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• W2053725151 abstract "To the Editor: I read with interest the case report by Thuraisingam et al.1.Thuraisingam A.I. Hughes M.L. Smart H.L. Down-staging of an advanced esophageal carcinoma with chemoradiotherapy leading to stent migration necessitating colectomy.Gastrointest Endosc. 2004; 59: 457-460Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar that describes a patient with dysphagia caused by locally advanced esophageal cancer. The patient was treated with a self-expandable metal stent (SEMS) followed by chemoradiotherapy (CRT), which resulted in migration of the stent, which became embedded in the colon. This case illustrates why a SEMS should not be first-line palliative therapy, even in patients with advanced esophageal cancer. CRT provides good long-lasting palliation for patients with dysphagia caused by unresectable disease.2.Coia L.R. Soffen E.M. Schultheiss T.E. Martin E.E. Hanks G.E. Swallowing function in patients with esophageal cancer treated with concurrent radiation and chemotherapy.Cancer. 1993; 71: 281-286Crossref PubMed Scopus (90) Google Scholar In a study by Coia et al.,2.Coia L.R. Soffen E.M. Schultheiss T.E. Martin E.E. Hanks G.E. Swallowing function in patients with esophageal cancer treated with concurrent radiation and chemotherapy.Cancer. 1993; 71: 281-286Crossref PubMed Scopus (90) Google Scholar 120 patients with unresectable esophageal cancer were treated with CRT; 88% noted improvement in dysphagia within an average of 2 weeks and almost all could swallow soft or solid food within 4 weeks. Two thirds of the patients had no significant dysphagia until death or last follow-up. CRT provides good palliation for patients with dysphagia, and even for those with unresectable T4 esophageal tumors, 2-year survival rates of 20% to 27% are obtained.3.Ohtsu A. Boku N. Muro K. Chin K. Muto M. Yoshida S. et al.Definitive chemoradiotherapy for T4 and/or M1 lymph node squamous cell carcinoma of the esophagus.J Clin Oncol. 1999; 17: 2915-2921PubMed Google Scholar, 4.Nishimura Y. Suzuki M. Nakamatsu K. Kanamori S. Yagyu Y. Shigeoka H. Prospective trial of concurrent chemoradiotherapy with protracted infusion of 5-fluorouracil and cisplatin for T4 esophageal cancer with or without fistula.Int J Radiat Oncol Biol Phys. 2002; 53: 134-139Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar Tumor shrinkage as a result of CRT can increase the risk of stent migration.5.Baron Y. Expandable metal stents for the treatment of cancerous obstruction of the gastrointestinal tract.N Engl J Med. 2001; 344: 1681-1687Crossref PubMed Scopus (347) Google Scholar It also is well known that SEMS placement can be associated with severe complications; the longer the patient survives, the higher the risk.5.Baron Y. Expandable metal stents for the treatment of cancerous obstruction of the gastrointestinal tract.N Engl J Med. 2001; 344: 1681-1687Crossref PubMed Scopus (347) Google Scholar In particular, several studies have found that patients who underwent radiotherapy (RT) after stent placement experienced severe complications more frequently than patients who were treated with SEMS after RT.6.Song H.Y. Lee D.H. Seo T.S. Kim S.B. Jung H.Y. Kim J.H. et al.Retrievable covered nitinol stents: experiences in 108 patients with malignant esophageal strictures.J Vasc Interv Radiol. 2002; 13: 285-293Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar, 7.Alberts A.S. Burger W. Greeff F. Schoeman L. Friediger D. Nel J. et al.Severe complications of 5-fluorouracil and cisplatin with concomitant radiotherapy in inoperable non-metastatic squamous cell oesophageal cancer after intubation: early termination of a prospective randomised trial.Eur J Cancer. 1992; 28A: 1005-1006Abstract Full Text PDF PubMed Scopus (22) Google Scholar One such complication was aorto-esophageal fistula with fatal bleeding.8.Nishimura Y. Nagata K. Katano S. Hirota S. Nakamura K. Higuchi F. et al.Japanese Society for Esophageal Diseases. Severe complications in advanced esophageal cancer treated with radiotherapy after intubation of esophageal stents: a questionnaire survey of the Japanese society for esophageal diseases.Int J Radiat Oncol Biol Phys. 2003; 56: 1327-1332Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar Because long-term survival can be expected for a substantial proportion of patients with locally advanced esophageal cancer who are treated by CRT, and because SEMS placement before or during RT is associated with a high risk of life-threatening complications, palliation of patients by SEMS insertion should not be done before CRT. SEMS placement should be delayed until RT or CRT appears to have failed, unless the patient is not a candidate for RT or CRT, or refuses such treatment. In patients with dysphagia who are undergoing CRT, a PEG can be placed, either endoscopically or by interventional radiology, for nutritional support until the dysphagia has resolved. Down-staging of an advanced esophageal carcinoma with chemoradiotherapy leading to stent migration necessitating colectomyGastrointestinal EndoscopyVol. 59Issue 3Preview Full-Text PDF Response:Gastrointestinal EndoscopyVol. 60Issue 5PreviewWe thank Dr. Azar for his comments regarding CRT and the placement of SEMS for palliation of patients with advanced esophageal carcinoma. We acknowledge that SEMS placement is associated with complications, especially in patients who survive for long periods. However, we disagree that SEMS placement should not be performed before RT or CRT has failed or is refused. There are some data that suggest that the frequency of severe complications is higher in patients who have RT or CRT before SEMS placement. Full-Text PDF" @default.
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• W2053725151 date "2004-11-01" @default.
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• W2053725151 title "Palliation of patients with esophageal cancer and metal stents" @default.
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