Self-expanding segmental radioactive metal stents for palliation of malignant esophageal strictures.

BACKGROUND: Traditional metal stents are not always suitable for patients with circuitous malignant esophageal stricture. PURPOSE: We aimed to report the safety and effectiveness of stent insertion using self-expanding segmental radioactive metal stent in the palliation of malignant esophageal stricture. MATERIAL AND METHODS: We conducted a retrospective analysis of 22 consecutive patients who underwent insertion of segmental radioactive metal stents from November 2016 to March 2019. Technical success, dysphagia score, and complications were analyzed. Kaplan-Meier analysis was used to analyze the survival time. RESULTS: The stenting procedure was successful in all 22 patients with no procedure-related deaths. Twenty-four segmental radioactive metal stents were successfully implanted. A total of 6 (27.3%) complications were found, mainly 5 (22.7%) stent migrations. The median follow-up period was 3.3 months. Stent removal was required in 4 (12.5%) patients due to complete stent migration. The mean dysphagia score decreased significantly after stent insertion (P<0.0001). During follow up, 13 patients survived with no obvious clinical symptom and nine patients died. The mean survival was 9.9 months. CONCLUSION: The stenting procedure using self-expanding segmental radioactive metal stents is safe and effective in dysphagia palliation of malignant esophageal stricture.

Esophageal self-expandable stent material and mesh grid density are the major determining factors of external beam radiation dose perturbation: results from a phantom model.

BACKGROUND: Self-expandable esophageal stents are increasingly used for palliation or as an adjunct to chemoradiation for esophageal neoplasia. The optimal esophageal stent design and material to minimize dose perturbation with external beam radiation are unknown. We sought to quantify the deviation from intended radiation dose as a function of stent material and mesh density design. METHODS: A laboratory dosimetric film model was used to quantify perturbation of intended radiation dose among 16 different esophageal stents with varying material and stent mesh density design. RESULTS: Radiation dose enhancement due to stent backscatter ranged from 0 % to 7.3 %, collectively representing a standard difference from the intended mean radiation dose of 1.9 (95 % confidence interval [CI] 1.5 - 2.2). This enhancement was negligible for polymer-based stents and approached 0 % for the biodegradable stents. In contrast, all metal alloy stents had significant radiation backscatter; this was largely determined by the density of mesh design and not by the type of alloy used. CONCLUSIONS: Stent characteristics should be considered when selecting the optimal stent for treatment and palliation of malignant esophageal strictures, especially when adjuvant or neo-adjuvant radiotherapy is planned.

Airway complications after covered stent placement for malignant esophageal stricture: special reference to radiation therapy.

OBJECTIVE: The purpose of this study was to evaluate the characteristics of airway complications and survival with special reference to radiation therapy in the care of patients undergoing covered stent placement for malignant esophageal strictures. MATERIALS AND METHODS: A total of 208 patients who underwent stent placement with or without palliative radiation therapy for inoperable esophageal cancer were included. The endpoints were frequency, type, and management of airway complications; association between occurrence of airway complications and radiation therapy history; and differences in stent-to-complication interval and survival period after esophageal stenting between patients who underwent radiation therapy before and those who underwent radiation therapy after stent placement. RESULTS: Airway complications occurred in 23 patients (11.1%): 18 (78.3%) had esophagorespiratory fistula, three (13.0%) had airway narrowing, and two (8.7%) had both complications. The frequency of airway complications was significantly greater among patients who underwent RT than those who did not (p = 0.005) but was not significantly different between the radiation before stenting and radiation after stenting groups (p = 0.158). The median stent-to-complication interval and survival period after esophageal stenting were significantly shorter in the radiation before stenting group than in the radiation after stenting group (p = 0.002, p = 0.001). CONCLUSION: Esophagorespiratory fistula is much more common than airway narrowing as an airway complication. The rate of complications increases significantly in association with radiation therapy among patients with malignant esophageal stricture. Clinicians need to be aware of earlier airway complications and poorer prognosis among patients who undergo radiation therapy before placement of an esophageal stent than in patients who undergo radiation after stent placement.

A Phase II Study of Biodegradable Stents Plus Palliative Radiotherapy in Oesophageal Cancer.

AIMS: Self-expanding metal stents provide rapid improvement of dysphagia in oesophageal cancer but are associated with complications. The aim of the present study was to test the effectiveness of an alternative treatment of combining biodegradable stents with radiotherapy. MATERIALS AND METHODS: A Simon two-stage single-arm prospective phase II trial design was used to determine the efficacy of biodegradable stents plus radiotherapy in patients with dysphagia caused by oesophagus cancer who were unsuitable for radical treatment. Fourteen patients were recruited and data from 12 were included in the final analyses. RESULTS: Five of 12 patients met the primary end point: one stent-related patient death; four further interventions for dysphagia within 16 weeks of stenting (41.7%, 95% confidence interval 15.2-72.3%). The median time to a 10-point deterioration of quality of life was 2.7 weeks. Nine patients died within 52 weeks of registration. The median time to death from any cause was 15.0 weeks (95% confidence interval 9.6-not reached). CONCLUSION: The high re-intervention observed, which met the pre-defined early stopping criteria, meant that the suggested alternative treatment was not sufficiently effective to be considered for a larger scale trial design. Further work is needed to define the place of biodegradable stents in the management of malignant oesophageal strictures.

