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Rovirosa A, Marsiglia H, Lartigau E, Zimmermann P, Chirat E, Delapierre M, Briot E, Gerbaulet A. Endoluminal High-Dose-Rate Brachytherapy with a Palliative aim in Esophageal Cancer: Preliminary Results at the Institut Gustave Roussy. TUMORI JOURNAL 2018; 81:359-63. [PMID: 8804454 DOI: 10.1177/030089169508100511] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Ten patients with advanced esophageal carcinoma were treated with endoluminal high-dose-rate brachytherapy at the Institut Gustave Roussy. Eight of them had recurrences after external beam radiotherapy. They were treated with a high-dose rate iridium-192 source. Five patients received 6 sessions of 4 Gy, 4 patients 3 sessions of 4 Gy, and 1 patient received 3 sessions of 8 Gy. The interval time between each session was 1 week. Seventy percent of patients improved their dysphagia, with 80% endoscopic tumor response. The Karnofsky index was improved in most of the patients. The mean survival was 4 months, and dysphagiafree survival was 2.5 months. Two patients had treatment toxicity but only a transitory WHO G1 esophagitis. Endoesophageal high-dose-rate curietherapy seems an effective technique in palliative treatments. We found low toxicity and an excellent tolerance to treatment in previously irradiated patients. The efficacy of the treatment is highly dependent on a precise tumor volume evaluation.
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Affiliation(s)
- A Rovirosa
- Servicio De Oncología Radoterápica, Hospital Clinic I Universitari, Barcelona, Spain
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2
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Clements WD, Johnston LR, McIlwrath E, Spence RA, McGuigan J. Self-Expanding Stents for Malignant Dysphagia. J R Soc Med 2018; 89:454-6. [PMID: 8795499 PMCID: PMC1295887 DOI: 10.1177/014107689608900809] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Self-expanding metallic stents have been employed successfully for vascular, urethral, and biliary strictures. In a prospective study we examined the efficacy of the 16 mm Wallstent for palliation of malignant dysphagia. Eight patients with severe dysphagia due to advanced primary (four) or secondary (four) oesophageal malignant disease were recruited and nine Wallstents were inserted (one patient required two). Dysphagia was reduced in all but one patient, who died after oesophageal perforation; a second patient had a self-limiting bout of haematemesis. Two patients required subsequent treatment for tumour ingrowth but five had no further palliative therapy from stent insertion to time of death. With careful patient selection and skilful application, a 16 mm self-expanding metal endoprosthesis affords effective palliation in malignant oesophageal obstruction.
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Affiliation(s)
- W D Clements
- Department of Thoracic Surgery, Royal Victoria Hospital, Belfast City Hospital, Belfast, Northern Ireland
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3
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Homs MYV, Eijkenboom WMH, Coen VLMA, Haringsma J, van Blankenstein M, Kuipers EJ, Siersema PD. High dose rate brachytherapy for the palliation of malignant dysphagia. Radiother Oncol 2003; 66:327-32. [PMID: 12742273 DOI: 10.1016/s0167-8140(02)00410-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND PURPOSE High dose rate (HDR) brachytherapy is a commonly used palliative treatment for esophageal carcinoma. We evaluated the outcome of HDR brachytherapy in patients with malignant dysphagia. MATERIAL AND METHODS A retrospective analysis over a 10-year period was performed of 149 patients treated with HDR brachytherapy, administered in one or two sessions, at a median dose of 15Gy. Patients were evaluated for functional outcome, complications, recurrent dysphagia, and survival. RESULTS At 6 weeks after HDR brachytherapy, dysphagia scores had improved from a median of 3 to 2 (n=104; P<0.001), however, dysphagia had not improved in 51 (49%) patients. Procedure-related complications occurred in seven (5%) patients. Late complications, including fistula formation or bleeding, occurred in 11 (7%) patients. Twelve (8%) patients experienced minor retrosternal pain. Median survival of the patients was 160 days with a 1-year survival rate of 15%. Procedure-related mortality was 2%. At follow-up, 55 (37%) patients experienced recurrent dysphagia. In 34 (23%) patients a metal stent was placed to relieve persistent or recurrent dysphagia. CONCLUSION HDR brachytherapy is a moderately effective treatment for the palliation of malignant dysphagia. The incidence of early major complications is low, however, persistent and recurrent dysphagia occur frequently, and require often additional treatment.
