On-line version ISSN 2078-5151
Print version ISSN 0038-2361
S. Afr. j. surg. vol.48 n.2 Cape Town May. 2010
D. LiakosI; D. W. R. DowerII; M. FlorizooneIII; D. B. BizosIV
IM.B. CH.B., B.SC; Department of Surgery, University of the Witwatersrand, Johannesburg
IIM.B. B.CH; Department of Surgery, University of the Witwatersrand, Johannesburg
IIIM.B. B.CH., F.C.S. (S.A.); Department of Surgery, Tshepong Hospital, North West
IVM.B. B.CH., F.C.S. (S.A.), M.MED. (SURG.); Department of Surgery, University of the Witwatersrand
INTRODUCTION: Oesophageal cancer causes much morbidity and mortality in South Africa. Social and economic constraints further impact on the management of these patients. Many prospective randomised trials of palliative treatment have been done in the developed world, not taking into account these socio-economic constraints. We present a study from Tshepong Hospital, a secondary hospital in South Africa, comparing stenting with radiation therapy in the palliative treatment of oesophageal cancer.
PATIENTS AND METHODS: We retrospectively reviewed the data on 30 patients seen between February 2005 and January 2008. All presented with inoperable oesophageal cancer and were palliated with either stenting (N=18) or radiotherapy (N=12). We compared number of admissions, length of hospital stay and time from when first seen to intervention as primary outcomes.
RESULTS: The number of admissions, length of hospital stay and days to procedure were significantly lower in the stent group. No major complications resulting from brachytherapy were reported. Complications in the stent group included chest pain, tumour overgrowth, stent migration and death.
DISCUSSION: Studies have shown the superiority of brachytherapy over stenting with regard to long-term palliation and number of complications. In our setting, however, socioeconomic constraints result in a delay in treatment. Given the short survival expected in these patients, stenting may be a reasonable option to consider given the decreased time to final intervention and hospital stay in patients with a poor prognosis. Adopting a prognostic score can help in identifying these patients.
“Full text available only in PDF format”REFERENCES
1. Mannell A, Murray W. Oesophageal cancer in South Africa: a review of 1926 cases. Cancer 1989; 64: 2604-2608. [ Links ]
2. Mqoqi N, Kellet P, Sitas F, Jula M. Incidence of histologically diagnosed cancer in South Africa. National Cancer Registry 1998-1999. www.nhls.ac.za/Updated%20cancer98_ALL.pdf (accessed 7 May 2010). [ Links ]
3. Polednak AP. Trends in survival for both histologic types of esophageal cancer in US surveillance, epidemiology and end results areas. Int J Cancer 2003; 105: 98-100. [ Links ]
4. Didcott CC. Oesophageal strictures: Treatment by slow continuous dilatation. Ann R Coll Surg Engl 1973; 53: 112-126. [ Links ]
5. Procter DSC. Esophageal intubation for carcinoma of the esophagus. World J Surg 1980; 4: 451-461. [ Links ]
6. De Palma GD, di Matteo E, Romano G, Fimmano A, Rondinone G, Catanzano C. Plastic prosthesis versus expandable metal stents for palliation of inoperable esophageal thoracic carcinoma: a controlled prospective study. Gastrointest Endosc 1996; 43: 478-482. [ Links ]
7. Sanyika C, Corr P, Haffejee A. Palliative treatment of oesophageal carcinoma - efficacy of plastic versus self-expandable stents. S Afr Med J 1999; 89: 640-643. [ Links ]
8. Mosca F, Consoli A, Stracqualursi A, Persi A, Lipari G, Portale TR. Our experience with the use of a plastic prosthesis and self-expanding stents in the palliative treatment of malignant neoplastic stenoses of the esophagus and cardia. Comparative analysis of results. Chir Ital 2002; 54: 341-350. [ Links ]
9. Schumacher B, Lubke H, Frieling T, Haussinger D, Niederau C. Palliative treatment of malignant esophageal stenosis: experience with plastic versus metal stents. Hepatogastroenterology 1998; 45: 755-760. [ Links ]
10. Marjolein YVH, Steyerberg EW, Eijkenboom WMH, et al. Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial. Lancet 2004; 364: 1497-1504. [ Links ]
