectomy, open UES/CP surgery, or samples with fewer than 5 patients were excluded. RESULTS An initial search identified 539 articles. All titles and abstracts were reviewed. One hundred and sixteen potentially relevant articles were inspected in more detail, and 14 retrospective studies met eligibility criteria. Dilation group included 10 studies on anterograde and/or retrograde dilation, with an overall 208 patients. Success rate ranged from 42% to 100%. The endoscopic CPM group included 3 studies with a total of 36 patients, and the success rate ranged from 27% to 90%. In the Botox group, 1 one study with 20 patients met our inclusion criteria, with an overall 65% success rate (13/20). Major complications were only reported in the dilation group, which included esophageal perforation and death. CONCLUSIONS The lack of consistency across trials indicates insufficient evidence for guiding clinical practice. This systematic review suggests the need for greater standardization of outcomes and instruments. Future prospective evaluation should use validated patient-rated and clinician-rated assessment tools to optimally measure postoperative swallowing outcomes of head and neck cancer dysphagic patients following organ preservation therapy.
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Affiliation(s)
- Sara Abu-Ghanem
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University-School of Medicine, Stanford, CA, USA
| | - Chin-Kwang Sung
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University-School of Medicine, Stanford, CA, USA
| | - Attapon Junlapan
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University-School of Medicine, Stanford, CA, USA
| | - Ann Kearney
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University-School of Medicine, Stanford, CA, USA
| | - Elizabeth DiRenzo
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University-School of Medicine, Stanford, CA, USA
| | - Karuna Dewan
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University-School of Medicine, Stanford, CA, USA
| | - Edward J Damrose
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University-School of Medicine, Stanford, CA, USA
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Total Pharyngo-esophageal Stenosis: A New Surgical Procedure Using Modified Retrograde Transillumination Approach. Surg Laparosc Endosc Percutan Tech 2018; 28:e75-e77. [PMID: 29746423 DOI: 10.1097/sle.0000000000000540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We performed a modified combined anterograde-retrograde dilatation in a 60-year-old woman with complete pharyngo-esophageal stricture (PES). With a large endoscopic view from the upper (laryngoscope) and lower (pediatric gastroscope introduced via gastrostomy tube) parts of the PES, the approach consisted of a retrograde puncture of the complete PES by transillumination to take the guide coming from the pediatric endoscope. The guide was pulled through the mouth and the PES dilatation was made using successive boogies of various diameters through the guide. Finally, a salivary bypass was placed to maintain the diameter of the pharyngo-esophageal way. The surgical approach was performed in 25 minutes without short, medium, and long-term complications. The patient started oral alimentation the day after the surgery, and the salivary bypass was removed after 6 months. The subject had no recurrence of the PES at 5 years.
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Jamal N, Ebersole B, Erman A, Chhetri D. Maximizing Functional Outcomes in Head and Neck Cancer Survivors. Otolaryngol Clin North Am 2017; 50:837-852. [DOI: 10.1016/j.otc.2017.04.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Moss WJ, Pang J, Orosco RK, Weissbrod PA, Brumund KT, Weisman RA, Brigger MT, Coffey CS. Esophageal dilation in head and neck cancer patients: A systematic review and meta-analysis. Laryngoscope 2017; 128:111-117. [DOI: 10.1002/lary.26618] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2017] [Indexed: 12/24/2022]
Affiliation(s)
- William J. Moss
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, University of California; San Diego California U.S.A
| | - John Pang
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, University of California; San Diego California U.S.A
| | - Ryan K. Orosco
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, University of California; San Diego California U.S.A
| | - Philip A. Weissbrod
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, University of California; San Diego California U.S.A
| | - Kevin T. Brumund
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, University of California; San Diego California U.S.A
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, VA San Diego Healthcare; La Jolla California U.S.A
| | - Robert A. Weisman
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, University of California; San Diego California U.S.A
| | - Matthew T. Brigger
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, University of California; San Diego California U.S.A
- Department of Otolaryngology-Head & Neck Surgery; Naval Medical Center San Diego; San Diego California U.S.A
| | - Charles S. Coffey
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, University of California; San Diego California U.S.A
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, VA San Diego Healthcare; La Jolla California U.S.A
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Raykher A, Russo L, Schattner M, Schwartz L, Scott B, Shike M. Enteral Nutrition Support of Head and Neck Cancer Patients. Nutr Clin Pract 2017; 22:68-73. [PMID: 17242458 DOI: 10.1177/011542650702200168] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Patients with head and neck cancer are at high risk for malnutrition due to dysphagia from the tumor and treatment. Despite difficulty with oral intake, these patients usually have a normal stomach and lower gastrointestinal tract. Enteral nutrition support via percutaneous endoscopic gastrostomy (PEG) administered in the home by the patient helps to prevent weight loss, dehydration, nutrient deficiencies, treatment interruptions, and hospitalizations. It also improves quality of life. Successful management of these patients requires orderly care and follow-up by a multidisciplinary nutrition team.