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Affiliation(s)
- Marjolein Y V Homs
- Department of Gastroenterology and Hepatology, Erasmus MC/University Medical Center, P.O. Box 2040, Rotterdam 3000 CA, Rotterdam, The Netherlands
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4
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Kubba AK, Krasner N. An update in the palliative management of malignant dysphagia. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2000; 26:116-29. [PMID: 10744928 DOI: 10.1053/ejso.1999.0754] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Oesophageal cancer is generally associated with late presentation and poor prognosis. Therefore palliative surgery has been largely superseded by less invasive non-surgical techniques. Once palliation is indicated, the aims of the management should be: the maintenance of oral intake, minimizing hospital stay, relief of pain, elimination of reflux and regurgitation and the prevention of aspiration. METHODS This study was a review of all published English language data on the palliation of malignant dysphagia between 1994-1999. The Medline and Bids databases were searched and other references were derived from the material perused. RESULTS AND CONCLUSIONS Palliative treatment for oesophageal cancer should be individualized and relate to tumour stage, size and location, the patient's medical condition and his/her personal wishes. The palliative treatment largely includes self-expanding metal stents (SEMS), laser (including photodynamic therapy (PDT)) or a combination of the two to relieve symptoms, this may be employed with or without other treatments such as radiotherapy/chemotherapy (RT/CT) with the aim of reducing tumour bulk and possibly prolonging survival. A multi-disciplinary approach is vital in patients with advanced oesophageal cancer.
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Affiliation(s)
- A K Kubba
- Dept of Surgery, University of Nottingham, Liverpool, UK
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Blazeby JM, Alderson D. Review: chemotherapy, irradiation and their roles in the management of oesophageal cancer. J Gastroenterol Hepatol 1997; 12:612-9. [PMID: 9304515 DOI: 10.1111/j.1440-1746.1997.tb00494.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The role of multimodality therapy in the treatment of oesophageal cancer has been extensively investigated in many longitudinal studies and randomized trials. Despite some promising results, no clear beneficial evidence has consistently been produced. At present it cannot be routinely recommended outside the context of controlled clinical trials.
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Affiliation(s)
- J M Blazeby
- University Department of Surgery, Bristol Royal Infirmary, UK
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6
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Spencer GM, Thorpe SM, Sargeant IR, Blackman GM, Solano J, Tobias JS, Bown SG. Laser and brachytherapy in the palliation of adenocarcinoma of the oesophagus and cardia. Gut 1996; 39:726-31. [PMID: 9014774 PMCID: PMC1383399 DOI: 10.1136/gut.39.5.726] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Palliation of malignant dysphagia is possible by a variety of methods although all have significant drawbacks. Laser therapy is an effective and safe treatment but has to be repeated at four to five weekly intervals to maintain palliation. A means of augmenting the benefits while reducing the need for repeat treatments would be highly beneficial to these patients. AIMS To prospectively explore the safety and efficacy of intraluminal radiotherapy (brachytherapy) when used to augment laser recanalisation for malignant dysphagia. PATIENTS Nineteen patients with dysphagia due to advanced adenocarcinoma of the oesophagus or cardia were recruited. METHODS All patients received laser recanalisation until able to swallow a soft diet or better, before the application of a single dose of brachytherapy (10 Gy at 1 cm from the source). Patients were followed up and treated promptly by further endoscopic means in the event of their dysphagia worsening. RESULTS Six patients (32%) required no further treatment until death at a median of 10 weeks (range 1-20 weeks). Further therapy was required at a median of 11 weeks (range 4-37 weeks) after brachytherapy for those 13 patients with recurrent dysphagia. Subsequent symptom control required endoscopic intervention at an average of once every nine weeks. There was no mortality associated with laser or brachytherapy. Median survival from initial treatment and including the one survivor was 36 weeks (range 5-132 weeks). CONCLUSIONS Laser plus brachytherapy offers a safe and effective means of palliating malignant dysphagia due to adenocarcinoma, with a longer dysphagia free interval than historical controls treated with laser alone.
