This case demonstrates a clear failure of those managing the patient to know about the other modalities of treatment applicable to the disease (see the references below).
Oesophagus cancer is an interesting disease in that surgery has not been shown to produce better SURVIVAL than chemoradiation, LOCAL CONTROL is a different matter. In fact several series have shown that 'gentle' chemoradiation (1 cycle of chemo and half a radical radiation dose) produced surprising CURES!
The desperately needed trial (this is is desperate because it was the obvious trial in 1995!) is surgery V chemoradiation stratified for stage and prognostic factors. Unfortunately, the upper GI surgeons fall into one of two groups - the optimists (who believe in surgery and won't enter patients on non-surgical trials) and the pessimists (who deny surgery and won't accept patients for surgical therapy).
Either way a T3N0M0 SCC of the upper oesophagus is NOT palliative unless there is good reason. They are curable and the data suggests that with chemoradiation that ~25% will be cured.
The role of stenting in malignancy is not as clear as might be first surmised. Hollow organs (blood vessels, oesophagus, bile ducts, ureters, urethra, bowel) are able to be stented. Where malignancy is involved the issues to be considered are:
- comfort
- the placement of a stent should not result in the prolonged and annoying feeling that something is stuck there. The places where this is most likely are at the upper oesophagus and the lower large bowel.
- migration
- the placement of a stent should trigger the thought that it might have to be removed if it moves. The surest way to have a stent move is to apply a treatment which will reduce the size of the lesion (e.g., specifically radiotherapy). It is not uncommon for a stent in the oesophagus placed to relieve the dysphagia of the original cancer to migrate into the stomach after the chemoradiation have provided a complete response)
- cover
- stents can be covered or uncovered. The uncovered stents are prone to cancer growing between the wires and resulting in further obstruction.
Cisplatin is a simple platinum ion with associated chlorides in a cis arrangement (the trans variety has little effect), which produces cross strand linkage in DNA.
5-fluorouracil is an antimetabolite of pyrimidine nucleotides, inhibiting thymidylate synthetase.
Reference:
- Relapse Patterns after Chemo-radiation for Carcinoma of the Oesophagus. Clinical Oncology. 2003. 15(3):98-108
- Factors influencing outcome following radio-chemotherapy for oesophageal cancer. Radiotherapy and Oncology. 1996. 40(1):31-43
- A comparison of multimodal therapy and surgery for esophageal adenocarcinoma.
T N Walsh. N Engl J Med. 1996. 335(7):462-467
Combined modality therapy for esophageal carcinoma: preliminary results from a large Australasian multicentre study. Int J Radiat Oncol Biol Phys. 1995. 32:997–1006