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Affiliation(s)
- Aleksandra Raykher
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Goguen LA, Posner MR, Norris CM, Tishler RB, Wirth LJ, Annino DJ, Gagne A, Sullivan CA, Sammartino DE, Haddad RI. Dysphagia after Sequential Chemoradiation Therapy for Advanced Head and Neck Cancer. Otolaryngol Head Neck Surg 2016; 134:916-22. [PMID: 16730530 DOI: 10.1016/j.otohns.2006.02.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2005] [Accepted: 02/01/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES: Assess impact of sequential chemoradiation therapy (SCRT) for advanced head and neck cancer (HNCA) on swallowing, nutrition, and quality of life. STUDY DESIGN: Prospective cohort study of 59 patients undergoing SCRT for advanced head and neck cancer. Follow-up median was 47.5 months. SETTING: Regional Cancer Center. RESULTS: Median time to gastrostomy tube removal was 21 weeks. Eighteen of 23 patients who underwent modified barium swallow demonstrated aspiration; none developed pneumonia. Six of 7 with pharyngoesophageal stricture underwent successful dilatation. Functional Assessment of Cancer Therapy—Head and Neck Scale questionnaires at median 6 months after treatment revealed “somewhat” satisfaction with swallowing. At the time of analysis, 97% have the gastronomy tube removed and take soft/regular diet. CONCLUSION: Early after treatment dysphagia adversely affected weight, modified barium swallow results, and quality of life. Diligent swallow therapy, and dilation as needed, allowed nearly all patients to have their gastronomy tubes removed and return to a soft/regular diet. SIGNIFICANCE: Dysphagia is significant after SCRT but generally slowly recovers 6 to 12 months after SCRT.
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Affiliation(s)
- Laura A Goguen
- Department of Surgery/Division of Otolaryngology, at the Brigham and Women's Hospital and the Dana Farber Cancer Institute, Boston, MA 02115, USA.
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Pauloski BR, Rademaker AW, Logemann JA, Discekici-Harris M, Mittal BB. Comparison of swallowing function after intensity-modulated radiation therapy and conventional radiotherapy for head and neck cancer. Head Neck 2015; 37:1575-82. [PMID: 24909649 PMCID: PMC4258519 DOI: 10.1002/hed.23796] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 03/18/2014] [Accepted: 06/04/2014] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Intensity-modulated radiotherapy (IMRT) is hoped to protect structures important for swallow function. We compared posttreatment swallow function in 7 pairs of patients with head and neck cancer treated with either IMRT or conventional radiotherapy (RT). METHODS Patients were matched on tumor characteristics. Swallowing function was evaluated with the modified barium swallow procedure pretreatment and at 3 and 6 months postcancer treatment completion. Swallows were analyzed for bolus transit times, bolus residues, laryngeal closure (LAC) duration, cricopharyngeal opening (CPO) duration, and oropharyngeal swallow efficiency (OPSE). Data were analyzed using multifactor repeated measures analysis of variance and adjusted for baseline function. RESULTS Main effect of radiation type was significant for all measures on at least 1 bolus type. Patients treated with IMRT demonstrated shorter bolus transit times, less oral and pharyngeal residue, longer LAC, and larger OPSE. CONCLUSION Patients treated with IMRT demonstrated faster, more efficient swallows, and greater airway protection.
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Affiliation(s)
- Barbara Roa Pauloski
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, Illinois
| | - Alfred W Rademaker
- Department of Preventive Medicine, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jerilyn A Logemann
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, Illinois
| | | | - Bharat B Mittal
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Successful Use of Esophageal Stent Placement to Treat a Postoperative Esophageal Stricture in a Toddler. ACG Case Rep J 2014; 2:61-3. [PMID: 26157909 PMCID: PMC4435343 DOI: 10.14309/crj.2014.86] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 08/29/2014] [Indexed: 11/17/2022] Open
Abstract
Esophageal atresia (EA) is the most common type of gastrointestinal atresia. The most common variant (type C) consists of a blind esophageal pouch with a fistula between the trachea and the distal esophagus. Surgical repair can be complicated by the development of benign stricture. Most strictures are amenable to dilation, but refractory strictures may require surgical intervention. A 24-month-old boy born with tracheoesophageal fistula and EA underwent surgical repair on day 1 of life. He developed esophageal stricture that responded to esophageal stent placement. Endoscopic biliary accessories can be safely used to dilate refractory esophageal strictures in children, and should be considered prior to seeking other complex alternatives.
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Peng KA, Feinstein AJ, Salinas JB, Chhetri DK. Utility of the transnasal esophagoscope in the management of chemoradiation-induced esophageal stenosis. Ann Otol Rhinol Laryngol 2014; 124:221-6. [PMID: 25228669 DOI: 10.1177/0003489414550858] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE This study aimed to describe management of esophageal stenosis after chemoradiation therapy for head and neck squamous cell carcinoma (HNSCC), with particular emphasis on techniques and outcomes with the use of the transnasal esophagoscope (TNE) in the office as well as operating room settings. METHODS Retrospective analysis of all patients with esophageal stenosis following head and neck cancer radiation, with or without chemotherapy, and managed with TNE-assisted esophageal dilation over a 5-year period. Preoperative and postoperative swallowing function were assessed objectively with the Functional Outcome Swallowing Scale (FOSS; ranging from score 0, a normal diet, to score 5, complete dependence on nonoral nutrition). RESULTS Twenty-five patients met inclusion criteria. The mean pretreatment FOSS score was 4.4, whereas the mean posttreatment FOSS score was 2.7 (Wilcoxon signed-rank test, P<.001). Prior to dilation, 16 patients were completely gastrostomy-tube dependent (FOSS 5), of whom 12 (75%) were able to tolerate oral nutrition for a majority of their diet following treatment according to our protocol. No complications were noted. CONCLUSION Dysphagia following chemoradiation therapy for HNSCC is often related to esophageal stenosis. With the aid of TNE, we have developed a successful treatment strategy for esophageal stenosis with improved success rates.
