Palliation of Malignant Dysphagia

Jason Klapman, MD FASGEDirector of EndoscopyMoffitt Cancer Center

Tampa, FL

Definition

To Palliate-From the Latin Palliatus-to cloak or conceal. To palliate a disease is to treat it partially and

insofar as possible, but not cure it completely. Easing the severity of a pain or a disease without

removing the cause

OUTLINE Methods of Palliation Endoscopic Management of TE Fistulas

Methods of Palliation

Dilation Ablation Radiation Stenting

Endoscopic dilation

Temporary relief of dysphagia Balloon or polyvinyl Bougies Goal to 15-16mm will allow most foods Need for repeat sessions Associated procedure risks

Aspiration Perforation

Ablation Methods

Nd:YAG laser APC PDT CRYO

Nd:YAG

Neodymium-yttrium-aluminum-garnet Fleisher et al. Am J Surg. 1982

A new palliative approach for esophageal cancer Fulgurating the esophageal cancer to make a

larger lumen. Generally requires multiple sessions Can be challenging at the cervical esophagus or

GE junction Risk of perforation is up to 7%*

Lightdale et al. GIE Dec1995

APC

Argon Plasma Coagulation Monopolar, non-contact method causes tissue

coagulation Main complication is bleeding Most useful in combination therapy

CONSORT 1a trial Rupinski et al. Am J of Gastro Sept 2011 93 pt’s randomized to APC with HDR,PDT or APC alone Time to first dysphagia recurrence was 88,59 and 35days

respectively APC with HDR fewest complications and highest QoL

PDT

Photodynamic Therapy Uses a photosensitizing agent in combination with laser

exposure to ablate malignant tissue Porfiner sodium (Photofrin) is the only photosensitizing agent

available in US More effective than other ablative techniques

Lightdale et al. GIE Dec 1995 Multicenter randomized trial of PDT vs. Nd:Yag laser for palliation of esophageal cancer

PDT equally efficacious and better tumor response Easier to perform Less complications than Nd:Yag (1% vs 7%)

Use is limited by photosensitivity and high cost

Cryotherapy

Used for early or superficial recurrent esophageal cancer

Not routinely used for palliation

Radiation

High-dose Brachytherapy (HDR) Localized treatment with high-dose radiation with sparing of the

surrounding structures Depth of 1cm and length adjustable to tumor length

Timing of Brachytherapy As Monotherapy? Before or after Stenting? In combination with

esophageal stenting or other modalities? HDR as Monotherapy

Homs et al. Lancet 2004 Brachytherapy better for long term palliation for patients with life

expectancy >3months but less than 6 months Stenting better for patients with <3months life expectancy

HDR combination therapy CONSORT 1a showed benefit in combination with APC Berquist et al. Dis Esophagus Jul 2012

Combined stent insertion and HDR pilot study 12 patients received stent insertion and then single dose of 12Gy Relief of dysphagia in 10/11 Median survival was 6.6months

Hirdes et al. GIE Aug 2012 Combination of Biodegradable stent and single-dose

brachytherapy Brachy 12Gy first then stent placement 19 patients 28 complications in 17patients (mainly pain and vomiting) causing

premature ending of study

Esophageal Stenting

ASGE Guidelines GIE March 2013 Esophageal Stenting should be the preferred method

for palliation of malignant dysphagia and Fistulae Provides immediate and durable relief in the majority

of patients

Esophageal Stents Types

Plastic or Metal Fully Covered Partially covered Uncovered Biodegradable

Choosing a stent

Majority are Metal stents Most SEMS are equally effective in relieving

symptoms, have similar complication rates No study has been done comparing all types of metal

stents Choice usually determined by perceived ease of

placement and personal experience of endoscopist

Low incidence of migration is the holy grail!!

Choosing a stent (con’t)

Stent characteristics Delivery systems Deployment patterns Expansile force Foreshortening characteristics Removability

Available Esophageal Stents (U.S.) Boston Scientific

Polyflex -strong expansile force,removable 16-21mm 9-12-15cm length Ultraflex- distal and proximal release option, most flexible, least expansile force

(partially or uncovered) 18 or 23 mm, 10,12,15cm lengths Wallflex-, no foreshortening, smooth delivery vs. Ultraflex, lasso loop

(fully/partially) 18 or 23mm 10,12,15cm Cook Endoscopy

Evolution-no shortening, recapturable, lasso loop, distal release only(fully18,20 -8,10,12cm or partially 20mm, 8,10,12.5,15

Z stent - no shortening, short bare wire at ends, has anti-reflux valve option (fully, partially, anti-reflux)18mm, 8,10,12,14

Merrit Medical EndoTek Alimaxx-E-non-foreshortening, fully covered, lasso loop, distal release only

multiple sizes 12-22mm 7,10,12cm lengths EndoMaxx-non-forshortening,fully covered,Metal loop, 19,23mm ,7,10,12,15cm

Endochoice-Bonastent- Fully covered, Hook/Cross technology, Non-foreshortening, retrieval lasso-18mm 6-16cm length

TaeWoong- Niti-S TTS, fully covered ,lasso loop 18mm, 6-15cm ,(

Non-TTS placement

A stiff 0.035 guidewire for stability, over which stent is deployed

Remove endoscope leaving wire in place Back load stent over wire and advance through

stricture Can place endoscope alongside stent to observe

deployment if desired (No fluoroscopy needed) Choose stent that is 4cm longer than tumor to

allow for 2cm above and below tumor for stability

Non-TTS placement

TTS placement

Niti-s esophageal stent 10.5 fr diameter deployment system Use therapeutic upper scope Proximal release

After stent placement

Starts clears and slowly advance to soft foods

Give post stent diet instructions-tailor it to the size of stent

Analgesics prn for pain

Complications

Chest pain Bleeding Perforation Aspiration Severe GERD Dysphagia: tumor ingrowth, migration, food

impaction, device malposition Tracheal Esophageal (TE) Fistula formation

OUTLINE Methods of Palliation Endoscopic Management of TE Fistulas

Case History 65 y.o definitive chemo XRT for proximal

squamous cell esophageal cancer Developed non-malignant XRT stricture 6mos

post treatment Underwent serial dilations ( 3 over 6 weeks

w/limited improvement) Feedings mainly through G-tube Presented with worsening dysphagia and cough

and CXR c/w pneumonia

Case History Endoscopy performed

Management of TE Fistula

Etiology Malignant vs. Benign Pre-treatment vs. during treatment

Risk factors Previous radiation Location (never distal) In situ esophageal Stent

Endoscopic options

Placement of a fully covered esophageal stent is the preferred treatment

TTS stent insertion for TE-Fistula

Stenting for TE-Fistula

Success rate is 70%-85% (consider double stenting)

Leave stent in for 4-6 weeks and re-evaluate Unsuccessful

Consider re-stenting Clipping (OTSC) +/- stenting Fibrin Glue application +/- Clipping +/-stenting Surgery bypass or mucus fistula

Summary

Palliation in esophageal cancer has one primary goal To allow patients to maintain oral intake and improve quality of

life Multiple palliative options are available which

may be used as monotherapy, in combination, or sequentially. Endoscopic stenting is now the preferred initial treatment

modality for both palliation of dysphagia and treatment of TE-fistula

Choosing the right stent involves many factors including physician preference, esophageal stricture characteristics and location, and patients clinical scenario

Thank You!!