Surgical Oncology 10 (2001) 123–126

Palliation of oesophageal cancer

Robert Mason*

Guy’s and St Thomas’ Hospitals, St. Thomas Street, London SE1 9RT, UK

1. Introduction

The last decade has seen a major increase in theincidence of adenocarcinoma close to the gastro-oeso-phageal junction [1]. This increase, together with thesteady incidence of squamous oesophageal cancer,presents a major challenge to health care professionals,as overall 5-year survival iso10%. The advent of multi-modality treatment in ‘‘curable disease’’ has failed tobreak the 35% barrier for 5-year survival [2,3]. Even inthis selected population of patients, such treatment forthe majority is, therefore, only palliative. As the ma-jority of patients are not suitable for such radicaltreatment due to age, infirmity or advanced disease,good palliation with minimum morbidity and mortalityis required as their life expectancy can be measured inmonths [4]. Assessment of quality of life mustform an integral part of an assessment of any palliativetreatment [5].Although the prospect of cure following surgery is

poor, it still provides the best long-term palliation for fitpatients with ‘‘early disease’’ [6]. It does place emphasison good preoperative staging of disease [7] andassessment of patient fitness [8], as to achieve anybenefit from major surgery, patients must have arealistic prospect of survival in excess of 12–18 months.It is now generally accepted that there is no role forpalliative resection in which macroscopic disease clear-ance is not achieved or the tumour is merely bypassed[3,9].In those patients unfit for surgery, either intubation of

the stricture or recannalisation can achieve palliation,especially of dysphagia. Simple dilatation gives onlyshort-term relief of symptoms with a significant risk ofperforation [10]. In patients, who are fit, additionalbenefit may be achieved by the addition of chemotherapyor radiotherapy.

2. Intubation

Intubation is the commonest means of palliation andcan be achieved by insertion of either rigid plastic tubesor self-expanding metal stents.Rigid plastic tubes were the major means of intuba-

tion, prior to the early 1990s [11]. The most frequentlyused types are the KeyMed Atkinson tube, the Wilson-Cook prosthesis and the Medoc-Celestin tube. Thesecan be inserted under either sedation or generalanaesthesia under fluoroscopic control. They can beplaced in 90% of cases but are associated with aprocedure-related mortality of up to 15% [11,12]. This isoften due to perforation resulting from preinsertionoesophageal dilatation. Although few patients canswallow normally, the vast majority can only take ablended or liquid diet. Late complications includetube migration, tumour overgrowth and aspirationpneumonia.These rigid tubes have been largely superseded by the

advent of self-expanding metal stents. Since the insertiondevice is narrow, predilatation is not required andinsertion can be achieved under light sedation undereither endoscopic or fluoroscopic control [13]. Successfulplacement can be achieved in over 95% of cases with amortality of o1.5%. Relief of dysphagia enabling asolid diet is achieved in the majority of cases.Such stents are produced either covered or uncovered

and are made of steel or nitinol. When expanded, theyhave an internal diameter of up to 2.5 cm. The commontypes are the nitinol Ultraflex stent, the Wallstent andthe Gianturco Z stent [14–16]. Although the immediateresults are good, long-term follow-up reveals problemsin up to 40% of cases. These include recurrentdysphagia due to tumour ingrowth with uncoveredstents, overgrowth, bolus obstruction, migration (parti-cularly with covered stents crossing the gastro-oesopha-geal junction), haemorrhage and perforation due tostent erosion of the oesophageal wall as well asoccasional intractable pain.*Tel.: +44-207-955-5000.

0960-7404/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved.

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The problem of stent migration at the gastro-oesophageal junction is a particular problem, as this isthe site of 75% of malignant strictures. A solutionappears to lie in the covered Flamingo conical stent [17].Covered stents are now the treatment of choice for the

palliation of perforated malignant strictures and malig-nant trachyo-oesophageal fistulae. Care must be ex-ercised in high fistulae because of the pain associatedwith the stent close to cricopharyngeus. In these cases,parallel stents in the trachea and oesophagus might bethe answer [18,19].