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Affiliation(s)
- Kevin A Peng
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Aaron J Feinstein
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jonathan B Salinas
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Dinesh K Chhetri
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Shah AT, Wein RO. Management of a postradiation esophageal web in the setting of a coexisting Zenker's diverticulum. Ann Otol Rhinol Laryngol 2014; 122:775-8. [PMID: 24592581 DOI: 10.1177/000348941312201208] [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: 11/15/2022]
Abstract
We present a case of postradiation obstructive esophageal web, seen in the setting of a coexisting Zenker's diverticulum, that was treated with combined anterograde and retrograde esophagoscopy puncture and dilation. We also review the relevant literature. Obstructing esophageal webs and stenoses are well-documented complications seen in patients with head and neck cancer treated with radiation therapy. For thin webs, combined anterograde and retrograde esophagoscopy along with puncture and dilation can be a relatively safe treatment option for selected patients. The presence of a coexisting Zenker's diverticulum may predispose the patient to the development of postradiation esophageal complications and make subsequent assessment more difficult to perform.
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Affiliation(s)
- Ameer T Shah
- Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Richard O Wein
- Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, USA
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Abstract
Pharyngo-oesophageal stricture (PES) is a serious complication that occurs in up to a third of patients treated with external beam radiotherapy or combined chemoradiotherapy for head and neck cancer. This entity is under-reported and as a result, our understanding of the pathophysiology and prevention of this complication is restricted. This Review presents the knowledge so far on radiation-related and non-radiation-related risk factors for PES, including tumour stage and subsite, patient age, and comorbidities. The interventions to decrease this toxicity are discussed, including early detection of PES, initiation of an oral diet, and protection of swallowing structures from high-dose radiation. We discuss various treatment options, including swallowing exercises and manoeuvres, endoscopic dilatations, and for advanced cases, oesophageal reconstruction. Study of the subset of patients who develop this toxicity and early recognition and intervention of this pathological change in future trials will help to optimise treatment of these patients.
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Chapuy CI, Annino DJ, Tishler RB, Haddad RI, Snavely A, Goguen LA. Success of endoscopic pharyngoesophageal dilation after head and neck cancer treatment. Laryngoscope 2013; 123:3066-73. [PMID: 23775806 DOI: 10.1002/lary.24268] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 05/02/2013] [Accepted: 05/30/2013] [Indexed: 12/24/2022]
Abstract
OBJECTIVES/HYPOTHESIS To assess clinical success and safety of endoscopic pharyngoesophageal dilation after chemoradiation or radiation for head and neck cancer and to identify variables associated with dilation failure. STUDY DESIGN Case series with chart review. METHODS Between 2000 and 2008, a total of 111 patients treated with chemoradiation or radiation for head and neck cancer with subsequent pharyngoesophageal stenosis requiring endoscopic dilation were identified. Patients were evaluated for endoscopic dilation technique, severity of stenosis, technical and clinical success, and intra- and postoperative complications. The Diet/GT score (range, 1-5) was utilized to measure swallow success. Variables associated with dilation failure were analyzed by univariate and multivariate logistic regression. RESULTS There were 271 dilations analyzed, with 42 combined antegrade retrograde dilations, 208 dilations over a guidewire, and 21 dilations without guidewire. Intraoperative patency and successful dilation of the stenotic segment was achieved in 95% of patients. A Diet/GT score of 5 (gastrostomy tube removed and soft/regular diet) was attained in 84 of 111 (76%) patients. Safety analysis showed complications occurred in 9% of all dilations. Perforations were noted in 4% of all procedures, with only two esophageal perforations requiring significant intervention. Multiple dilations were associated with an increased risk for perforations. Further logistic regression analyses revealed that the number of dilations was indicating a poor outcome and low Diet/GT score. CONCLUSIONS Pharyngoesophageal stenosis, occurring after chemoradiation and radiation treatment, can be successfully and safely treated with endoscopic dilation techniques. Patients with restenosis, requiring multiple dilations, have a higher risk of persistent dysphagia.
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Affiliation(s)
- Claudia I Chapuy
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Hypopharyngeal presentation of cicatricial pemphigoid: videofluorographic and direct laryngoscopic findings. The Journal of Laryngology & Otology 2013; 127:429-31. [DOI: 10.1017/s0022215113000212] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:Cicatricial pemphigoid can affect all mucosa of the upper aerodigestive tract; however, hypopharyngeal involvement is less frequent.Case report:This paper presents a 69-year-old male diagnosed as having cicatricial pemphigoid who was experiencing difficulty swallowing. Videofluorography with barium swallow demonstrated narrow flow through the medial hypopharynx, but not through the lateral hypopharynx. Direct laryngoscopy revealed that the postcricoid hypopharyngeal lumen had become narrow due to circumferential scar formation. Interestingly, detached thin membranous webs were observed beyond the circumferential scar.Conclusion:This report describes important videofluorographic and direct laryngoscopic findings showing rare hypopharyngeal involvement in a case of cicatricial pemphigoid.
