Stent, Surgery, Tube, or Radiation??

pjlee123 said:

Thanks for the replies
Really appreciate the feedback.

He's stage IV with 3-4 metastatic foci in the liver as well as para-aortic / para-esophageal lymph nodes.

I don't know -- I researched a bit about these esophgeal stents and get mixed reviews. His oncologist and the GI doc both recommended it. Sounds like many patients are sent home with only NSAIDs (see link below). His liver function tests are still normal, so I'm sure he can tolerate Tylenol. But once his pain was bad for > 12 hours or so, I wish they wouldn't have called the MD for a fentanyl patch or something.

Today he says the pain is 80% better. I hope so and I hope he can start eating more than juice and ensure.

I know he has good insurance, but I hope he's getting the care that's best for him, not just the care that reimburses the most.

Anyway, sounds like lots of folks have had bad luck with stents. I hope he had better luck. The GI doc wants to try to dilate it to 2 cm at some point in the future.

Also, he's still getting used to what this diagnosis means for him, and I'm pretty sure he's not ready to think about having a tube placement -- either per mouth / nose or through the abd wall.

Finally -- I know curative surgery isn't an option unless chemo can get him to be down-staged (unlikely), but I have heard that minimally invasive esophageal surgery is an option for palliative / quality of life. Over than his cancer, he has been doing well -- no real heart / lung issues, etc.

Thanks again!

http://www.nature.com/ajg/journal/v102/n12/full/ajg2007524a.html

chemosmoker said:

PJ,
I have to agree with Terry and William, and most ALL of the other people on this board and at my cancer center-that NO ONE I have ever even heard of is sent home taking NSIADS with cancer!!!

In fact, they are HIGHLY discouraged, as they are blood thinners, as you should know working in the medical field as you state, and as most of us stage IV's (myself included) have BLEEDING METASTATIC tumors, sticking out of or through our esophagus or stomachs (I have both), it is not advisable to ALSO bleed out internally due to taking NSIAD'S or Aspirins. Just not logical to any doctor. I was told not to EVER take them again on day 1, with a STERN warning by both my GI doctor who diagnosed me, and the THREE different oncologists who staged me.

We take the drugs my Oncologist says she prescribes to ALL cancer patients, and Tylenol for a fever and toothaches (she put it to me in those words when I asked her today after reading your post this morning!).

I would HATE to think of your father in law suffering, as I did before getting PROPER pain medication and management, and having my pain under control. Makes one not want to eat or move, much less live for much of anything with this EC cancer.

Just my non-medically trained 2 cents worth.

On the stint issue, I have YET to see a positive experience, except for one person on this board, and it is my understanding that that was for a consciously short period of time, in hospice, near the end and not a long term solution to begin with. Certainly not for living on so to speak.

Sorry if I come of strong. this is a powerful issue as we are all dying of our stage IV cancer and to hear it's treatment, and the accompanying pain, talked about so "lightly" as it came across to me, is hard to hear. It's not personal with you-just so you know, PJ (as I don't know your name).

Best wishes for your father in law and you, and God bless,
Eric

pjlee123 said:

PS
Ah -- one more thing -- after a little googling:

Looks like there's a minimally invasive surgery option for those with low grade cancer (stage I or II maybe) with an intent to cure -- and then a different kind of option for stage IV EC called photodynamic surgery, with the intent of removing the inner layer of the esophageal mass to open things up. Sounds like this may be the least popular option, maybe due to risks of perforation.

pjlee123 said:

Good Article on Stents vs other

Hey gang, all this prompted more research. Here's a very good article on treatment options. The article's target audience is mainly doctors.

My summary: Multiple minimally invasive options are out there, including photodynamic therapy, plain old esophageal balloon dilation, laser and chemical ablation, etc, but it sounds like stents are the best option. Sounds like stents got a very bad name for years because early versions were too big and bulky, and doctors didn't start to treat until esophageal narrowing was severe or complete. Now we have smaller stents, and doctors are learning they have to balloon dilate and place stents EARLY -- not late (as in my FIL's case).

There ARE lots of complications and side effects with stents -- as described -- but for my father in law, who suddenly couldn't eat and who didn't want a tube (yet), I'm not sure what else we could have done.

It does sound like the Mayo doc should have done serial dilation before placing the stent given that he was almost 100% stenosed, and it sounds like she should have admitted him overnight for observation in case of perforation or other serious side effect.