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Affiliation(s)
- G M Spencer
- National Medical Laser Centre, University College London Medical School, London
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7
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Shmueli E, Srivastava E, Dawes PJ, Clague M, Matthewson K, Record CO. Combination of laser treatment and intraluminal radiotherapy for malignant dysphagia. Gut 1996; 38:803-5. [PMID: 8984013 PMCID: PMC1383182 DOI: 10.1136/gut.38.6.803] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Laser treatment for malignant dysphagia is limited by recurrent intraluminal tumour requiring repeated treatment at four to eight week intervals. AIMS To reduce the need for follow up treatment and to improve survival, patients successfully palliated by laser were treated with intraluminal radiotherapy. PATIENTS 32 patients with inoperable oesophageal carcinoma (18 adeno and 14 squamous cell carcinoma). METHODS The patients were initially palliated by a median of three laser treatments. They were then treated with intraluminal radiotherapy, receiving 10-15 Gy at 1 cm from the source as a single treatment with the Selectron system. Patients with squamous cell carcinoma also received external radiotherapy (30 to 50 Gy). RESULTS After the radiotherapy nine patients survived a median of 22 (range 4-40) weeks without requiring any further endoscopic treatment. The remaining patients survived a median of 40 (range 4-102) weeks and required a median of three follow up endoscopic treatments over that time. Eleven patients developed fibrous strictures with no intraluminal tumour and were treated by dilatation. Twelve patients required dilatation and repeat laser therapy for a combination of fibrous stricture and recurrent intraluminal tumour. Six patients eventually required Atkinson tubes. CONCLUSIONS The combination of laser treatment with intraluminal radiotherapy provides good palliation and may reduce the need for repeated endoscopic treatment. Fibrous stricture formation is a common complication.
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Affiliation(s)
- E Shmueli
- Department of Gastroenterology, Royal Victoria Infirmary, Newcastle Upon Tyne
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8
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Maciel J, Barbosa J, Leal AS. Nd-YAG laser as a palliative treatment for malignant dysphagia. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 1996; 22:69-73. [PMID: 8846872 DOI: 10.1016/s0748-7983(96)91616-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Two hundred and twenty-four patients with histologically-confirmed carcinoma of the oesophagus received palliative Nd-YAG laser therapy for malignant dysphagia between January 1986 and December 1994. The results are appraised in terms of the degree of relief obtained, its relation to the macroscopic type and the size of the tumour, peri-operative complications, duration of hospitalization and survival after treatment. Recannulation of the oesophageal lumen was obtained in 98.2% of the patients, after which 93.7% were able to ingest at least semi-solids. Although the lumen was permeable for a 9.8 mm endoscope, the remainder could only ingest liquids. The only complication was a perforation is six cases (2.7%). After treatment, 14.8% survived more than 1 year and 3.4% more than 2 years. After discussing the role of lasers in the palliative treatment of malignant dysphagia, the authors conclude that it can be considered effective in that it relieves the dysphagia and improves the patients' quality of life.
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Affiliation(s)
- J Maciel
- St. John's Hospital, Surgery 1, Oporto Medical School, Portugal
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9
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Spinelli P, Mancini A, Dal Fante M. Endoscopic treatment of gastrointestinal tumors: indications and results of laser photocoagulation and photodynamic therapy. SEMINARS IN SURGICAL ONCOLOGY 1995; 11:307-18. [PMID: 7481368 DOI: 10.1002/ssu.2980110406] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Both Nd:YAG laser and photodynamic therapy (PDT) have ideal indications in endoscopic treatment of gastrointestinal (GI) tumors. A retrospective analysis of 3,505 Nd:YAG laser treatments in 1,015 patients revealed that recanalization of inoperable tumors can be obtained in 93% and 97% of patients with upper and lower GI neoplasms, respectively. Subjective improvement of symptoms was achieved in 74% and 97%, respectively. The overall morbidity and mortality rates were 3% and 1%, respectively, for upper GI tumors and 3% and 0.5% for lower GI tumors. Colorectal adenomas were eradicated in 84% of cases, with a morbidity and mortality of 5% and 0%, respectively. Early stage esophageal and gastric carcinomas were treated with Nd:YAG laser when lesions had well-defined borders or protruded over the mucosal surface and with PDT (38 PDT cycles in 27 patients) in the case of undefined borders or ulcerated lesions. The cure rate was 73% for esophageal tumors and 85% for gastric tumors. Sunburns after photosensitization and local complications occurred in 7% and 6% of patients, respectively. No death was related to endoscopic treatment.