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Boyce HW, Estores DS, Gaziano J, Padhya T, Runk J. Endoscopic lumen restoration for obstructive aphagia: outcomes of a 25-year experience. Gastrointest Endosc 2012; 76:25-31. [PMID: 22482914 DOI: 10.1016/j.gie.2012.02.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 02/20/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND After chemoradiation therapy for head/neck cancer, some patients develop strictures that progress to complete pharyngoesophageal occlusion. Total lumen occlusion is less often due to other conditions. Enteral access (enterostomy tube) and good nutritional status tend to minimize the significance of dysphagia and therefore may mask recognition of impending complete lumen occlusion. OBJECTIVE Review outcomes of a 25-year experience with endoscopic lumen restoration (ELR) in 30 patients. DESIGN Retrospective, case review study. SETTING Two tertiary-care referral centers. PATIENTS This study involved 30 consecutive patients referred for obstructive aphagia due to complete lumen occlusion, primarily after chemoradiation therapy for head/neck cancer. INTERVENTION Antegrade and retrograde endoscopy with tri-plane fluoroscopy for penetrating the occluded segment, serial retrograde and antegrade dilations, plus swallowing rehabilitation therapy. MAIN OUTCOME MEASUREMENTS Restoration of lumen patency, swallowing function, and removal of enteral feeding tube. RESULTS ELR was successful in 30 patients in 31 of 33 attempts (93%). Return to soft to regular diet was achieved in 15 of 30 patients (50%), and fluids to pureed food with partial percutaneous endoscopic gastrostomy nutrition was achieved in 5 of 30 patients (17%). Ten of 30 patients (33%) were considered unsafe for oral feeding because of oropharyngeal neuromotor deficits. Complications occurred in 5 of 30 patients (17%), with no prolonged sequelae, deaths, or surgery, but two stents were placed for anastomotic fistulas. The median duration of follow-up was 22.75 months. LIMITATIONS Retrospective, case review study. CONCLUSION ELR by using tri-plane fluoroscopic guidance with antegrade and retrograde endoscopy and serial dilations allows lumen restoration and swallowing to some degree in a majority of patients. Engagement of a core team of specialists can provide optimal restoration of swallowing function.
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Affiliation(s)
- H Worth Boyce
- Joy McCann Culverhouse Center for Swallowing Disorders, Department of Internal Medicine, University of South Florida College of Medicine, Tampa, Florida 33612, USA
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Grossman EB, Schattner MA, Dimaio CJ, Gerdes H, Wong DW, Markowitz AJ. Endoscopic management of complete colonic obstruction. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 1:179-181. [PMID: 22586533 DOI: 10.4161/jig.1.4.19969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Accepted: 12/16/2011] [Indexed: 12/19/2022]
Abstract
A patient with metastatic rectal cancer underwent a diverting transverse loop colostomy due to rectal obstruction. 16 months later, he underwent a low anterior resection to resect his rectal cancer along with reversal of his transverse colostomy, and creation of a temporary loop ileostomy. Six months later, he was brought to the operating room for closure of his ileostomy. Post-operatively, the patient developed nausea, vomiting, and abdominal distention and imaging revealed a large bowel obstruction, confirmed by colonoscopy. The patient refused surgical diversion and a cecostomy tube was placed for decompression. After maturation of the cecostomy fistula, a rendezvous colonoscopy was performed, retrograde through the rectum and antegrade through the cecostomy fistula. The obstructing mucosa was traversed and the site of obstruction was balloon dilated, relieving the obstruction endoscopically.
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Affiliation(s)
- Evan B Grossman
- Division of Gastroenterology and Hepatology, Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA
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Tuna Y, Koçak E, Dinçer D, Köklü S. Factors affecting the success of endoscopic bougia dilatation of radiation-induced esophageal stricture. Dig Dis Sci 2012; 57:424-8. [PMID: 21879280 DOI: 10.1007/s10620-011-1875-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2011] [Accepted: 08/12/2011] [Indexed: 12/09/2022]
Abstract
AIMS The purpose of this retrospective study was to assess clinical outcomes of endoscopic bougie dilation of esophageal strictures after radiation therapy for head and neck cancer, and to assess the risk factors which affect the treatment success. METHODS Thirty-one patients with esophageal stricture due to radiation therapy were treated with endoscopic bougie dilation. The following parameters were evaluated; age, gender, primary site of the tumor, initial treatment of the tumor, prescribed dose of radiation, the time to onset of esophageal stricture after radiation therapy, grade of esophageal stricture according to clinical and endoscopic findings, number of dilatations, recurrence of esophageal stricture, and the result of the therapy. RESULTS The average follow-up was 26 months with a range of 1-84 months. Successful endoscopic bougie dilation was achieved in 26 of 31 patients. The median time to onset of esophageal stricture after radiation therapy was significantly shorter in patients who did not respond to endoscopic bougie dilation. CONCLUSION Endoscopic bougie dilation is a safe and effective procedure for the management of radiation-induced esophageal stricture. Time to onset of esophageal stricture is the most important factor for the treatment success. In addition, the total prescribed dosage of radiation has minimal effects on the result of endoscopic bougie dilation.
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Affiliation(s)
- Yaşar Tuna
- Department of Gastroenterology, Akdeniz University Medical School of Medicine, Antalya, Turkey
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Wilkie MD, Hathorn IF, Evans AS. Total neopharyngeal stenosis following pharyngolaryngo-oesophagectomy with gastric interposition: Successful recanalisation using a transcervical radiologically guided technique. Int J Surg Case Rep 2011; 2:297-300. [PMID: 22096759 DOI: 10.1016/j.ijscr.2011.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 10/03/2011] [Accepted: 10/04/2011] [Indexed: 10/16/2022] Open
Abstract
INTRODUCTION Pharyngo-oesophageal stricturing is common following treatment of head and neck cancers. Absolute dysphagia secondary to total stenosis, although rare, is particularly debilitating and presents a significant therapeutic challenge. We present a strategy for managing total neopharyngeal stenosis following pharyngolaryngo-oesophagectomy (PLOG). PRESENTATION OF CASE A 71-year-old female developed total neopharyngeal stenosis following PLOG with gastric interposition for squamous cell carcinoma of the proximal cervical oesophagus/post-cricoid. A transcervical, percutaneous, radiologically guided procedure was performed to restore lumenal patency, which enabled resumption of oral feeding. DISCUSSION Established treatments for pharyngo-oesophageal strictures are frequently limited by complications in patients with complex strictures or total stenoses. Whilst several interventions have been described, recent interest has focussed on combined antegrade/retrograde endoscopic procedures dilating a pre-existing gastrostomy site for access. This was not possible in our patient due to the surgically altered anatomy which posed a unique therapeutic challenge. CONCLUSION This is the first reported percutaneous, transcervical, radiologically guided technique to treat neopharyngeal stenosis following PLOG. It demonstrates a novel and efficacious approach which may be considered in the management of this rare but significant complication.