Article link: http://www.moffitt.org/CCJRoot/v6n1/article7.html

Copy and paste of some key tidbits:

The author reviews the literature on optimal endoscopic lumen restoration techniques, including dilation, thermal laser and chemical ablation, photodynamic therapy, and stents. Procedures for pain relief and nutritional support are also presented.

Results: Lumen restoration to relieve dysphagia and provide the opportunity for sustaining reasonable peroral nutrition is an essential element in the overall management. Nonsurgical lumen restoration procedures have much to offer for dysphagia palliation and are briefly reviewed in this presentation. The major options include ablation of intraluminal tumor mass by thermal laser, photodynamic laser, chemical ablation, peroral dilation, and placement of esophageal stents. Most patients require more than one palliative method to sustain lumen patency during the course of their disease.

All too often, quality of life is neither protected nor supported adequately between the stage of recognized incurability and death. All-out 11th-hour, relatively heroic efforts should not occur or, at most, should be the exception. Proven palliative measures are safer, less expensive, and more cost effective when applied at the first indication of need. This is especially true for those techniques designed to relieve the dysphagia of malignant esophageal obstruction.

Peroral dilation should begin as soon as possible in patients with dysphagia. When proper instruments and techniques are used, risk in dilating a malignant stricture either before, during or after radiation therapy is minimal.

There is no evidence that properly performed esophageal dilation of obstructing carcinoma carries an unacceptable risk. Failure to dilate a malignant esophageal stricture is due more to a lack of proper training of the physician or surgeon in dilation therapy than to inherent dangers of the methods.

One helpful application of laser ablation is for pre-stent ablation of a polypoid, eccentric intraluminal mass that typically would either cause acute angulation and partial occlusion or prevent suitable anchoring of a stent (Figs 1A-B). Other special cases in which laser or other thermal ablation may help include hemostasis for necrotic chronic bleeding lesions and for ablation of tumors obstructing a stent by overgrowth at either end or by ingrowth through an uncoated metal expandable stent.

Transendoscopic injection of absolute alcohol, using a standard sclerotherapy needle, has been reported as safe, simple, and effective. Initial results are similar to laser therapy.15 The injected tumor necroses and sloughs within several days after absolute alcohol injection. Repeat sessions are needed as with laser ablation. In the small number of cases reported thus far, complications have been rare, and costs above the basic endoscopy charge are minimal.

Photodynamic Therapy
Photodynamic therapy (PDT) begins with administration of a chemical photosensitizer that accumulates in higher concentrations in neoplastic tissue than in normal tissue.13,16-19 This chemical, porfimer sodium (Photofrin II, Quadra Logic Technologies, Vancouver, British Columbia), is given intravenously in a dose of 2 mg/kg of body weight. After approximately 48 hours, the area of cancer is exposed to a red light with a wavelength of 630 nm provided by a continuous-wave argon-pumped dye laser via a quartz fiber passed through a standard videoendoscope. This light exposure initiates a chemical reaction of the porphyrin compound within the cells that leads to production of oxygen radicals that destroy the cells. .... Transient side effects include odynophagia, chest pain, low-grade fever and, uncommonly, minor pleural effusion. There is a 1% perforation rate reported in the largest series to date.13


Esophageal Stents
Palliation of dysphagia due to esophageal cancer by placement of peroral stents has been performed for over 100 years but was not safe and effective until the 1950s.

There is a developing consensus that esophageal obstruction due to either fibrosis from radiation or residual recurrent neoplasm is best managed by dilation followed by peroral stent placement.2,3,29

If dilation therapy has failed, a peroral stent may be inserted through the adequately dilated stricture using only mild sedative analgesic medication and an anesthetic gargle. When malignant strictures have been neglected and severe lumen stenosis has developed, it is necessary to plan adequate dilation over several sessions before stent placement. The literature has clearly demonstrated that those who dilate severe strictures and place stents in a single session have unacceptably high perforation rates.30

When proper technique is used, the perforation risk for peroral esophageal stents will be less than 5% and the mortality near zero. In our recent series of 212 plastic stents, the perforation rate was 2.8% and stent-related mortality was 1.8%.

Usually, only one or two days of hospital observation is necessary unless the patient is suffering from other problems associated with advanced disease. Some reports indicate stent placement can be done on an outpatient basis; however, at least one overnight period of observation is prudent, considering the physical status of these patients.34


As with other palliative therapies, increased risk and technical difficulty are concerns for lesions in the cervical esophagus and at the gastroesophageal junction.35,36 Cancer in the cervical esophagus also presents problems for stents and other therapies, but stents are safe and effective at this location in approximately two thirds of patients.36-38 Lesions of the lower esophageal and gastric cardia can be effectively stented but do present potential technical problems.35


Once some metal stents are placed, they cannot be easily repositioned and are either very difficult or impossible to remove.23 In some cases, malposition can be compensated for by placing a second stent overlapping (piggybacking) the first.

