Self-expanding plastic stent to palliate symptomatic tissue in/overgrowth after self-expanding metal stent placement for esophageal cancer

Embryonic esophageal rhabdomyosarcoma in an adult male: A case report and literature review

Basic principle

There exists a rare aggressive neoplasm called esophageal rhabdomyosarcoma. It originates in cells of the striated muscle or mesenchymal cells which differ from the striated muscle. This tumor has a high degree of malignancy and extensive metastasis. Masses of the sick people are at a high phase when going to hospital. Consequently, the prognosis is exceedingly bad.

Patient concerns

A 54-year-old male presented with dysphagia as the initial symptom. Gastroscopy showed an irregular protuberant lesion about 18–22 cm from the incisor. The lesion was observed to be pathological under gastroscopy and was diagnosed as an (esophageal) sarcoma.

Diagnosis

Embryonic esophageal rhabdomyosarcoma.

Interventions

After receiving two cycles of DP (docetaxel and cisplatin) chemotherapy in the local hospital, the patient received 60 Gy of radiotherapy in 30 fractions combined with chemotherapy at our hospital. Dysphagia was relieved, and the tumor appeared significantly shrunken on imaging after the treatment.

Outcomes

Lung metastasis occurred 1 month after radiotherapy, and the patient died of pulmonary edema on March 11, 2022.

Lessons

Previously reported cases of embryonic esophageal rhabdomyosarcoma are few. Theoretically, the disease should occur in adolescents; nevertheless, our case was a man who was in middle-aged; the neoplasm was in an unusual position: the upper part of the esophagus. Moreover, the patient initially had good response to the combination of radiotherapy and chemotherapy. Although he died 8 months after diagnosis, the presented data represent a valuable resource for understanding the survival benefits of treating embryonic esophageal rhabdomyosarcoma patients with radiotherapy combined with chemotherapy. In addition, we reviewed the previously reported literature, and a total of 17 cases of esophageal rhabdomyosarcoma were identified and analyzed.

Esophageal extraskeletal neoplasm Ewing's sarcoma: Case report

INTRODUCTION AND IMPORTANCE

Ewing sarcomas are a group of small round cell tumors that occur predominantly in the long bones as well as in extraosseous locations such as the extremities, trunk, and retroperitoneum (Gier, 1997) [2]. Extraosseous Ewing sarcoma (EES) is a type of small round cell tumor that occurs in soft tissues. I rare cases, EES occurs in the esophagus (Maesawa et al., 2002; Johnson et al., 2010) [1,3]. Ewing's sarcoma is a rare and highly aggressive cancer most frequently arising in people under 20 years of age. We report an uncommon case of primary paraesophageal Ewing's sarcoma in a 25-year-old female.

CASE PRESENTATION

A 26 years old Asian female referred primarily for surgical treatment due to esophageal cancer detected on her diagnostic investigations and revealed a primary tumor located near the gastroesophageal junction. Based on the results of diagnostic investigations which confirmed the possibility of the tumor Ewing sarcoma of esophagus, which was biopsy and immune histochemical stain proven the patient was qualified for surgical treatment. She underwent Mckewon esophagectomy on October 2021 for Ewing sarcoma of esophagus. She was first followed with neoadjuvant intravenous chemotherapy, after taking three cycles of neoadjuvant chemo showed good response in CT scan the patient underwent Mckewon esophagectomy, post op recovery was smooth she underwent 2 cycles of adjuvant chemotherapy after four months of surgery. Her followup visit was uneventful.