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Affiliation(s)
- P Spinelli
- Endoscopy Department, Instituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
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10
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MRI-guided brachytherapy for cancer of the oesophagus. Eur Radiol 1993. [DOI: 10.1007/bf00425897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Shmueli E, Myszor MF, Burke D, Record CO, Matthewson K. Limitations of laser treatment for malignant dysphagia. Br J Surg 1992; 79:778-80. [PMID: 1382796 DOI: 10.1002/bjs.1800790822] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Of 86 patients with inoperable malignant dysphagia, 68 (79 per cent) underwent successful palliation by endoscopic laser therapy, of whom 24 remained well palliated until the time of death. In 18 patients laser treatment was unsuccessful and nine of these underwent intubation, eight successfully. After successful laser therapy, dysphagia recurred in 44 patients a mean of 7.8 weeks later. Of these, 31 received palliation until death by dilatation with or without laser therapy, and 13 required intubation. The overall laser-related complication rate was 12 per cent with a mortality rate of 4 per cent. The intubation-related mortality rate was 9 per cent.
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Affiliation(s)
- E Shmueli
- Gastroenterology Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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12
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Spinelli P, Dal Fante M, Mancini A. Current role of laser and photodynamic therapy in gastrointestinal tumors and analysis of a 10-year experience. SEMINARS IN SURGICAL ONCOLOGY 1992; 8:204-13. [PMID: 1379372 DOI: 10.1002/ssu.2980080405] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Laser energy can be used for a variety of neoplastic diseases including benign tumors, early stage malignancies, and advanced carcinomas, either with curative intent or for palliation. Nd:YAG laser photocoagulation of 168 colorectal adenomas allowed a complete eradication in 70% of cases, after a mean follow-up of 22 months. Advanced and obstructing tumors were treated with Nd:YAG laser to recanalize the lumen. In the upper gastrointestinal tract the recanalization of the lumen by means of laser photocoagulation improved the quality of life and survival. In fact, in our series of 308 patients treated, 1-year survival was 23% in recanalized patients and 7% in nonrecanalized patients. In the lower gastrointestinal tract, 289 cancer patients were treated and an amelioration of symptoms related to the obstruction was obtained in 93%. The current indication for photodynamic therapy is mainly the treatment of flat or ulcerative early stage tumors in the esophagus and stomach of high risk patients. Out of 17 patients treated, 14 were locally cured.
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Affiliation(s)
- P Spinelli
- Endoscopy Division, Istituto Nazionale Tumori, Milan, Italy
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13
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Abstract
Lasers have contributed in a significant way to the evolution of therapeutic endoscopy. Their ability to coagulate and ablate tissue precisely has been applied to a wide variety of lesions in the upper gastrointestinal tract. Meanwhile, the number of nonlaser devices has also continued to expand, making it necessary to frequently reassess their respective roles. Available evidence suggests that current laser equipment is best suited for the palliative ablation of tumors, especially in the esophagus. On the other hand, the hemostatic properties of the laser are still indicated in the control of vascular malformations but have been largely displaced in the management of peptic ulcer disease by other, more convenient and less expensive methods. With a new generation of laser equipment likely to be introduced soon, these comparisons will undoubtedly need to continue for some time.
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14
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Tobias JS, Bown SG. Palliation of malignant obstruction--use of lasers and radiotherapy in combination. Eur J Cancer 1991; 27:1350-2. [PMID: 1720633 DOI: 10.1016/0277-5379(91)90007-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- J S Tobias
- Department of Radiotherapy and Oncology, University College Hospital, London, U.K
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15
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Fuchs KH, Freys SM, Schaube H, Eckstein AK, Selch A, Hamelmann H. Randomized comparison of endoscopic palliation of malignant esophageal stenoses. Surg Endosc 1991; 5:63-7. [PMID: 1719650 DOI: 10.1007/bf00316838] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In a randomized study, palliative therapy of malignant esophageal and gastric stenosis was investigated by a comparison of endoscopic laser therapy (ELT) with palliative endoscopic perturbation (PEP). A total of 124 patients exhibiting a malignant stenosis in the esophagus and proximal stomach were referred to our unit between January 1, 1987, and March 31, 1990. Criteria for randomization were: (1) inoperable malignant stenosis, (2) dysphagia enabling the ingestion of semi-solid food, (3) the possibility of performing ELT and PEP, and (4) the absence of fistula formation. Only 40 patients met these criteria; the remaining 84 subjects were assigned to an escape group whose treatment consisted of ELT, PEP, percutaneous endoscopic gastrostomy, transnasal feeding tube, radiotherapy, and endoscopic bougienage. We found no significant difference between ELT and PEP with regard to survival, food passage, or quality of life. We recommend the application of PEP in patients exhibiting advanced tumor disease and a poor general condition and favour the use of ELT combined with afterloading in patients with a life expectancy of greater than or equal to 3 months.
