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Palliative Therapy for Esophageal Cancer
The American Cancer Society estimates that 16,940 new cases of esophageal cancer will be diagnosed in 2016, and in the same year there will be 15,690 deaths from esophageal cancer. Unfortunately, more than half of patients present with advanced disease with symptoms of dysphagia, weight loss, and less often bleeding. Palliative interventions are needed to optimize quality of life by reducing hospital admissions for aspiration and bleeding, as well as allow them to enjoy eating. The goals for treating malignant dysphagia are ease of treatment and short hospital stay. For patients who may be candidates for palliative chemotherapy or chemoradiation therapy, the only palliative procedural intervention may be a need for a percutaneous gastrostomy tube for caloric supplementation.
Depending on the degree of dysphagia and the performance status of the patient, a significant number of patients may need endoscopic interventions to improve oral intake and nutritional status as the first step in their treatment algorithm. Patients who cannot swallow their saliva need an urgent endoscopic intervention to reduce their risk of aspiration, a potentially fatal event.
Most endoscopic therapies provide initial improvement in dysphagia but vary in their durability. After improvement in oral nutrition, performance may improve and other therapies may be tolerated. In this chapter, we review all the commonly used methods for endoscopic palliation of malignant dysphagia. In general, these methods deliver rapid relief and allow intake of a soft to regular diet with some modifications depending on the individual. Dilation and endoscopic stents are considered the mainstay of palliative options. As the durability of the relief of dysphagia is variable, a multimodality approach is often required. Laser therapy with thermal ablation and nonthermal photodynamic therapy have been options for many years; however, cryoablation has now joined the ranks. The palliative options for bleeding or obstructing esophageal cancer are summarized in Table 42.1 . On the rare occasion, in a very good performance with incurable disease, esophagectomy may be indicated for palliation when other interventions fail. In our practice, advances in endoscopic palliative modalities have made this unusual.
TABLE 42.1
Palliative Options for Bleeding or Obstructing Esophageal Cancer
| Modality | Bleeding | Obstruction | Weight Loss |
|---|---|---|---|
| Balloon dilation | N | Y | N |
| Self-expanding metal stent | N | Y | N |
| Laser | |||
| Thermal laser (Nd:YAG) | Y | Y | N |
| Photodynamic therapy | Y | Y | N |
| Cryoablation | Y | Y | N |
| Radiation therapy | N | Y | N |
| Chemotherapy | N | Y | N |
| Percutaneous gastrostomy tube | N | N | Y |
Nd:YAG, Neodymium:yttrium-aluminum-garnet.
Esophageal Dilation
Malignant esophageal dysphagia can be relieved immediately to some degree with dilation with a bougie or a balloon dilator. If this is the only therapy, recurrent dysphagia will occur in almost all patients within 1 to 2 weeks. This temporary intervention may allow improvement of oral intake, particularly fluids, for a short period of time while other therapies, including chemotherapy and radiation, are initiated. Dilation is more commonly carried out in conjunction with other modalities such as stenting or ablation to provide longer relief for the patient. The Savary bougie dilators produce both radial and longitudinal forces to the esophagus ( Fig. 42.1 ), whereas a balloon dilator produces only a radial force ( Fig. 42.2 ). The balloon dilator is better for a longer stricture, such as a malignant stricture, and the bougie is better for the more focal anastomotic or postfundoplication stricture. The balloon dilation can be done under direct vision with a through-the-scope dilator or over a guidewire and with fluoroscopic guidance to confirm safe placement of the balloon across the tumor. When the esophageal lumen is very narrow, expandable metal stent placement without initial dilation may lead to stent infolding and an initial dilation may be indicated. Similarly, after expandable metal stent placement, careful balloon dilation may facilitate immediate expansion. However, overzealous dilation may lead to a less snug fit of the stent and early migration. Dilation is often used before and after ablative therapy including cryoablation or laser therapy to allow passage of the endoscope and laser fiber. Complications after esophageal dilation range from pain and fever to perforation. Although risk of perforation is uncommon in experienced hands, the endoscopist should have a low threshold for further diagnostic studies, such as an intraoperative esophagram with gastroview or postoperative barium esophagography, to rule this out, in particular in the patient with excessive pain or pneumomediastinum, pneumoperitoneum, or a pneumothorax after dilation. If there is no leak, the patient can be started on clear liquids for 24 hours, followed by a soft diet as tolerated. In some cases, if the perforation is minor and contrast agent shows no or minimal extravasation, with good drainage into the esophageal lumen, patients can be conservatively managed and treated with antibiotics and nothing by mouth for a short period of observation. In some cases, immediate deployment of a covered, expandable metal stent will seal more substantial leaks. It is imperative that an experienced thoracic surgeon evaluate these patients because, even in the era of covered expandable stents, surgical intervention may be indicated for perforations.