CLINICAL DISCUSSION

Ewing's sarcoma is the second most frequent primary malignant bone cancer, after osteosarcoma. It was first described by James Ewing in 1921, as an undifferentiated tumor developing in the diaphysis of the ulna of a young female patient (Ushigome et al., 2002) [6]. Ewing sarcoma/primitive neuroectodermal tumor (ES/PNET), previously thought to be separate tumors, is now treated as the same tumor; both have similar immunohistochemical characteristics and chromosomal translocation (Maesawa et al., 2002) [1]. They are malignant tumors composed of undifferentiated small round cells, usually affecting children, adolescents, and young adults (Kondo et al., 2005) [7]. Generally ES/PNET affects the bones and deep soft tissues (Soulard et al., 2005) [8], although other organs such as the pancreas, small bowel, esophagus, kidneys, prostate, ovaries, vagina and rectovaginal septum have been reported; this is termed as extraskeletal ES/PNET (Bloom et al., 1995) [9]. To the best of our knowledge, only 5 cases of gastric ES/PNET have been reported in the English language literature. Extraskeletal Ewing's sarcoma is a very rare disease, accounting for 6 %-47 % of all cases of Ewing's sarcoma. It is mainly diagnosed in the trunk, extremities, retroperitoneum, and head and neck region. Patients with extraosseous Ewing's sarcoma are more likely to be older, female, and not of Caucasian origin. An extraskeletal origin of the disease is correlated to poor prognosis (Siegel et al., 1988; Granowetter and West, 1997; Ushigome et al., 2002) [4-6]. We present an uncommon case of extraskeletal Ewing's sarcoma, and discuss its rare presentation and evolution. To our knowledge, this is the first reported case of paraesophageal primary Ewing's sarcoma and primitive neuroectodermal tumor. Adenocarcinoma and squamous cell carcinoma account for the vast majority of esophageal malignancies. Other malignancies known to occur in the esophagus include melanoma, sarcoma, and lymphoma. Among the sarcomas, carcinosarcoma is the commonest with both carcinomatous and sarcomatous elements followed by leiomyosarcoma of mesenchymal origin. Other sarcomas reported in the literature are liposarcoma, synovial sarcoma, myxofibrosarcoma, Ewing's sarcoma, granulocytic sarcoma, histiocytic sarcoma, schwannoma rhabdomyosarcoma, and epithelioid sarcoma.

CONCLUSION

Ewing sarcoma is a rare entity among all esophageal malignancies. It presents as an exophytic mass, and in this case, it has presented as a mass occluding the lumen of esophagus. Most of these tumors present in locally advanced and disseminated condition, one of the reasons being difficulty and hence delay in diagnosis. In spite of best efforts, a group among them remains to be histologically uncharacterized.

Malignant Bowel Obstruction: Reappraising the Value of Surgery

Urgent palliative surgery in the setting of advanced malignancy is associated with significant morbidity, mortality, and cost. Malignant bowel obstruction is the most frequent indication for such intervention. Traditional surgical dogma is often invoked to justify associated risks and cost, but little evidence exists to support surgical over nonsurgical approaches. Evolving evidence may provide more meaningful guidance for treatment selection.

Value in palliative cancer surgery: A critical assessment

Emergency operations are associated with increased morbidity, mortality, and cost compared to elective operations. Palliative and emergent surgery for patients with advanced malignancies is associated with additional risk and remains controversial. Emergent or palliative interventions can be broadly categorized according to indication. Tumor related complications (bleeding, obstruction, or perforation) merit specific consideration, as do specific presentations such as pneumoperitoneum, pneumatosis intestinalis, or peritonitis from other causes that may arise during active therapy for malignancies. Although nonoperative, endoscopic, and interventional treatment modalities are frequently available, surgery remains the only effective therapy in selected situations such as small intestinal obstruction and tumor perforation. Selection of patients for surgery requires consideration of factors including overall prognosis, performance status, and patients' priorities. Selection and risk assessment tools underscore the limited capacity of patients' with higher risk features for durable recovery but do not supplant nuanced clinical judgment. J. Surg. Oncol. 2016;114:311-315. © 2016 Wiley Periodicals, Inc.

Randomized controlled trial to investigate the effect of metal clips on early migration during stent implantation for malignant esophageal stricture

BACKGROUND

The rate of stent migration, especially in the short term after implantation, is high in the treatment process. We sought to explore an effective method for preventing early migration after stent implantation for malignant esophageal stricture and to provide the basis for clinical treatment.

METHODS

We conducted a prospective, open-label, parallel-assignment randomized controlled trial with patients undergoing stent implantation for malignant esophageal stricture. The proximal segments of stents in the treatment group were fixed with 2 metal clips during the perioperative period of esophageal stent implantation, while no treatment was used in the control group. All patients underwent radiography at 3 and 7 days and 1 and 3 months after placement to assess the stent migration.

RESULTS

There were 83 patients in our study. Demographic characteristics were similar between the groups. There was no stent migration observed in the treatment group within 2 weeks of the operation, while stent migration was observed in 6 of 41 (14.6%) cases in the control group, occurring at 3 and 7 days after placement. There were no perioperative complications.

CONCLUSION

Perioperative fixation of the proximal segments of stents with metal clips is effective in preventing early stent migration.

