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New developments in palliative therapy

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Over the past 5 years, new developments in the palliative treatment of incurable cancer of the oesophagus and gastro-oesophageal junction have been introduced with the aim of palliating dysphagia and improving the survival of patients. Stent placement is currently the most widely used treatment for palliation of dysphagia from oesophageal cancer. A stent offers rapid relief of dysphagia; however, current recurrent dysphagia rates vary between 30 and 40%. Recently introduced new stent designs are likely to reduce recurrent dysphagia by decreasing stent migration and non-tumoral tissue overgrowth. Intraluminal radiotherapy (brachytherapy) has been demonstrated to compare favourably with stent placement in long-term effectiveness and safety. A disadvantage of brachytherapy, however, is that one-fifth of patients need an additional treatment because of persistent tumour growth in the oesophagus. A solution may be to administer brachytherapy not in a single fraction but in multiple fractions. Finally, efforts have been undertaken to improve survival of patients by using chemotherapy. In the future, a multimodal approach—for example by combining stent placement with chemotherapy or radiotherapy—may improve the prognosis of patients without jeopardizing their quality of life.

Section snippets

Palliative treatment to relieve dysphagia

Since most patients with incurable oesophageal cancer live no longer than 6 months, the aim of palliative treatment is rapid relief dysphagia to maintain swallowing during life and to avoid serious complications. Furthermore, it is important to realize that treatment of incurable oesophageal cancer should be individualized and based on tumour stage, medical condition, and performance status of the patient, and the patient's personal wishes. Finally, both the available expertise and the results

Stents

Placement of a stent is nowadays the most frequently used method for palliation of malignant dysphagia. Since 1990, more than 75 studies on the outcome of stent placement for palliation of malignant dysphagia have been published.5, 6, 7

Brachytherapy

Brachytherapy was first used in 1980 as a boost after external-beam radiotherapy for the treatment of oesophageal carcinoma. Patients received 40–50 Gy external-beam radiation followed by 10 Gy brachytherapy given in one or two sessions, starting 2–3 weeks after completion of external-beam radiotherapy. A decade later, brachytherapy as a sole treatment was introduced for the palliation of dysphagia from incurable oesophageal carcinoma. An advantage of brachytherapy in comparison to external-beam

Brachytherapy versus stent placement

Recently, the first randomized trial was published comparing single-dose brachytherapy with metal stent placement for the palliation of dysphagia from incurable oesophageal cancer.52 In total, 209 patients recruited in nine hospitals in the Netherlands were randomized to single-dose (12 Gy) brachytherapy or stent placement (Ultraflex stent). Of these 209 patients, 144 (69%) had an adenocarcinoma, 58 (28%) a squamous-cell carcinoma, and seven (3%) another malignant tumour in the oesophagus.

Prognostic model

On the basis of the findings in the above-mentioned trial52 and additional data on stent placement and brachytherapy from our institution, we developed a prognostic model which could help to identify patients with a poor prognosis in whom stent placement should be at least equivalent to brachytherapy.53 Significant prognostic factors for survival included tumour length, WHO performance score, and the presence of metastases. A simple score was developed which included age (a score varying

Palliative chemotherapy

Patients with incurable disease due to metastasis but in a relatively good general condition (WHO performance score 0–2) are increasingly considered to be candidates for palliative chemotherapy. However, prior to the use of chemotherapy, it is important to first treat dysphagia. This can be done by stent placement, brachytherapy, or placement of a nasoenteric feeding tube. A disadvantage of stent placement prior to chemotherapy is the risk of stent migration into the stomach if a tumour is

Conclusion

The currently available endoscopic treatment modalities for the palliation of malignant dysphagia are, as yet, not optimal in achieving fast and sustained dysphagia relief with minimal morbidity and mortality. Recently, new developments have been introduced that should result in better palliation of patients with incurable oesophageal cancer.

Stents are effective in improving dysphagia; however, the number of reinterventions for recurrent dysphagia is still rather high. The recently introduced

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