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Affiliation(s)
- K H Fuchs
- Chirurgische Universitäsklinik und Poliklinik, Würzburg, Federal Republic of Germany
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16
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Sander R, Hagenmueller F, Sander C, Riess G, Classen M. Laser versus laser plus afterloading with iridium-192 in the palliative treatment of malignant stenosis of the esophagus: a prospective, randomized, and controlled study. Gastrointest Endosc 1991; 37:433-40. [PMID: 1717341 DOI: 10.1016/s0016-5107(91)70775-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Thirty-nine patients with malignant stenoses of the esophagus (22 adenocarcinomas, 17 squamous cell carcinomas) were treated either with Nd:YAG laser recanalization alone (N = 20) or with laser recanalization and subsequent endoluminal afterloading irradiation with iridium-192 at a dose of 3 x 7 Gy (6 x 7 Gy). Squamous cell carcinoma patients in the afterloading group showed a prolonged dysphagia-free first interval (65 vs. 30 days, p less than 0.03), while patients with an adenocarcinoma did not share this benefit, and had a need for more frequent endoscopic procedures (p less than 0.05). The complication of esophagitis was only seen following afterloading treatment (21%, N = 4). Re-stenosis occurred in all patients. Neither the duration of relative dysphagia nor survival time was prolonged after endoluminal irradiation in adenocarcinoma or squamous cell carcinoma patients. After prior laser recanalization, palliative afterloading treatment with iridium-192 would seem helpful only in cases of squamous cell carcinoma with a high performance status with the aim of prolonging the first dysphagia-free interval.
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Affiliation(s)
- R Sander
- I. Med. Abteilung-Gastroenterologie, Städtisches Klinikum Harlaching, Munich, Germany
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17
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Urschel JD, Cockburn JS, Foote AV. Palliation of oesophageal cancer--endoscopic intubation and laser therapy. Postgrad Med J 1991; 67:414-6. [PMID: 1712967 PMCID: PMC2398847 DOI: 10.1136/pgmj.67.787.414] [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: 12/28/2022]
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18
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Loizou LA, Grigg D, Atkinson M, Robertson C, Bown SG. A prospective comparison of laser therapy and intubation in endoscopic palliation for malignant dysphagia. Gastroenterology 1991. [PMID: 1707386 DOI: 10.1016/0016-5085(91)90782-g] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
There is little objective long-term follow-up comparing laser therapy with intubation for palliation of malignant dysphagia. In a prospective, nonrandomized two-center trial 43 patients treated with the neodymium:yttrium-aluminum-garnet laser were compared with 30 patients treated by endoscopic intubation; the two groups were comparable for mean age and tumor position, length, and histology. Dysphagia was graded from 0 to 4 (0, normal swallowing; 4, dysphagia for liquids). Pretreatment mean dysphagia grades were similar: laser-treated group, 2.9 (SD, 0.6); intubated group, 3.2 (SD, 0.55). For thoracic esophageal tumors, the percentage of patients achieving an improvement in dysphagia grade by greater than or equal to 1 grade initially and over the long term was similar (laser, 95% and 77%; intubation, 100% and 86%). For tumors crossing the cardia, intubation was significantly better (laser, 59% and 50%; intubation, 100% and 92%, respectively; P less than 0.001). In patients palliated over a long period, however, the mean dysphagia grade over the remainder of their mean dysphagia grade over the remainder of their lives (mean survival: laser, 6.1 months; intubation, 5.1 months) was better in the laser group (1.6 vs. 2.0; P less than 0.01); 33% of laser-treated and 11% of intubated patients could eat most or all solids (P less than 0.05). For long-term palliation, laser-treated patients required on average more procedures (4.6 vs. 1.4; P less than 0.05) and days in the hospital (14 vs. 9; P less than 0.05). The perforation rate was lower in the laser-treated group (2% vs. 13%; P less than 0.02); no treatment-related deaths occurred in either group. For individual patients, the best results are likely to be achieved when the two techniques are used in a complementary fashion in specialist centers.