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Affiliation(s)
- Mark D Wilkie
- Department of Otorhinolaryngology and Head and Neck Surgery, St. John's Hospital, Howden Road West, Livingston, West Lothian EH54 6PP, UK
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Urken ML, Jacobson AS, Lazarus CL. Comprehensive approach to restoration of function in patients with radiation-induced pharyngoesophageal stenosis: Report of 31 patients and proposal of new classification scheme. Head Neck 2011; 34:1317-28. [DOI: 10.1002/hed.21927] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2011] [Indexed: 01/13/2023] Open
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Fowlkes J, Zald PB, Andersen P. Management of complete esophageal stricture after treatment of head and neck cancer using combined anterograde retrograde esophageal dilation. Head Neck 2011; 34:821-5. [PMID: 22127917 DOI: 10.1002/hed.21826] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 03/29/2011] [Accepted: 04/05/2011] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Complete esophageal stricture is a difficult problem to manage. There is limited literature to support clinical decision-making. To evaluate outcomes and efficacy, we performed a retrospective medical chart review of patients who received combined anterograde retrograde esophageal dilation (CARD) between 2002 and 2009 at our institution. METHODS Fifteen patients were identified who developed a stricture requiring CARD after treatment for head and neck cancers. Outcomes were pretreatment and posttreatment diet, gastrostomy tube status, and operative complications. RESULTS Six of 15 patients were gastrostomy tube-free at last follow-up and 11 of 15 patients were taking oral nutrition. There were 4 complications. One patient died. Two gastrostomy tube site complications occurred. One patient sustained a dental injury. CONCLUSION CARD offers benefit to most patients. Despite risks associated with the procedure, CARD should be considered by the clinician and patient in management of complete esophageal stricture.
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Affiliation(s)
- Jonathan Fowlkes
- Department of Otolaryngology, Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
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Zald PB, Andersen PE. Fatal central venous air embolism: a rare complication of esophageal dilation by rendezvous. Head Neck 2011; 33:441-4. [PMID: 19953633 DOI: 10.1002/hed.21304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Esophageal dilation by rendezvous is a useful technique for the treatment of complicated esophageal strictures. METHODS AND RESULTS We present a case of a 74-year-old man with chronic dysphagia caused by a complete cervical esophageal stricture that developed after external beam radiotherapy for treatment of papillary thyroid carcinoma. During attempted dilation using the rendezvous technique, the patient suffered a fatal pulmonary air embolism. The technique of esophageal dilation by rendezvous, complications, and risk factors for development of venous air embolism are discussed. CONCLUSION To the best of our knowledge, this is the first report in the literature of fatal venous air embolism after dilation by rendezvous.
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Affiliation(s)
- Philip B Zald
- Department of Otolaryngology Head and Neck Surgery, Oregon Health and Sciences University, Portland, OR 97239, USA
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Goguen LA, Norris CM, Jaklitsch MT, Sullivan CA, Posner MR, Haddad RI, Tishler RB, Burke E, Annino DJ. Combined antegrade and retrograde esophageal dilation for head and neck cancer-related complete esophageal stenosis. Laryngoscope 2010; 120:261-6. [PMID: 19998421 DOI: 10.1002/lary.20727] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES/HYPOTHESIS Assess the safety and efficacy of combined antegrade and retrograde esophageal dilation (CARD) for complete esophageal stenosis following head and neck cancer (HNC) treatment. Review HNC dysphagia management. STUDY DESIGN Retrospective review of all patients undergoing CARD following HNC treatment between May 2001 and September 2008. METHODS Forty-five patients were identified for review. Parameters assessed included: ability to obtain intraoperative esophageal patency, complications, number of dilations required, diet, and gastric tube (GT) status. Factors associated with dilation failure were analyzed. RESULTS Intraoperative esophageal patency was obtained in 91% of patients. Median number of all dilations per patient was three. Median number of CARDs per patient was one. Resumption of oral intake occurred in 36/45 (80%). Diet results included: regular or soft diet 32/45 (71%), GT removal 27/45 (60%), and GT dependence with nothing by mouth 9/45 (20%). Laryngeal and pharyngeal stenosis, radionecrosis, tracheotomy dependence, and elongated stenosis were associated with dilation failure. Complications occurred in 18/63 (29%) CARD procedures: eight pneumomediastinum, seven GT site problems, two esophageal perforations, and one pharyngeal infection. All complications resolved spontaneously or with minimal interventions. CONCLUSIONS CARD was safe and effective. Intraoperative patency was achieved in 91% of patients. Eighty percent resumed oral intake. The majority of patients had their GTs removed and resumed a soft or regular diet. Dilation failure was associated with laryngeal, pharyngeal, and excessively long esophageal stenosis, often resulting from radionecrosis. Complications were minor. CARD should be considered before relegating patients with complete esophageal stenosis to chronic GT dependence or subjecting them to laryngopharyngo esophagectomy.