Silver-nanoparticle-coated biliary stent inhibits bacterial adhesion in bacterial cholangitis in swine

BACKGROUND

One of the major limitations of biliary stents is the stent occlusion, which is closely related to the over-growth of bacteria. This study aimed to evaluate the feasibility of a novel silver-nanoparticle-coated polyurethane (Ag/PU) stent in bacterial cholangitis model in swine.

METHODS

Ag/PU was designed by coating silver nanoparticles on polyurethane (PU) stent. Twenty-four healthy pigs with bacterial cholangitis using Ag/PU and PU stents were randomly divided into an Ag/PU stent group (n=12) and a PU stent group (n=12), respectively. The stents were inserted by standard endoscopic retrograde cholangiopancreatography. Laboratory assay was performed for white blood cell (WBC) count, alanine aminotransferase (ALT), interleukin-1beta (IL-1beta), tumor necrosis factor-alpha (TNF-alpha) at baseline time, 8 hours, 1, 2, 3, and 7 days after stent placements. The segment of bile duct containing the stent was examined histologically ex vivo. Implanted biliary stents were examined by a scan electron microscope. The amount of silver release was also measured in vitro.

RESULTS

The number of inflammatory cells and level of ALT, IL-1beta and TNF-alpha were significantly lower in the Ag/PU stent group than in the PU stent group. Hyperplasia of the mucosa was more severe in the PU stent group than in the Ag/PU stent group. In contrast to the biofilm of bacteria on the PU stent, fewer bacteria adhered to the Ag/PU stent.

CONCLUSIONS

PU biliary stents modified with silver nanoparticles are able to alleviate the inflammation of pigs with bacterial cholangitis. Silver-nanoparticle-coated stents are resistant to bacterial adhesion.

Randomized controlled trial to investigate the effect of metal clips on early migration during stent implantation for malignant esophageal stricture

BACKGROUND

The rate of stent migration, especially in the short term after implantation, is high in the treatment process. We sought to explore an effective method for preventing early migration after stent implantation for malignant esophageal stricture and to provide the basis for clinical treatment.

METHODS

We conducted a prospective, open-label, parallel-assignment randomized controlled trial with patients undergoing stent implantation for malignant esophageal stricture. The proximal segments of stents in the treatment group were fixed with 2 metal clips during the perioperative period of esophageal stent implantation, while no treatment was used in the control group. All patients underwent radiography at 3 and 7 days and 1 and 3 months after placement to assess the stent migration.

RESULTS

There were 83 patients in our study. Demographic characteristics were similar between the groups. There was no stent migration observed in the treatment group within 2 weeks of the operation, while stent migration was observed in 6 of 41 (14.6%) cases in the control group, occurring at 3 and 7 days after placement. There were no perioperative complications.

CONCLUSION

Perioperative fixation of the proximal segments of stents with metal clips is effective in preventing early stent migration.

Role of stenting in gastrointestinal benign and malignant diseases

Advances in stents design have led to a substantial increase in the use of stents for a variety of digestive diseases. Initially developed as a non-surgical treatment for palliation of esophageal cancer, the stents now have an emerging role in the management of malignant and benign conditions as well as in all segments of the gastrointestinal tract. In this review, relevant literature search and expert opinions have been used to evaluate the key-role of stenting in gastrointestinal benign and malignant diseases.

Small bowel perforation due to a migrated esophageal stent: Report of a rare case and review of the literature

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Palliation of dysphagia with esophageal stenosis via esophageal stent placement is an effective procedure.

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Migration is one of the most common complication after stent placement.

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The lumen of stent is often allow to the passage in the intestine, so symptoms may develop much later.

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Intestinal perforation is a rare but serious complication of stent migration.

Introduction

Endoscopic esophageal stent placement is used to treat benign strictures, esophageal perforations, fistulas and for palliative therapy of esophageal cancer. Although stent placement is safe and effective method, complications are increasing the morbidity and mortality rate. We aimed to present a patient with small bowel perforation as a consequence of migrated esophageal stent.

Presentation of case

A 77-years-old woman was admitted with complaints of abdominal pain, abdominal distension, and vomiting for two days. Her past medical history included a pancreaticoduodenectomy for pancreatic tumor 11 years ago, a partial esophagectomy for distal esophageal cancer 6 months ago and an esophageal stent placement for esophageal anastomotic stricture 2 months ago. On abdominal examination, there was generalized tenderness with rebound. Computed tomography showed the stent had migrated. Laparotomy revealed a perforation localized in the ileum due to the migrated esophageal stent. About 5 cm perforated part of gut resected and anastomosis was done. The patient was exitus fifty-five days after operation due to sepsis.

