Self-expanding metal stent insertion for inoperable esophageal carcinoma in Belfast: an audit of outcomes and literature review

Outcomes following interventions to sustain body weight in esophageal cancer patients starting preoperative therapy: a retrospective cohort study

Background

To improve nutritional status and dysphagia, esophageal cancer patients starting neoadjuvant therapy in advance of curative-intent surgery may receive a jejunostomy tube (J-tube) or esophageal stent, or they may be managed without a feeding modality. We examined percent total weight loss (%TWL), reinterventions, and progression to surgery in relation to these options.

Methods

The retrospective cohort study included stage II–III esophageal cancer patients diagnosed during 2010–2017 who received J-tube, stent, or nutritional counseling only, without a procedure, when starting chemotherapy or combined modality chemoradiation. Data were obtained from the electronic medical record and chart review. We compared median %TWL between intervention groups and reinterventions using Chi-square and Kruskal-Wallis tests.

Results

Among the 366 patients, median %TWL reached a nadir at 120 days, when it was 7% for patients with no procedure (N=307), 4% for J-tube (N=39), and 16% for stent (N=20) (P=0.01). Individual case analysis revealed 72–80% of the patients in the three groups started chemotherapy or chemoradiation as neoadjuvant curative-intent therapy (P difference =0.79). In J-tube patients, the reasons for intervention was anticipation of weight loss in 49% and mitigation of actual weight loss in 15%, whereas 95% of stent patients received the stent for dysphagia (P<0.001). A complication of the procedure was recorded in 85% of stent patients and 74% of J-tube patients (P<0.001). Among those who received no procedure initially, 25% received one later, compared with 15% of J-tube patients and 70% of stent patients who received a second procedure (P<0.001). Progression to surgery was observed in 65% of patients with no procedure, 51% of patients with J-tube, and 40% of stent patients, P=0.28).

Conclusions

For stage II–III esophageal cancer patients starting chemotherapy, this study gives evidence that stents were associated with significant %TWL and risk of reintervention. Although J-tube patients returned to baseline weight sooner than those with no procedure, they experienced complications from their J-tubes. For esophageal cancer patients undergoing curative-intent treatment and with acceptable levels of weight loss, no procedure at all may be superior to placing a J-tube in terms of complications, weight loss, and progression to curative-intent surgery.

Characteristics and Outcomes of Airway Involvement in Esophageal Cancer

BACKGROUND

Airway involvement, such as airway invasion, compression, and tracheobronchoesophageal fistula (TEF), in esophageal cancer is associated with significant morbidity. However, the risk factors and outcomes of airway complications remain unclear, with limited evidence to guide management.

METHODS

This retrospective analysis included 804 patients with a diagnosis of esophageal cancer from 1998 to 2018 at a tertiary care medical center (Singapore General Hospital, Singapore). Patients' demographics, treatment details, and airway involvement, as determined by bronchoscopic evaluation or computed tomographic imaging, were recorded and analyzed to determine risk factors and outcomes of airway involvement.

RESULTS

The incidence of airway involvement and TEF was 36.6% and 13.1%, respectively. Airway involvement was associated with reduced survival from the time of diagnosis (hazard ratio, 1.52; 95% confidence interval [CI], 1.30 to 1.79) and increased hospitalizations per year (4.53 ± 4.80 vs 2.75 ± 3.68; P < .001). On multivariate analysis, midesophageal tumors (odds ratio [OR], 11.0; 95% CI, 6.3 to 19.0) and upper esophageal tumors (OR, 8.5; 95% CI, 4.7 to 15.6), previous treatment with esophageal stenting (OR, 17.8; 95% CI, 4.1 to 77.6), and chemotherapy or radiotherapy were associated with development of airway involvement. In patients with TEF, treatment with chemotherapy (OR, 0.34; 95% CI, 0.20 to 0.60) and combined airway and esophageal stenting (OR, 0.48; 95% CI, 0.25 to 0.91) were independently associated with improved survival.

CONCLUSIONS

Airway involvement and TEF are common and are associated with increased morbidity and poorer survival. Clinicians should remain vigilant for airway complications after treatment with esophageal stenting, chemotherapy, or radiotherapy, especially in patients with midesophageal and upper esophageal cancers. In patients with TEFs, survival is improved when they are treated with airway stenting, esophageal stenting, or chemotherapy.