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Affiliation(s)
- Laura A Goguen
- Department of Surgery/Division of Otolaryngology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts 02115, USA.
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Abstract
Patients who have cancers of the oral cavity, pharynx, or larynx may be treated with surgery, radiotherapy, chemotherapy, or a combination of these modalities. Each treatment type may have a negative impact on posttreatment swallowing function; these effects are presented in this article. A number of rehabilitative procedures are available to the clinician to reduce or eliminate swallowing disorders in patients treated for cancer of the head and neck. The various procedures-including postures, maneuvers, modifications to bolus volume and viscosity, range-of-motion exercises, and strengthening exercises-and their efficacy in patients treated for head and neck cancer are discussed.
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Affiliation(s)
- Barbara R Pauloski
- Communication Sciences and Disorders, Northwestern University, 2240 Campus Drive, Suite 3-331, Evanston, IL 60208-3540, USA.
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Hasan M, Maple JT. Traversing Difficult Esophageal Strictures from the Retrograde Approach. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2008. [DOI: 10.1016/j.tgie.2008.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Ahlawat SK, Al-Kawas FH. Endoscopic management of upper esophageal strictures after treatment of head and neck malignancy. Gastrointest Endosc 2008; 68:19-24. [PMID: 18355822 DOI: 10.1016/j.gie.2007.11.027] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Accepted: 11/14/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND Dysphagia, usually due to proximal esophageal strictures, is a debilitating complication of therapy (surgery, radiotherapy, or chemotherapy) for head and neck malignancy. Scant attention has been given in the literature to the endoscopic management of these proximal esophageal strictures. OBJECTIVE Our purpose was to assess the technical and functional outcomes of endoscopic management of proximal esophageal strictures after therapy for head and neck cancers. DESIGN Retrospective case series. SETTING Academic medical center. PATIENTS Consecutive patients undergoing endoscopy and dilation of proximal esophageal strictures caused by chemoradiation or surgery for head and neck malignancy. MAIN OUTCOME MEASUREMENT Technical and functional success after endoscopic dilation. RESULTS Twenty-four patients were included. The mean age of patients was 70.4 years (range 42 to 82 years). The primary tumor site was larynx in 10 patients, oropharynx or hypopharynx in 4 patients, upper esophagus in 4 patients, and other sites in the remainder. Technical success (a luminal diameter of 42F or greater) was achieved in 80% of patients. Adequate dysphagia relief was achieved in 84% of patients whose esophageal stricture was dilated at least up to 42F. The average follow-up was 22 months (range 1-96 months). Repeat dilation was needed in 58% of patients. No complications or death occurred during the study period. LIMITATIONS Retrospective design and highly selected patient population. Dysphagia assessment in conjuction with a speech pathologist was not performed in all patients. Results may not be applicable to other settings. CONCLUSION In this case series, proximal esophageal strictures after treatment of head and neck malignancy were amenable to antegrade endoscopic dilation; however, no patient in our study had complete lumen obstruction. Repeat dilations are often needed and are effective in achieving and maintaining adequate dysphagia relief.
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Affiliation(s)
- Sushil K Ahlawat
- Division of Gastroenterology and Hepatology, University of Medicine and Dentistry New Jersey-New Jersey Medical School, Newark, New Jersey, USA
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Ahlawat SK, Davidson BJ, Al-Kawas FH. Successful use of biliary accessories in antegrade dilation of complex upper esophageal stricture due to chemoradiation and surgery. Dis Esophagus 2008; 21:86-9. [PMID: 18197945 DOI: 10.1111/j.1442-2050.2007.00705.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Endoscopic management of complete or near complete upper esophageal strictures is challenging. Current methods such as retrograde esophageal access are high risk and may require additional abdominal surgery. A biliary cannulation technique with a 0.035 inch guidewire was utilized to obtain antegrade esophageal access in a patient with near complete high esophageal stricture due to chemo radiation and surgery for head and neck cancer. Biliary accessories including bougie and balloon dilators were used for the initial dilation of the esophageal stricture, followed by the traditional approach of stricture dilation using over-the-wire dilators. The procedure was successfully performed in a patient with near complete upper esophageal stricture due to chemo radiation and surgery for recurrent laryngeal cancer. The dysphagia of this patient was resolved following serial esophageal dilations and his esophageal stricture was wide open on the last upper endoscopy. Biliary accessories can be safely used for obtaining antegrade esophageal access and dilation of near complete upper esophageal strictures. This approach should be considered in patients with complex esophageal strictures, especially after chemo radiation or surgery for head and neck cancer and prior to seeking other more complex alternatives involving retrograde esophageal access.
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Affiliation(s)
- S K Ahlawat
- Division of Gastroenterology, Georgetown University Hospital, Washington, DC 20007, USA
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Haddad R, Annino D, Tishler RB. Multidisciplinary approach to cancer treatment: focus on head and neck cancer. Dent Clin North Am 2008; 52:1-vii. [PMID: 18154862 DOI: 10.1016/j.cden.2007.10.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
This article focuses on squamous cell carcinoma of the head and neck (SCCHN), the most common malignancy of the head and neck area. Early detection limits morbidity of treatment and increases the chances of a cure. The treatment of SCCHN is often multidisciplinary in nature and provides a model for how multimodality therapy may be applied for optimal patient management. The role of surgery in SCCHN is continually undergoing evolution, and the surgeon's role in the multidisciplinary treatment of head and neck cancers has changed as more cancers are being treated by chemoradiotherapy. Salvage surgery has become more common, and with it the increased challenges in managing metastatic disease to neck nodes as well as managing failure of organ preservation treatments. Surgeons continue to develop and refine reconstruction techniques to optimize cosmetic and functional outcomes.