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Affiliation(s)
- L A Loizou
- National Medical Laser Centre, University College Hospital, London, England
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19
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Hölting T, Friedl P, Schraube N, Fritz P, Schlag P, Herfarth C. Palliation of esophageal cancer--operative resection versus laser and afterloading therapy. Surg Endosc 1991; 5:4-8. [PMID: 1714631 DOI: 10.1007/bf00591377] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Since 1985, 71 patients with end-stage esophageal cancer have been treated either by surgical (n = 26) or endoscopic laser palliation (n = 45). In 16 of 45 patients treated by endoscopy, additional radiotherapy (extrenal and endoluminal irradiation) was performed. Surgery and Nd:YAG recanalization were initially effective in removing the malignant obstruction in 80% of cases. There were no significant differences in survival in either group. The stenosis-free interval was longer in patients who underwent surgery: 24 weeks; minimal stenosis-free interval: 20 weeks. Local recurrences occurred earlier in the endoscopic study group (mean survival: 36 weeks; minimal stenosis-free interval: 20 weeks). Most stenoses successfully underwent further laser treatment. Although only 35% of patients treated endoscopically underwent additional afterloading therapy, this treatment appears to prolong palliation (mean survival: 38 weeks; minimal stenosis-free interval: 36 weeks). A few patients bled after endoscopy and were treated conservatively. The most important complication in the afterloading group was esophagobronchial perforation, which caused one death in our series. Transient pulmonary problems were the most common complication (31%) in the surgical group with a hospital mortality of 19%. Overall, the improvement in the quality of life after surgery was better. However, our results show that Nd:YAG recanalization and afterloading therapy are effective therapeutic alternatives in patients unfit for surgery.
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Affiliation(s)
- T Hölting
- Chirurgische Universitätsklinik, Heidelberg, Federal Republic of Germany
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20
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Spinelli P, Dal Fante M, Mancini A. Endoscopic palliation of malignancies of the upper gastrointestinal tract using Nd:YAG laser: results and survival in 308 treated patients. Lasers Surg Med 1991; 11:550-5. [PMID: 1721673 DOI: 10.1002/lsm.1900110609] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Three hundred eight patients with obstructing malignant tumors of the gastrointestinal tract were submitted to endoscopic Nd:YAG laser palliation. The number of sessions as well as the number of days and total energy required for initial recanalization of the stenosis were related to tumor length. Luminal patency was obtained in 94% of patients, but improved swallowing was achieved in 74% of patients. The technical success rate did not depend on tumor site, whereas functional positive results are related to the location of the stenosis, with worst results for tumors involving the upper third of the esophagus. Life-table analysis revealed that 1-year survival was 23% when a luminal patency was achieved and 7% when treatment failed.
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Affiliation(s)
- P Spinelli
- Division of Endoscopy, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
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21
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Abstract
The palliative effect of endoscopic Nd:YAG laser treatment of malignant strictures of the oesophagus and cardia was prospectively evaluated in 30 patients. Most (n = 28) were primarily treated for dysphagia, and swallowing was improved in 21 and normalized in 14 of these patients. Two patients were successfully treated for bleeding. Six patients developed complications (including two perforations), and four of these were fatal. The median survival was 4 months (range, 17 days to 14 months). It is concluded that in a great number of patients with inoperable cancer of the oesophagus and cardia, laser treatment is better than other palliative procedures.
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Affiliation(s)
- S Schulze
- Dept. of Surgery C, Rigshospitalet, University of Copenhagen, Denmark
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Abstract
The rapid evolution of fiberoptic endoscopes over the past three decades has greatly enhanced our understanding of esophageal diseases and has stimulated significant improvements in their management. With the early endoscopic diagnosis of infectious and inflammatory lesions, specific medical or surgical treatment can be initiated promptly and the results monitored easily. Although the diagnosis of malignant lesions is still commonly delayed because of the absence of early symptoms, surveillance of Barrett's esophagus offers the hope of more definitive management in these patients. Endoscopy has assumed an increasingly important therapeutic role in patients with inoperable cancer because it provides access for new ablative techniques or the placement of palliative prosthetic devices. Continuing advances in the use of endoscopic ultrasound, the delivery of photodynamic therapy, and the adjunctive application of intraluminal irradiation promise to further broaden the scope of fiberoptic intervention.