Radioactive Stent for Malignant Esophageal Obstruction: A Meta-Analysis of Randomized Controlled Trials.

Purpose: To compare the relative clinical efficacies of radioactive and normal stent insertion methods as a means of treating patients suffering from malignant esophageal obstruction (MEO). Materials and Methods: The Pubmed, Embase, and Cochrane Library databases were searched for relevant randomized controlled trials (RCTs) from the date of inception through to July 2020. RevMan v5.3 was used for all data analyses. Results: This meta-analysis included six RCTs that included a total of 194 patients who had undergone radioactive stent insertion and 209 who had normal stent insertion. There were no significant differences in pooled improvement of dysphagia scores (P = .40), rates of stent restenosis (24.7% versus 28.7%, P = .35), stent migration (3.3% versus 4.4%, P = .61), severe chest pain (22.8% versus 20.3%, P = .61), hemorrhage (11.0% versus 9.8%, P = .80), or fistula formation (6.1% versus 4.2%, P = .55) between two groups. The pooled time to restenosis (P < .00001) and survival (P < .00001) were significant longer in the radioactive stent group. Significant heterogeneity was detected in the endpoint of improvement of dysphagia score (I2 = 89%; P = .0002). Funnel plot analyses did not detect any evidence of publication bias pertaining to the selected study endpoints. Conclusions: Our meta-analysis demonstrated that radioactive stent insertion can prolong stent patency and survival for patients with MEO compared with normal stent insertion.

[Palliative care for patients with oesophageal cancer]. / Palliativtherapie beim Ösophaguskarzinom.

BACKGROUND: Palliative therapy for patients with incurable oesophageal cancer necessitates a broad spectrum of different measures to relieve symptoms. METHODS: Surgical procedures (palliative tumour resections, bypass surgery) are rarely indicated on account of the high morbidity. Preeminent treatment options to eliminate dysphagia and to ensure food passage are endoscopic procedures, in particular, the endoscopically or radiologically guided stent implantation. In case of failure, a percutaneous feeding tube and general palliative measures are required. Furthermore tumour-specific therapies (brachytherapy, radiochemotherapy, chemotherapy) are applied. DISCUSSION: The choice of the procedure is based on the symptoms, the tumour situation, the patients' general status, and their preferences. If possible, an individual, interdisciplinary treatment concept for each patient should be designed and modified according to the course of the disease. CONCLUSIONS: It should be the aim of future studies to elucidate the optimal combination of a merely symptomatic treatment with tumour-specific measures under the aspect of the achievable quality of life.

Intraluminal high dose rate brachytherapy of tumorous esophageal stenoses.

BACKGROUND/AIMS: The prognosis of inoperable carcinomas of esophagus is poor, and therapeutic efforts are generally limited to palliation. The aim of this study was to retrospectively evaluate the effectiveness of intraluminal high dose rate brachytherapy in the palliative treatment of tumorous esophageal stenoses. METHODOLOGY: Between February 1997 and July 2002 intraluminal brachytherapy was performed in 19 patients with inoperable esophageal carcinoma (squamous cell carcinoma in 14 cases and adenocarcinoma in 5 cases). All patients had dysphagia at presentation. Brachytherapy was performed using high dose rate afterloading system. RESULTS: Dysphagia was improved in all patients. The mean survival was 248 days. No mechanical complications were observed during introduction of the applicator. CONCLUSIONS: Our experience indicates that intraluminal brachytherapy is an effective and safe method of palliation of dysphagia caused by malignant esophageal stenosis.

Self-expandable metallic stent for unresectable malignant strictures in the esophagus and cardia.