Plastic and metal stents become dislocated in 5% to 10% of cases but usually can be properly repositioned.

Food impaction is not a complication of a plastic or fully deployed metallic stent per se. It is usually due to a lack of patient education or noncompliance with instructions for proper food selection, chewing, and swallowing. Stent diet instructions, verbal and written, should be given to patients and family members or caregivers prior to patients’ discharge from the hospital.3

Current models of stents are safe. The major risks result from an untrained operator, the pre-stent dilation, the placement apparatus and technique used, the premedication or general anesthesia, and the post-placement dietary management.29 One danger of making devices easy to use is that those who are ill-prepared to use them will assume that simplicity of placement equates with safety. Anyone who assumes responsibility for application of a technique, regardless of its publicized simplicity and efficacy, is responsible for having a thorough understanding of the disorder being treated, its indications, its contraindications and the principles of long-term management before attempting use of the method.

The timing for placement of either plastic or metal expandable stents is important for procedure safety, quality of life, and duration of survival. This short survival is in some measure due to the habit of late referral. Unfortunately, physicians in past years have neglected to refer patients for stents until very late in their illness. Nearly all series report the average survival after stent placement to range between three and five months.6,11,38-40

However, stents do allow the patient to enjoy the pleasures of oral alimentation and less time in the physician’s office or hospital during the relatively short interval before death. At present, too few patients are informed of a peroral esophageal stent or given the option to have one placed early enough to provide optimum benefit.

The increase in enthusiasm for esophageal stents is impressive and long overdue. Needless to say, the development of metal expandable stents and insertion devices of small diameter have much to do with this trend. The unacceptable complication and mortality rates associated with plastic and silicone esophageal stents occurred after development of commercial insertion devices that were larger and more rigid than necessary.30 The other major negative factor in plastic stent safety was the practice by some of rapid dilation of a malignant stricture at the same sitting the stent was placed. An apparatus that was too large and rigid, combined with overly vigorous dilation of malignant strictures, proved to be a dynamic duo with unfair mechanical advantage over a very diseased and weakened esophagus and patient.


However, the pendulum is rapidly swinging in favor of stents.

A peroral stent to restore and maintain lumen patency usually is well tolerated, can significantly improve quality of life, has a low procedure-related morbidity and mortality, requires a minimal hospital stay, and does not require regular repeat treatment sessions. A stent is the least expensive, fastest, and most desirable method to maintain lumen patency sufficient for adequate caloric intake and the related pleasures of drinking and eating.

unclaw2002 said:

Photodynamic Therapy
Thanks for the info. I wanted to learn more about this treatment and found this fact sheet from the NCI --- Photodynamic Therapy http://www.cancer.gov/cancertopics/factsheet/Therapy/photodynamic (cut and paste into your browser).

Photodynamic Therapy is an FDA approved treatment for Esophageal Cancer (there are more studies ongoing to expand its use in the treatment of cancer) ... below is a part of the fact sheet. Note this type of treatment appears to be for Barretts and for early stages of EC, when the tumor is smaller and not indicated when the cancer has metastasized and reached Stage IV.

3.What types of cancer are currently treated with PDT?
To date, the FDA has approved the photosensitizing agent called porfimer sodium, or Photofrin®, for use in PDT to treat or relieve the symptoms of esophageal cancer and non-small cell lung cancer. Porfimer sodium is approved to relieve symptoms of esophageal cancer when the cancer obstructs the esophagus or when the cancer cannot be satisfactorily treated with laser therapy alone. Porfimer sodium is used to treat non-small cell lung cancer in patients for whom the usual treatments are not appropriate, and to relieve symptoms in patients with non-small cell lung cancer that obstructs the airways. In 2003, the FDA approved porfimer sodium for the treatment of precancerous lesions in patients with Barrett esophagus, a condition that can lead to esophageal cancer.

4.What are the limitations of PDT?
The light needed to activate most photosensitizers cannot pass through more than about one-third of an inch of tissue (1 centimeter). For this reason, PDT is usually used to treat tumors on or just under the skin or on the lining of internal organs or cavities (3). PDT is also less effective in treating large tumors, because the light cannot pass far into these tumors (2, 3, 6). PDT is a local treatment and generally cannot be used to treat cancer that has spread (metastasized) (6).