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Affiliation(s)
- W H Schwesinger
- Department of Surgery, University of Texas Health Science Center, San Antonio
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23
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Abstract
The Nd:YAG and, to a lesser degree, the argon laser have become valuable tools for the surgical endoscopist. Over the last 10 years, the impetus for application of these expensive instruments has changed from what the laser can do to what the laser can do better than less expensive technology. Whereas a few controlled randomized studies suggest that the Nd:YAG laser is better than no therapy and equivalent to other heat-producing instruments for control of upper gastrointestinal bleeding, such studies do not exist for other laser applications. Despite the lack of such studies, we remain convinced that, where available, lasers are the instrument of choice for palliation of unresectable mucosal-based cancers, coagulation of arteriovenous malformations, and ablation of certain adenomatous polyps in selected patients. New techniques on the horizon include the use of endoscopic photo-dynamic therapy for treatment of gastrointestinal cancers and endoscopic laser fragmentation of large common bile duct stones. The potential role for a nonthermal "endoscopic scalpel" is questionable because most gastrointestinal tissues are well vascularized; however, a pulsed laser capable of cutting and coagulation, such as the holmium:YAG laser, may be of some value for incisional endoscopic procedures.
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Affiliation(s)
- J G Hunter
- University of Utah, Department of Surgery, Salt Lake City
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24
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Moon BC, Kenneth Woolfson I, Dale Mercer C. Neodymium:yttrium-aluminum-garnet laser vaporization for palliation of obstructing esophageal carcinoma. J Thorac Cardiovasc Surg 1989. [DOI: 10.1016/s0022-5223(19)34454-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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25
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Fleischer D. Endoscopic laser therapy for esophageal cancer: present status with emphasis on past and future. Lasers Surg Med Suppl 1989; 9:6-16. [PMID: 2467155 DOI: 10.1002/lsm.1900090104] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Although the major initial application for endoscopic laser therapy was for the management of gastrointestinal hemorrhage, it is now more common to use the laser endoscopically for the treatment of gastrointestinal neoplasms. A major body of literature surrounds the use of endoscopic laser therapy for esophageal cancer. The initial patient evaluation to determine if laser therapy is indicated includes a contrast radiograph, a screening endoscopy, and an imaging study. After these tests have been performed, it can be determined whether endoscopic laser therapy (ELT) is the best of the many endoscopic options. There is some difference of opinion as to the specifics of the treatment technique, and these are described. There is general agreement from reviewing the clinical data that it is possible to open the obstructed lumen in a large majority of cases and that functional success (the ability to achieve technically good results as well as clinical improvement without complications) is also possible in the majority of patients. Despite the information suggesting the benefits of ELT for esophageal cancer, there are both conceptual and technical limitations to the current approach to therapy. These limitations as well as potential future applications are discussed.
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Affiliation(s)
- D Fleischer
- Georgetown University Hospital, Washington, D.C. 20007
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26
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Lambert R. Cancer in the oesophagus--palliation with laser or endoprosthesis. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1987; 1:905-15. [PMID: 2452662 DOI: 10.1016/0950-3528(87)90026-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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27
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Kiefhaber P. Indications for endoscopic neodymium-YAG laser treatment in the gastrointestinal tract. Twelve years' experience. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1987; 139:53-63. [PMID: 3324300 DOI: 10.3109/00365528709089775] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Application of clinical endoscopic Nd:YAG laser (lambda = 1.06 micron) therapy has been introduced in 1975. It is suitable to stop all kinds of gastrointestinal bleeding with a primary success rate of 94% (1144/1212). Compared to surgical results a reduction in mortality rate has been achieved. These results have been confirmed worldwide in routine clinical application and in controlled trials with selected patients. Potential bleeding lesions such as Osler haemangiomas and angiodysplasias can be sealed. Recanalization of inoperable obstructed oesophageal and gastric carcinoma by laser vaporization to relieve dysphagia and subsequently endoscopic iridium after loading irradiation show a medium survival time of 7.4 months. Preoperative recanalization of obstructed colorectal carcinoma to relieve ileus or subileus allows preoperative peroral bowel lavage and total colonoscopy to find synchronous cancers and polyps and to perform primary resections without intraoperative colon lavage. Sessile benign neoplastic polyps can be resected curatively by Nd:YAG laser vaporization. Recanalization of peptic stenosis and anastomotic scar stenosis can be performed.
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Affiliation(s)
- P Kiefhaber
- Stradtkrankenhaus Traunstein, Akademisches Lehrkrankenhaus, University of Munich, FRG
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