Palliative Radiotherapy Versus Esophageal Stent Placement in the Management of Patients With Metastatic Esophageal Cancer

Background:Patients with advanced esophageal cancer often experience pain and dysphagia, yet the optimal palliative management remains unclear. This retrospective study evaluated outcomes and adverse effects of palliative radiotherapy (RT) compared with esophageal stenting among a cohort of U.S. veterans with metastatic esophageal cancer.Patients and Methods:We identified 1,957 veterans in the United States with metastatic esophageal cancer who received palliative RT to the esophagus or esophageal stenting, and assessed the risks of severe adverse effects, including esophageal fistula formation, perforation, obstruction, hemorrhage, and esophagitis. We determined palliative efficacy by evaluating pain and dysphagia scores before and after intervention. Multivariable analyses were used to control for potential confounding factors.Results:In our cohort, 1,593 patients underwent RT and 364 underwent esophageal stenting. The cumulative incidence of any severe adverse effect at 6 months was higher among patients who received stents compared with those who received RT (21.7% vs 12.4%;P<.0010). In multivariable analysis, patients who received stents had an increased risk of any severe adverse effect, including fistula, perforation, and hemorrhage (allP<.0500). Multivariable analysis also showed that, compared with stenting, RT was associated with more rapid and durable pain relief (P<.0010) with no difference in relief of dysphagia over time when accounting for pretreatment dysphagia scores (P=.1029).Conclusions:Compared with esophageal stenting, RT was associated with a decreased risk of adverse effects, greater pain relief, and equivalent relief of moderate to severe dysphagia over time. Unmeasured patient- or tumor-related factors could have influenced the choice of intervention, thereby impacting our study outcomes. To our knowledge, this is the largest study to date analyzing the comparative risks and benefits of palliative RT and esophageal stenting among patients with metastatic esophageal cancer.

Argon plasma coagulation compared with stent placement in the palliative treatment of inoperable oesophageal cancer

BACKGROUND

Self-expandable metal stents (SEMSs) are the main palliative modality used in inoperable oesophageal cancer. Other palliative modalities, including argon plasma coagulation (APC), have also been used.

OBJECTIVE

The purpose of this study was to assess the relative efficacy of SEMS and APC regarding the survival of patients with inoperable oesophageal cancer, not receiving chemo/radiotherapy.

METHODS

Single centre, retrospective analysis of all patients (n = 228) with inoperable oesophageal cancer between January 2000 and July 2014, not receiving chemo-radiotherapy, treated with SEMS (n = 160) or APC (n = 68) as primary palliation modalities. Cox regression analysis was performed to identify individual factors affecting survival and Kaplan-Meier curves were created for patients treated with APC and SEMS for stage III and IV disease. Survival intervals were compared by the log-rank test.

RESULTS

Type of treatment was the only statistically significant factor affecting survival, after disease stage stratification (hazard ratio (HR): 1.36, 95% confidence interval (CI): 1.13-1.65 of SEMS over APC, p: 0.002). Median survival for patients treated with APC and SEMS was 257 (interquartile range (IQR): 414, 124) and 151 (IQR: 241, 61) days respectively in stage III disease. It was 135 (IQR: 238, 43) and 70 (IQR: 148, 32) days respectively in stage IV disease. Both differences were statistically significant (p = 0.02 and 0.05 respectively).

CONCLUSIONS

APC is a promising palliation modality in inoperable oesophageal cancer, when patients are not candidates for chemo-radiotherapy. A randomized controlled trial will be needed to confirm those results.

Tracheo-oesophageal fistula after palliative treatment of oesophageal cancer

We present a case of an 86-year-old male who presented with severe pneumonia in the context of having undergone radiotherapy and then an oesophageal stent insertion for palliation of oesophageal cancer. He was diagnosed with a tracheo-oesophageal fistula (TOF) which was successfully managed by deploying a second stent within the first stent.

Clinical outcomes of esophageal stents in patients with malignant esophageal obstruction according to palliative additional treatment

OBJECTIVE

To evaluate the efficacy and feasibility of esophageal self-expanding metal stents (SEMS) insertion for malignant esophageal obstruction (MEO) in patients with or without additional palliative treatment.

METHODS

We retrospectively reviewed the medical records of the patients with SEMS for MEO. Baseline characteristics, changes in Mellow-Pinkas dysphagia score, and adverse events were collected and compared according to the presence and absence of additional palliative treatment.

RESULTS

Altogether 192 patients underwent 236 SEMS insertion procedures. Esophageal, gastric cardiac and lung cancers were seen in 46.4%, 33.3% and 15.1% of the patients, respectively. Their Mellow-Pinkas score significantly decreased within one week and one month after the SEMS insertion (1.66 ± 0.79 and 1.71  ±  0.87 vs 3.09  ±  0.79, respectively, P =  0.000). Complications occurred in 54 (22.9%) of 236 SEMS insertion; there were 28 (11.9%) stent obstruction, 5 (2.1%) perforation (2.1%), 10 (4.2%) stent migration, 5 (2.1%) tracheoesophageal fistula, but no procedure-related death. Most complications were managed by inserting additional SEMS. The risk of stent obstruction was significantly higher in uncovered stents than in covered SEMS (OR 3.56, 95% CI 1.39-9.12, P = 0.006). Mean duration to the development of complications was 74.8 ± 111.1 days. Overall survival (169.0 ± 127.8 days vs 96.4 ± 90.6 days, P = 0.000) and stent patency (143.3 ± 123.9 days vs 67.6 ± 71.3 days, P = 0.000) were significantly favorable in patients with SEMS and additional palliative treatments compared with those with SEMS alone.

CONCLUSION

SEMS insertion is effective and safe for treating MEO, and additional palliative treatment might lengthen stent patency by prolonging the patient's survival.