11. Steyerberg EW, Marjolein YVH, Stokvis A, et al. Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer: a prognostic model to guide treatment selection. Gastrointest Endosc 2005; 62: 333-340. [ Links ]
12. Wengera U, Johnsson E, Bergquist H, et al. Health economic evaluation of stent or endoluminal brachytherapy as a palliative strategy in patients with incurable cancer of the oesophagus or gastro-oesophageal junction: results of a randomized clinical trial. Eur J Gastroenterol Hepatol 2005; 17(12): 1369-1377. [ Links ]
13. Sur RK, Didcott CC, Levin CV, et al. Palliation of carcinoma of the oesophagus with brachytherapy and the Didcott dilator. Ann R Coll Surg Engl 1996; 78(2): 124-128. [ Links ]
14. Didcott CC. Slow continuous dilatation of oesophageal strictures using the Didcott dilator, with reference to its wider use. S Afr J Surg 1999; 37(3): 72-78. [ Links ]
15. Bergquist H, Wenger U, Johnsson E, et al. Stent insertion or endoluminal brachytherapy as palliation of patients with advanced cancer of the esophagus and gastroesophageal junction. Results of a randomized, controlled clinical trial. Diseases of the Oesophagus 2005; 18: 131-139. [ Links ]
16. Wong SK, Chiu PW, Leung SF, et al. Concurrent chemoradiotherapy or endoscopic stenting for advanced squamous cell carcinoma of esophagus: a case-control study. Ann Surg Oncol 2008; 15(2): 576-582. [ Links ]
17. Khushalani NI. Cancer of the esophagus and stomach. Mayo Clin Proc 2008; 83(6): 712-722. [ Links ]
18. Syrigos KN, Zalonis A, Kotteas E, Saif MW. Targeted therapy for oesophageal cancer: an overview. Cancer Metastasis Rev 2008; 27: 273-288. [ Links ]
19. Sur RK, Levin VC, Donde B, Sharma V, Miszczyk L, Nag S. Prospective randomized trial of HDR brachytherapy as a sole modality in palliation of advanced esophageal carcinoma - an International Atomic Energy Agency study. Int J Radiat Oncol Biol Phys 2002; 53: 127-133. [ Links ]
20. Homs MYV, Essink-Bot M, Gerard JJM, Borsboom GJJM, Steyerberg EW, Siersema PD. Quality of life after palliative treatment for oesophageal carcinoma - a prospective comparison between stent placement and single dose brachytherapy. Eur J Cancer 2004; 40: 1862-1871. [ Links ]
21. Wallace MB. Stent vs. brachytherapy: does life expectancy help you decide? Gastrointest Endoscoc 2005; 62: 343. [ Links ]
The treatment of advanced oesophageal cancer in a resource-constrained clinical setting is difficult and frustrating, and the authors are to be congratulated on documenting their experience. Nevertheless, the conclusion they present is based on a small retrospective series, and this does not trump the evidence of a large prospective randomised trial. I accept that the logistic conditions, nutritional status and even the advanced stage of the cancer (as shown by the larger-bore catheter used by the Dutch investigators compared with what is used in Johannesburg), and our lower mean survivals, are worse in South Africa, but given that intraluminal HDR brachytherapy is available in tertiary hospitals, is relatively complication free, and only incurs additional transport and hospital stay costs, its benefits, namely prolonged dysphagia-free survival (a mean of 7.1 months was reported in the IAEA trial, including South African patients), should not be denied to patients as a matter of course.
I agree with the authors that a prognostic index needs to be developed to determine which patients will benefit from intraluminal brachytherapy. It is important for a South African trial to be set up in this regard, so that the competing modalities of stenting versus HDR brachytherapy can be compared under local conditions, and a locally validated prognostic index can be developed. With regard to delay in implementing treatment, it should be noted that stenting does not preclude subsequent HDR, and early stenting followed by delayed HDR brachytherapy for selected patients needs to be one of the options to consider.
Department of Radiation Oncology Charlotte Maxeke Johannesburg Hospital