OBJECTIVE: Self-expandable metallic stent (EMS) placement has been the first choice for dysphagia because of the certainty over its safety, low invasiveness, and immediate efficacy. However, there still remain some problems in relation to the EMS placement site and anticancer therapies before and after EMS placement. METHODS: Consecutive 78 patients in whom EMS was placed due to the unresectable malignant stricture in the esophagus or cardia from July 1995 to August 2003 in our department were studied. RESULTS: Gastroesophageal reflux was found in 5 of 8 patients after placement of conventional EMS for the stricture in the gastroesophageal junction. Meanwhile, acid and bile reflux into the esophagus were not detected by pH and bilirubin monitoring, respectively, in 6 patients after placement of the EMS with an anti-reflux mechanism for the stricture in the gastroesophageal junction. The median survival period of all patients after EMS placement was 123 days. The median survival period of 7 patients with radiotherapy only after EMS placement was 138 days and that of 17 patients with radiotherapy before EMS placement was 60 days, which was shorter than that of the former (p<0.05). On the other hand, the median survival period after hospital admission due to dysphagia of these 7 patients was longer than that of 17 patients with radiotherapy only before EMS placement, although, the difference was not significant. CONCLUSION: EMS with an antireflux mechanism is not commercially available in Japan and approval is urgently required. The indication of radiotherapy associated with EMS placement is to be studied further.

Combined modality therapy for esophageal carcinoma: preliminary results from a large Australasian multicenter study.

PURPOSE: This report updates local control and survival experience and focuses on treatment toxicity in 294 patients with esophageal cancer who have been treated at six Australasian centers using three prospective unrandomized protocols that used concurrent radiation, cisplatin, and modest dose infusional fluorouracil. METHODS AND MATERIALS: Protocol 1--"definitive" chemoradiation. One hundred and thirty-seven patients have been treated with "definitive" radiation to 60 Gy in 6 weeks plus two courses of cisplatin (80 mg/m2) and infusional fluorouracil (800 mg/m2/day over 4 days) during the first and fourth weeks of radiation. Protocol 2--"preoperative" chemoradiation and surgery. Seventy-eight patients received chemoradiation using the same chemotherapy, but 30-35 Gy in 3-4 weeks prior to surgery. Protocol 3--"palliative" chemoradiation. Seventy-nine patients deemed incurable were treated "palliatively" with the same chemoradiation protocol without surgery. Follow-up ranges from 6 months to 7 years (mean 22 months) in live patients. RESULTS: Durable palliation of dysphagia in all three treatment groups has been reflected by encouraging 3-year survival expectations of 43.2 +/- 5% in definitively treated patients, 40.3 +/- 7.65% in surgically treated patients, and 8.5% +/- 3.9% in the palliatively treated patients. There are early indications that female patients have fared better than males. Toxicity levels were modest in all three groups. Following definitive treatment, severe myelotoxicity (World Health Organization grades 3 and 4) occurred in 19%, severe esophagitis (World Health Organization grade 3) in 11%, and moderate or severe benign stricture in 17%, depending upon age and sex of the patient (being worse in female patients). CONCLUSIONS: These studies demonstrate that the concurrent addition of modest dose cisplatin and infusional dose fluorouracil to radiation in the definitive, preoperative, and palliative settings contribute to high rates of durable dysphagia-free survival, with overall survival comparable to (and possibly better than) the chemoradiation arm of the recently reported Intergroup Study, but at the cost of less morbidity.

A single session of intraluminal brachytherapy in palliation of oesophageal cancer.

Between September 1987 and September 1993, 88 patients with oesophageal cancer were treated by a single session of intraluminal brachytherapy of 15 Gy prescribed at 1 cm distance from the central axis, using MDR137Cs (n = 51) during the first part of the study and HDR192Ir (n = 37) during the second part of the study. All patients were regarded as inoperable. Improvement of dysphagia, assessed 4-6 weeks after treatment, was noted in 50 of 75 (67%) evaluable patients, whereas swallowing ability was completely restored in 47% of them. Relapse of dysphagia occurred in 28 (37%) patients during follow-up. Additional palliative treatment consisted of endoprosthesis in 14 (19%), a second course of brachytherapy in 13 (17%), one or more dilatations only in 11 (15%) and laser treatment in four (5%) patients. One non-fatal haemorrhage and five fistulae occurred, all in the presence of tumour. Two severe ulcerations without evidence of tumour were noted, both managed by combined curative treatment. The median survival of the group investigated was 5.5 months. An exophytic, non-circular growth pattern was associated with a better response. In a multivariate analysis the presence of distant metastases (p = 0.0028), weight loss (p = 0.0051) and an exophytic growth pattern (p = 0.0199) were associated with a worse survival. The present data indicate that a single session of ILB is appropriate in the palliation of dysphagia in patients with inoperable oesophagal cancer showing bad prognostic signs. Up to now there has been no clear evidence for benefit of addition of ERT.

[A case of cardiac cancer for which radiation therapy was effective in improving stenosis of the esophagogastric junction].

The patient was a seventy-seven-year old woman, who was diagnosed with advanced gastric cancer with stenosis of the esophagocardiac junction. Her cancer was diagnosed as Stage IV (T3N3H0P3M0). As there was no indication for surgery, radiation therapy (Linac electron beam, 1.8 Gy/day, total 50.4 Gy) was selected to improve the stenosis, after which she was able to eat food. Subjective complaints such as nausea and vomiting were also decreased, promoting her QOL. We conclude that radiation therapy treatment can be a treatment option for far advanced cardiac cancer.