Discussion

Small bowel perforation is a rare but serious complication of esophageal stent migration. Resection of the esophagogastric junction facilitates the migration of the stent. The lumen of stent is often allow to the passage in the gut, so it is troublesome to find out the dislocation in an early period to avoid undesired results. In our case, resection of the esophagogastric junction was facilitated the migration of the stent and late onset of the symptoms delayed the diagnosis.

Conclusion

Patients with esophageal stent have to follow up frequently to preclude delayed complications. Additional technical procedures are needed for the prevention of stent migration.

Role of stenting in the palliation of gastroesophageal junction cancer: A brief review

Gastroesophageal junction cancer has an increasing incidence in western countries. It is inoperable when first manifested in more than 50% of cases. So, palliation is the only therapeutic option for the advanced disease to relieve dysphagia and its consequences in weakened patients with an estimated mean survival under 6 mo. This article has tried to identify trends focusing on current information about the best palliative treatment, with an emphasis on the role of stenting. Self-expanding stent placement, either metal or plastic, is the main management option. However, this anatomical location creates some particular problems for stent safety and effectiveness which may be overcome by properly designed novel stents. The stents ensure a good quality of life and must be preferred over other alternative methods of loco-regional modalities, i.e., external radiation, laser thermal or photodynamic therapy. Although stent placement is generally a simple, safe and effective method, there are sometimes complications, increasing the morbidity and mortality rate. Bypass operative procedures have now been abandoned as a first choice. The stomach instead of the colon must be used for a bypass operation when it is needed. Chemotherapy, despite the toxicity, and intraluminal radiation (brachytherapy) have a well-defined role.

Bypass laparoscopic procedure for palliation of esophageal cancer

Esophageal cancer is a devastating disease with rapidly increasing incidence in Western countries. Dysphagia is the most common complication, causing severe malnutrition and reduced quality of life. A 69-year-old male with persistent esophageal cancer after radiation therapy was subjected to palliative by-pass surgery using a laparoscopic approach. Due to the advanced stage at diagnosis, palliative treatment was a more realistic option. Dysphagia is a most distressing symptom of this disease, causing malnutrition and reducing quality of life. The goal of palliation is to improve swallowing. The most common methods applied are endoscopic stenting, radiation therapy (external or brachytherapy), chemotherapy, yttrium-aluminum-garnet laser rechanneling or endoscopic dilatation. Palliative surgery is rarely proposed due to morbidity and complications. This paper demonstrates an update in the technique proposed by Postlethwait in 1979 for palliation of esophageal cancer.

Rare Cause of Stricture Esophagus-Sarcoma: A Case Report and Review of the literature

Adenocarcinoma and squamous cell carcinoma account for the vast majority of oesophageal malignancies. Other malignancies known to occur in the oesophagus include melanoma, sarcoma, and lymphoma. Among the sarcomas, carcinosarcoma is the commonest with both carcinomatous and sarcomatous elements followed by leiomyosarcoma of mesenchymal origin. Other sarcomas reported in the literature are liposarcoma, synovial sarcoma, myxofibrosarcoma, Ewing's sarcoma, granulocytic sarcoma, histiocytic sarcoma, schwannoma rhabdomyosarcoma, and epithelioid sarcoma. We report a case of malignant spindle cell tumour of oesophagus. Sarcomas of esophagus present as a polypoid exophytic soft tissue mass. Our patient presented with a stricture which is a rare presentation. Locally aggressive treatment with surgery is beneficial, and local palliative treatment including radiotherapy is worthwhile.

Gastrointestinal stent update

The use of self-expanding metallic stents in the upper gastrointestinal tract, placed under radiologic imaging or endoscopic guidance, is the current treatment of choice for the palliation of malignant gastrointestinal outlet obstructions. Advances in metallic stent design and delivery systems have progressed to the stage where this treatment is now considered a minimally invasive therapy. Metallic stent placement will broaden further into the field of nonsurgical therapy for the gastrointestinal tract. To date, metallic stents placed in the esophagus, gastric outlet, colorectum, and bile ducts are not intended to be curative, but rather to provide a palliative treatment for obstructions. The evolution of metallic stent technology will render such procedures not only palliative but also therapeutic, by enabling local drug delivery, and the use of biodegradable materials will reduce procedure-related complications.