Stents
With the advent of the self-expanding metal stent (SEMS), now more than 20 years ago, endoscopic palliation is now easier and associated with fewer complications than with the historical open traction and push-through techniques. A SEMS can be placed via upper endoscopy with fluoroscopic guidance and does not require general anesthesia. The primary risks are aspiration at time of placement, so general anesthesia may reduce the risk of periprocedural aspiration. Communication with the anesthesiologist is paramount to optimize safety. Perforation is uncommon. One of the earlier reports on the SEMS involved placing a Wallstent, which was originally designed for vascular stenosis. In a small series the endoluminal tumor was partially obliterated with laser and then the SEMS was placed with safe and effective results. Ell et al. also reported a small series of 20 patients with malignant obstruction treated with Gianturco-Z stents 20 years ago. Of the 20 patients, 19 (95%) reported immediate relief in their dysphagia, and there were no technical problems. Fifty percent of the patients complained of chest or epigastric pain after the procedure. The migration rate was 5%.
Table 42.2 summarizes the more commonly used SEMS for malignant obstruction. There are several types of expandable metal stents, and all share many features but have minor design modifications, which may offer advantages of one over the other. The Evolution Controlled-Release Stent or Z-stent (Wilson Cook, Winston-Salem, North Carolina) is composed of stainless steel in either a mesh or zigzag design. It is released with a sheath and pusher rod mechanism, which is meant to optimize accurate placement. The Ultraflex and WallFlex SEMS (Boston Scientific, Watertown, Massachusetts) are knitted stents deployed with the removal of a string. After deployment, typical stent diameter ranges from 18 to 23 mm and stent length is 10 to 15 cm.
TABLE 42.2
Stent Options for Palliation of Malignant Dysphagia
| Stent Type | Manufacturer | Covered | Stent Material | Release | Foreshortening |
|---|---|---|---|---|---|
| Ultraflex | Boston Scientific | Partially Fully |
Nitinol | Proximal and distal | 35% |
| Wallflex | Boston Scientific | Partially Fully |
Cobalt based | Distal | 35% |
| Evolution | Cook Medical | Partially Fully |
Stainless steel | Distal | None |
| Alimaxx-ES | Merit Medical | Fully | Nitinol | Distal | None |
The high radial force of SEMS may result in postoperative pain, which is usually mild and transient. In unusual cases it may persist and require removal. A SEMS is available covered or uncovered. The covered stents reduce tumor ingrowth except at the ends, which are uncovered to reduce stent migration. When tumor ingrowth of the stent occurs or overgrowth at the end of the stent occurs, additional stents can be applied, or neodymium:yttrium-aluminum-garnet (Nd:YAG) laser or photodynamic therapy (PDT) laser can be used to ablate the tumor. Thermal laser may be limited in these situations because the laser can damage the stent nitinol itself. Some of the newer designs of expandable metal stents (Alveolus) offer full-length coverage with options for more stable esophageal wall contact that may minimize migration yet allow full-length coverage.
Self-expanding plastic stents (SEPSs), including Polyflex (Boston Scientific), have more commonly been used to treat benign esophageal lesions because these stents are easier to retrieve given less tissue reaction in comparison to metal stents. Other benefits of plastic stents include lower cost, although they are prone to stent migration. Malignant esophageal disease and palliation has typically been addressed with SEMS. Conio et al. randomized patients to receive either the Polyflex or the Ultraflex stent and reported no difference in palliation of dysphagia but a significantly higher rate of complication, particularly stent migration, in the SEPS group. In addition, a meta-analysis conducted by Yakoub et al. in London also reported metal stents performed superiorly to plastic stent for palliative management of malignant dysphagia.
In our practice, we use a combination of endoscopic and fluoroscopic guidance to measure the length of esophageal obstruction before deploying the expandable metal stents. After adequate seating in the esophagus, the intrinsic radial force of the most expandable metal stents leads to continued expansion to its maximal diameter, depending on the severity of the obstruction. Thus, if a stent appears patent but not open completely on initial placement, the clinician can repeat the endoscopy the next day or obtain a barium esophagram to see if the stent has expanded fully. Poor initial stent deployment, especially with significant infolding, may indicate an improper stent diameter or length. Immediate intervention, such as gentle dilation, or even stent removal may be necessary if an obvious failure is observed. Complications from stent placement can occur early and late. The early complications include aspiration pneumonia during the procedure, esophageal perforation, malpositioned stent, airway compression and compromise with mid to upper esophageal stents, persistent obstruction, and pain. Late complications include intractable reflux, stent obstruction, or migration. The risk of delayed perforation or erosion into adjacent structures is rare but has been described. Delayed removal or repositioning of expandable esophageal stents is generally avoided but in experienced hands has been done. The obvious risk is esophageal trauma with the potential for esophageal perforation. In summary, expandable metal stents provide rapid improvement in malignant dysphagia, allowing patients a short or no hospital stay and improved quality of life. The need for repeat intervention is common in patients who live longer than a few months. In these cases a careful investigation of the causes for stent failure should be made to determine if additional dilation, stent placement, or laser therapy may be indicated to provide continued relief of obstruction.
Recent advancements in stents also include the development of drug-eluting stents, radioactive stents, as well as biodegradable stents. The role of these types of stents for palliation of esophageal malignancy remains to be determined.
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