Treatment options for esophageal strictures.

Esophageal strictures are a problem commonly encountered in gastroenterological practice and can be caused by malignant or benign lesions. Dysphagia is the symptom experienced by all patients, regardless of whether their strictures are caused by malignant or benign lesions. The methods most frequently used for palliation of malignant esophageal strictures are stent placement (particularly in patients with an expected survival of 3 months or less) and brachytherapy (in patients with a life expectancy of more than 3 months). Brachytherapy has been shown to be beneficial in patients with an expected survival of longer than 3 months with regard to (prolonged) dysphagia improvement, complications and quality of life. The mainstay of benign esophageal stricture treatment is dilation. Although dilation usually results in symptomatic relief, recurrent strictures do occur. In order to predict which types of strictures are most likely to recur, it is important to differentiate between esophageal strictures that are simple (i.e. focal, straight strictures with a diameter that allows endoscope passage) and those that are more complex (i.e. long (>2 cm), tortuous strictures with a narrow diameter). These complex strictures are considered refractory when they cannot be dilated to an adequate diameter. Novel treatment modalities for refractory strictures include temporary stent placement and incisional therapy.

A case report of advanced thoracic esophageal cancer with severe malignant stricture.

We experienced one case with locally advanced esophageal cancer that he gained a good result by the multidisciplinary treatment including the operation followed by chemoradiation. The case was a 74-year old man with the middle thoracic esophageal cancer accompanied by severe malignant stricture. He couldn't take any water, and his general condition was poor, because he lost 5 kg of his weight. By the clinical examinations, his cancer had no apparent invasion to adjacent organ. So, we planned the operation gone ahead the chemoradiation for him to take water and meals earlier, and to prevent pneumonia. The esophagectomy through right-thoracotomy was done, and the pathological findings were type 3, well differentiated squamous cell carcinoma, pT3 N0, pStageII. Two months later after the operation, he took the chemoradiotherapy. 50 gray radiation therapy was done with chemotherapy including Cisplatin (10 mg/a time/week) and Tegafur (200 mg/day). About one and half a year after the operation, he sends good daily life with no recurrence. Recently, chemoradiotherapy is the first choice of the treatment for the locally advanced esophageal cancer. But in cases without apparent invasion to adjacent organ, it might be advisable that the operation goes ahead the chemoradiotherapy in the multidisciplinary treatment.

[Effectiveness of the treatment of chemical burns of the esophagus by local endoscopic laser therapy]. / Effektivnost' lecheniia khimicheskikh ozhogov pischevoda metodami mestnoi éndoskopicheskoi lazeroterapii.

Overall 240 patients with chemical burns of the esophagus were examined. Local endoscopic treatment with the aid of lasers was applied in 180 victims. The efficacy of different types of laser radiation was compared in terms of the times of the healing of the esophageal wall. It is concluded that further studies should be carried out in the given area.

[The use of copper-vapor laser radiation on patients with chemical burns of the esophagus via fiber esophagoscopy]. / Ispol'zovanie izlucheniia lazera na parakh medi u bol'nykh s khimicheskimi ozhogami pishchevoda pri fibroézofagoskopii.

Fifty patients with chemical burns of the esophagus were examined fibroesophagoscopically. All of them underwent local endoscopic irradiation by a copper vapour laser. Laser treatment promoted more rapid healing of the esophageal wall. No cicatrization-induced strictures were noted. Adjuvant local laser therapy is believed valid in management of esophageal chemical trauma.

[Gastrointestinal laser treatment]. / Gastrointestinal laserbehandling.

During the seven-year period from 1983 to 1990, 210 patients with gastrointestinal disorders were treated by laser at Aker Hospital. The main reason for the laser treatment was gastrointestinal bleeding, malignant tumour obstruction in oesophagus and rectum, and colorectal adenoma. This treatment has also been used in some patients with benign strictures and in 30 patients with perianal condylomata. In this paper we present the results of the treatment, and our experiences. We conclude that the use of laser has become an established alternative treatment for a number of gastrointestinal conditions.

Role of gastric irradiation in management of peptic ulceration and oesophagitis.

Twenty-four patients with peptic oesophagitis or ulceration of the stomach or duodenum have been treated with irradiation of the stomach. They were selected on the grounds of their unsuitability for surgery because of associated medical conditions or because of failure of repeated gastric surgery. Twenty of the patients (83%) were 60 years of age or over. Of those treated 19 (79%) obtained complete symptomatic relief. Endoscopic improvement occurred in most cases. Acid reduction to an average of 30% of the pretreatment levels was noted at 11 months and 58% at 30 months. No morbidity was observed attributable to the irradiation.