3. Recanalisation of malignant strictures

This can be achieved by the use of lasers, argon beamphotocoagulation, and injection of ethanol. The mostwidely used laser is the neodymium yttrium aluminiumgarnet (Nd :YAG) laser. This produces a wavelength inthe infrared spectrum producing coagulative necrosis inthe tumour. Laser treatment must be applied in aretrograde fashion requiring pretreatment dilatation toenable passage of the endoscope in one-third of thecases. Good results with significant relief of dysphagiaare achieved in 90% of the cases with near normalswallowing in two-third of them [4,20]. The treatmenthas a mortality of o2% and can be performed undersedation, but needs to be repeated on a monthly basisfor life. The incidence of post-procedure complicationsis low, the commonest being perforation related todilatation [21].The use of the laser in photodynamic therapy; in

which laser light activates a photosensitising drug, islimited by the side effects of the drug namely skinphotosensitivity and the high incidence of tight fibroticstrictures produced by the treatment [22].Argon beam photocoagulation offers a cheaper

alternative to laser without the safety problems inherentwith its use. This is a non-touch electrocoagulationtechnique in which a high-frequency alternating currentis delivered to the tissue through a stream of ionisedargon gas. The effects of treatment are more superficialthan seen with the YAG laser and long-term results areawaited on its use in advanced disease although earlyresults are encouraging [23].Both laser and argon-beam photocoagulation are

good techniques to treat problems of tumour ingrowthand overgrowth in stents. The use of ethanol to producea chemical necrosis by injection of aliquots of absolutealcohol into the tumour, endoscopically, was firstdescribed in 1987. This technique has the advantagesof being cheap and requires no special expertise. Resultsappear to show similar results to laser with improvementin dysphagia in 80% of cases [24,25]. Complicationsinclude perforation and fistula.

3.1. Comparison of treatments

Although many reports of phase 2 studies of themethods of palliation, described above, exist, fewprospective randomised studies exist in the literature,comparing techniques, and those that do have smallnumbers randomised. The results of these studies aresummarised below:

(1) Laser vs. plastic tubes: no difference in relief ofdysphagia or morbidity [26].

(2) Laser vs. ethanol injection: no difference in relief ofdysphagia, or frequency of treatment [25].

(3) Laser vs. photodynamic therapy: both equallyeffective at relieving dysphagia, PDT may be betterfor high and low strictures [27].

(4) Stents vs. plastic tubes: both relieve dysphagia, lowermorbidity with stents [28].

(5) Laser vs. stents: better relief of dysphagia with stentswhen compared to laser; problems with migrationof covered stents at the gastro-oesophageal junctionwhen compared with uncovered stents [16].

3.2. Chemoradiotherapy in the palliation of oesophagealcancer

A full review of the role of chemoradiotherapy inpalliation of oesophageal cancer is beyond the scope ofthis article. Any patient treated with chemotherapyalone or in combination with radiotherapy should do soonly as part of a clinical trial.External beam radiotherapy used as sole treatment

modality or combined with 5-fluorouracil can lead torelief of dysphagia in over two-third of the patients, butrecurrent symptoms due to either recurrent cancer orfibrotic stricture occur in most cases [29]. The additionof external beam radiotherapy to laser treatment reducesthe frequency of laser treatment needed to maintainswallowing [30].The use of intracavity radiotherapy–brachytherapy,

in which a small probe is passed through the tumour,and caesium-137, administered from a selectron ma-chine, offers promise with rapid relief of dysphagiaobtained in most patients with squamous and adeno-carcinoma [31]. Comparing this with laser treatmentshowed similar benefit with regard to relief of dysphagiawith less-frequent treatment episodes [32].The most effective chemotherapeutic regimen in

advanced oesophageal cancer is, currently, epirubicin,cisplatin and continuous infusion of 5-fluorouracil(ECF). In advanced disease, response occurs in overtwo-third of the cases with improvement in dysphagia.When compared with best supportive care (includinglaser recannalisation), ECF significantly reduces theneed for laser and is associated with improvement in

R. Mason / Surgical Oncology 10 (2001) 123–126124

quality of life scores. It is unclear whether responseto treatment confers any significant survival benefit[33,34].The use of chemotherapy in combination with laser

and stents is controversial. In patients, being consideredfor chemotherapy, in whom there is significant dyspha-gia, it is recommended that laser should be used torecanalise the oesophagus. If patients respond and havea stent in situ, the stent frequently migrates into thestomach. Stents are best reserved for treatment failures.

4. Conclusion

It is recommended that laser or argon beam is thetreatment of choice for friable intraluminal disease withstents used for the majority of cases, where the disease ismural or extramural. Laser and argon beams areeffective treatments for tumour ingrowth and over-growth in stents and stents for failures of lasertreatment. Covered stents should be used in preferenceto uncovered stents to minimise ingrowth of tumour.The conical Flamingo stent should be used where thestent crosses the gastro-oesophageal junction, or, if notavailable, an uncovered stent should be used to minimisemigration. Covered stents are the treatments of choicefor perforated cancers and malignant tracheo-oesopha-geal fistulae. The addition of chemoradiotherapy in suchpatients should only be undertaken in the context ofappropriate controlled clinical trials.

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