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Affiliation(s)
- Robert Haddad
- Department of Medical Oncology, Dana Farber Cancer Institute, 44 Binney Street, Boston, MA 02115, USA.
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Nguyen NP, Smith HJ, Sallah S. Evaluation and management of swallowing dysfunction following chemoradiation for head and neck cancer. Curr Opin Otolaryngol Head Neck Surg 2007; 15:130-3. [PMID: 17413416 DOI: 10.1097/moo.0b013e32801da0e8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Concurrent chemoradiation offers excellent local control and survival for patients with locally advanced head and neck cancer while allowing anatomic organ preservation. Treatment toxicity is significant, however, often resulting in long-term dysphagia and aspiration. We review the prevalence of post-treatment swallowing dysfunction, describe current thinking about its pathogenesis and management, and signal possible directions for future research. RECENT FINDINGS Apoptosis from chemoradiation induces abnormal motility of the upper aerodigestive tract, resulting in stasis of the bolus in all phases of the swallow, and resulting in aspiration when the larynx is not protected during swallow. Long-term scarring may result in stenosis of the upper digestive tract. Recent findings suggest the role of transforming growth factor beta 1 in the pathogenesis of normal tissue damage and late scarring induced by radiation. Aspiration is often silent, and therefore a modified barium swallow or videofluoroscopy are required for its diagnosis. Swallowing therapy may improve swallowing efficiency and reduce the aspiration rate, and should be started immediately. SUMMARY Successful management of swallowing dysfunction following chemoradiation is a complex undertaking requiring a team approach. Collaboration among different specialists (physicians, speech pathologist, dietitian, and psychologists) remains the key to a desirable outcome.
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Affiliation(s)
- Nam P Nguyen
- Radiation Oncology Department, University of Arizona, Tucson, Arizona 85724, USA.
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Abstract
Head and neck cancer frequently presents at a late stage, leading to a poor prognosis despite optimal treatment with surgery and/or radiotherapy. Chemotherapy for advanced disease has shown little benefit as a single-modality treatment, and the use of concurrent chemoradiation is limited by problems with severe toxicity at higher doses. RADPLAT is the acronym used to describe a new technique, combining intra-arterial delivery of cisplatin with systemic neutralization by i.v. sodium thiosulphate, and concurrent radiotherapy. This allows very high cisplatin dose intensities to be used while potentially minimizing adverse systemic effects. Initial results suggest that excellent locoregional control rates are achievable in patients with unresectable disease, with a favorable side-effect profile when compared with conventional chemoradiation protocols. In addition, RADPLAT may potentially be of benefit in selected patients with resectable disease, allowing for preservation of organ function and quality of life without compromising locoregional control or survival. While current phase II data are encouraging, phase III randomized controlled trials are required in order to directly compare RADPLAT with i.v. chemoradiation therapy, the current standard of care. This article reviews the evolution of the RADPLAT concept, from initial clinical trials to its current application in the treatment of patients with advanced head and neck cancer.
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Affiliation(s)
- Lee W T Alkureishi
- Department of Plastic Surgery, Christie Hospital, Southmoor Road, Manchester, United Kingdom, and Department of Otolaryngology/Head and Neck Surgery, VU University Medical Center, Amsterdam, The Netherlands
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Garcia A, Flores RM, Schattner M, Kraus D, Bains MS, Wong RJ, Rizk N, Markowitz A, Gerdes H, Shike M. Endoscopic retrograde dilation of completely occlusive esophageal strictures. Ann Thorac Surg 2006; 82:1240-3. [PMID: 16996914 DOI: 10.1016/j.athoracsur.2006.05.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2006] [Revised: 05/08/2006] [Accepted: 05/11/2006] [Indexed: 12/14/2022]
Abstract
BACKGROUND Completely occlusive esophageal strictures may develop after head and neck radiotherapy or esophagectomy with gastric or colonic interposition. Major surgical intervention may be required to restore alimentary tract patency when endoscopic lumen reconstitution is not feasible by routine antegrade endoscopy. Retrograde endoscopic lumen identification and dilation is a useful method to reestablish alimentary tract patency, thereby avoiding surgical intervention. METHODS Patients requiring endoscopic dilation for completely occlusive esophageal strictures were identified by the gastroenterology, thoracic, and head and neck services. Retrograde access was obtained by balloon dilation of either a jejunostomy or gastrostomy tract, and an endoscope was passed to the area of stricture. Antegrade and retrograde endoscopy were performed simultaneously. A guidewire was passed either retrograde or antegrade under direct endoscopic visualization, followed by antegrade Savary dilation under fluoroscopic guidance. RESULTS From 2003 to 2006, 9 patients were identified with completely occlusive esophageal strictures requiring retrograde lumen identification and dilation. Stricture developed in 6 patients after radiotherapy for head and neck cancer and in 3 after esophagectomy with either gastric or colonic interposition for esophageal cancer. Endoscopic dilation was successful in all patients, without perforation. CONCLUSIONS Retrograde endoscopic lumen identification and dilation is an option to reestablish lumen patency of completely occlusive esophageal strictures after esophagectomy with gastric or colonic interposition or after head and neck chemoradiotherapy.
