Endoscopic Palliation of Esophageal Cancer

Jon P Walker, MD MS Assistant Professor of Clinical Medicine

April 9, 2016

Objectives

Understand the options for endoscopic palliation of esophageal cancer Understand options for stent types Understand the potential complications and aftercare

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Therapy of Dysphagia

Assess the severity – endoscopic Assess the severity – patient perspective Does the patient need therapy? Medication options (ie GERD, spasm, etc) Endoscopic therapy: will we be providing the patient

an improved quality of life.

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Options for Palliation of Malignant Stenosis

Dilation: Balloon or Savary Argon plasma coagulation Yag-laser Photodynamic therapy PEG/ J-tube NG/NJ Esophageal stent Brachytherapy

Options for Palliation of Malignant Stenosis

Argon plasma coagulation Yag-laser Photodynamic therapy PEG/ J-tube NG/NJ Esophageal stent Brachytherapy

Options for Palliation of Malignant Stenosis

Argon plasma coagulation Yag-laser Photodynamic therapy PEG/ J-tube NG/NJ Esophageal stent

– Polyflex (plastic) stent placement – Metal stents

• Uncovered stent placement • Partially covered stent placement • Fully covered stents

Stent Placement

Stent Placement

Esophageal Stents Other roles in esophageal malignancy • Sticture patency maintenance

– Post-radiation – Post-ablative therapy of high grade dysplasia – Post-operative anastomotic stricture

• Post-operative anastomotic leaks – Requires removable/temporary stent

• Fistulas – Tracheoesophageal fistula – Secondary to tumor or radiation therapy

• Determination of stent type – Condition duration – Patient prognosis – Luminal diameter – Location of defect

Stent Placement

Issues to keep in mind Will it palliate? Will stent really improve

current diet Tolerate endoscopy? What kind of stent?

Metal Stent Placement Partially Covered

• Permanent placement – Epithelialization – Complication:better get them

out early • Decreased tumor ingrowth

– Overgrowth or Undergrowth – Re-stent if needed

Partially Covered Stent

Bjerring et al 2012 87 patients with non-resectable malignant stricture Partially covered stents Dysphagia scores and complications/reinterventions

recorded. Dysphagia score before and after stent: 2.4 to 0.8 (p < 0.01) 78% score was a 0-1 2.8 endoscopies required per patient.

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Partially Covered Stent Complications

Immediate Deaths: 0 Perforation: 0 Migration: 0 Stent fracture: 1

Late Stent Fracture: 1(1) Migration: 11(13) Food impaction: 19(22) OverIngrowth: 40(46) Bleeding: 5(6)

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Plastic Stent Placement

• Polyflex stent - silicone • Removability • Temporary • Easy placement • Bridge to surgery • Difficult to assemble • Bulky (poorly tolerated) • Migration

Esophageal Stent Polyflex

Metal Stent – Fully Covered

• Emerging • Minimal migration • Minimal epithelialization • Permanent • ?Removable • Easy to place

Metal stent - deployment

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Stent Placement

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Esophageal Stent Full-covered

Stent Removal

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Stent Removal

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Metal Stent – Neoadjuvant therapy

Effect of trans-GEJ stenting in patients with malignant dysphagia Prospective trial – 40 patients Stage 2/3 adenocarcinoma Receiving neoadjuvant chemotherapy/radiation GERD symptom and Quality of Life

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Philips et al.; J Am Coll Surg; 2015: 221: 165-73

Metal Stent – Neoadjuvant therapy

Median Dysphagia Score Before stent: 3 (liquids only) After stent: 0 (all foods)

Stent Migration: 63% Migration corresponded to pathology response: 85%

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Philips et al.; J Am Coll Surg; 2015: 221: 165-73

Metal Stent – Neoadjuvant Therapy

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Philips et al.; J Am Coll Surg; 2015: 221: 165-73

Metal Stent – GE Junction

Kofoed et al. 2012 8 year period 312 patient with non-resectable distal

esophageal/GEJ cancer SEMS or APC or Both Non-traversed stenosis: APC Traversed stenosis: SEMS 707 procedure (246 SEMS; 461 Ablations)

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Kofoed et al; Dan Med J; 59; 1-5

Metal Stent: GE Junction

SEMS n=246

APC n=461

Bleeding 2 20 Perforation 1 0

Misplacement 1 - Migration 1 -

SEMS n=246

APC n=461

Overgrowth 25 -

Food Impaction

11 -

Migration 8 - Failure 5 -

Ingrowth 3 -

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Early Complication < 48 hours Late Complication > 48 hours

Kofoed et al; Dan Med J; 59; 1-5

Fully Covered Metal Stent Siddiqi GIE 2012 55 patients with FCSEMS Followed post procedure Chest pain: 13 patient (2 required stent removal) 1 severe acid reflux required stent removal. 1 perforation (delayed; after neoadjuvant tx) Migration: 17 patient (31%) Mean time to migration: 44d (6-154d) Only 1 required stent replacement

Fully Covered Stent Placement

Siddiqi GIE 2012

Fully Covered Stent Placement

Siddiqi GIE 2012

Benefit of Stenting During Neoadjuvant Therapy Martin et al 2014 52 patients Malignant strictures Plastic stents Followed up to 9 weeks after stent placement

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Benefit of Stenting During Neoadjuvant Therapy

Oncologist. 2014 Mar; 19(3): 259–265.

Benefit of Stenting During Neoadjuvant Therapy

Oncologist. 2014 Mar; 19(3): 259–265.

Radiation Scatter? Concern for metal stent Traditionally preferred plastic stent No support from data Recent study: Solid acrylic phantom as mimic

for esophageal tissue; 2Gy dose Dose perturbation measured with various stent

types: Stainless steel Nitinol Plastic

Jalaj, et al. Endosc Int Open. 2015 Feb; 3(1): E46–E50.

Radiation Scatter?

Jalaj, et al. Endosc Int Open. 2015 Feb; 3(1): E46–E50.

Esophageal Stent Placement Post-procedure Chest pain Tumor compression Esophageal spasm Reflux

Reposition patient immediately IV PPI (ie Nexium 80mg IVPB TID x 3 days) PPI BID indefinetely

Admit overnight IV pain medications PRN IV Zofran scheduled Advance diet slowly

Esophageal Stent Placement

Advance diet slowly Clear liquid diet for 24 hours, Full liquid diet for 24 hours, Soft pureed foods x indefinitely.

Eat multiple small meals Chew food thoroughly Sit upright while eating Drink plenty of fluids w/ and between meals Remain upright for 30-60 min after eating

Long Term Complications

Migration Tumor Overgrowth/Ingrowth Reflux esophagitis Perforation Fistula Formation Gastric ulcer/GI bleeding

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Multimodality

Brachytherapy Endoscopic assessment Clip placement Guidewire Then the smart people take over!

Chemotherapy-eluding Stent 5-FU Paclitaxel

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Conclusion

Multiple options for endoscopic therapy for malignant dysphagia Stent is primary choice APC could be beneficial in conjunction Must be done when necessary Dysphagia seems effectively improved May not necessarily improve the quality of life Drug eluding stents could be emerging Brachytherapy could be effective alternative

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Time is shortening. But every day that I challenge this cancer and survive is a victory for me. Ingrid Bergman