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Affiliation(s)
- Alejandro Garcia
- Division of Thoracic Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Tishler RB, Posner MR, Norris CM, Mahadevan A, Sullivan C, Goguen L, Wirth LJ, Costello R, Case M, Stowell S, Sammartino D, Busse PM, Haddad RI. Concurrent weekly docetaxel and concomitant boost radiation therapy in the treatment of locally advanced squamous cell cancer of the head and neck. Int J Radiat Oncol Biol Phys 2006; 65:1036-44. [PMID: 16682134 DOI: 10.1016/j.ijrobp.2006.02.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2005] [Revised: 02/05/2006] [Accepted: 02/06/2006] [Indexed: 11/30/2022]
Abstract
PURPOSE In a Phase I/II trial, we investigated concurrent weekly docetaxel and concomitant boost radiation in patients with locally advanced squamous cell cancer of the head and neck (SCCHN) after induction chemotherapy. PATIENTS AND METHODS Patients presented with American Joint Committee on Cancer Stage III/IV and were treated initially with induction chemotherapy using cisplatinum/5-fluorouracil (PF), carboplatinum-5-FU, or docetaxel-PF. Patients then received docetaxel four times weekly with concomitant boost (CB) radiation (1.8 Gy once-daily X20, 1.8/1.5 Gy twice a day). Fifteen patients each received 20 mg/M2 and 25 mg/M2. RESULTS Thirty-one patients were enrolled and 30 were evaluable for response and toxicity. Median follow-up was 42 months (range, 27-63 months). Primary sites were: oropharynx 19, oral cavity 2, larynx/hypopharynx 5, and unknown primary 4. Eighty-seven percent of patients had N2/N3 disease; 60% had T3/T4 disease. Twenty percent of patients had a complete response (CR) to induction chemotherapy. After chemoradiotherapy, 21 of 30 patients had a CR, 2 had progressive disease, and 7 had partial response (PR). Nineteen of 26 patients presenting with neck disease had neck dissections, and 7 of 19 were positive. Ninety-three percent of all patients were rendered disease-free after all planned therapy. Treatment failed in 8 patients, and 7 have died of disease. An additional patient died with no evidence of disease. Twenty-one patients (70%) are currently alive with no evidence of disease. No acute dose-limiting toxicity was observed at either dose level. CONCLUSIONS This intensive treatment regimen of concurrent docetaxel/concomitant boost radiation and surgery after induction chemotherapy in poor prognosis patients yields good local regional control and survival. Docetaxel/CB chemoradiotherapy represents an aggressive alternative regimen to platinum-based chemoradiotherapy or surgery in patients who have a poor response to induction chemotherapy.
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Affiliation(s)
- Roy B Tishler
- Department of Radiation Oncology, Dana Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Roh JL, Yoon YH. Prevention of hypopharyngeal stenosis with silastic sheeting following transoral resection. Dysphagia 2006; 21:112-5. [PMID: 16708264 DOI: 10.1007/s00455-006-9018-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Hypopharyngeal stenosis following transoral laser microresection (TLM) of hypopharyngeal carcinomas is a rare but devastating complication. Early oral intake and insertion of a nasogastric feeding tube have been thought to prevent stenosis after surgery. However, though rare, severe dysphagia can be caused by hypopharyngeal stenosis following TLM despite preventive efforts. We suggest a new way to prevent hypopharyngeal stenosis by using silastic sheeting with a feeding tube. This stent was inserted in three patients who underwent extensive TLM of hypopharyngeal carcinomas. This technique will help in the treatment and prevention of hypopharyngeal stenosis following TLM in selected patients with wide or circumferential hypopharyngeal tumors.
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Affiliation(s)
- Jong-Lyel Roh
- Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap-dong, Seoul, 138-736, South Korea.
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Delaere P, Hierner R, Goeleven A, D'Hoore A. Reconstruction for Postcricoid Pharyngeal Stenosis after Organ Preservation Protocols. Laryngoscope 2006; 116:502-4. [PMID: 16540919 DOI: 10.1097/01.mlg.0000194224.37329.c3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Pierre Delaere
- Department of Otorhinolaryngology-Head and Neck Surgery, KU Leuven, Kapucijnenvoer 33, B-3000 Leuven, Belgium.
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Abstract
PURPOSE OF REVIEW This paper reviews recent surgical contributions to the multidisciplinary approach to head and neck cancer treatment as well as published data on pertinent questions in the field. RECENT FINDINGS The role of surgery in the strategy of organ preservation via chemoradiation, including treatments of complications and locoregional recurrences, such as when N1-N3 necks should be operated on and the role of CT and positron emission tomography (PET) scanning. Also covered are the role of sentinel lymph node biopsy for the detection of occult micrometastases in the N0 neck and the value of fluorodeoxyglucose PET scanning combined with the former. Transoral laser surgery for tumors of the larynx or of the hypopharynx is discussed, as is a new technique of reconstruction involving the anterolateral thigh free flap. Also included are quality of swallowing after resections and reconstruction of the oral cavity and orpharyngeal tumors. SUMMARY Surgery must define its role in the multidisciplinary treatment of advanced cancers, which currently often favors (chemo)radiotherapy protocols. Organ sparing by transoral laser surgery for laryngeal and hypopharyngeal cancer has established itself within our armamentarium and its exact role will be further refined. Larger and well-executed studies on sentinel lymph node biopsy in the clinically negative neck are needed before this procedure can be implemented in our routines. The latest addition, the anterolateral thigh flap, to further decrease patients' morbidity is unlikely to completely replace the currently favored radial forearm flap in soft tissue replacement of the head and neck. Outcome analysis, including swallowing, is a major step that surgeons should further investigate.
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Affiliation(s)
- Guy Andry
- Department of Surgery, Institut Jules Bordet, Bruxelles, Belgium.
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