Palliative Intent Treatment or Procedures

Palliative Intent Treatment or Procedures

In spite of endoscopy and other investigations, the treatment of carcinoma oesophagus is palliative in more than 75% of cases, especially in our country. By the time the first symptom of dysphagia appears, it is too advanced. Also, the location of the tumour, adjacent structures in the mediastinum, widespread lymphatic drainage alters the overall prognosis to a very low percent of survival.

A few considerations before treatment of carcinoma— since they often present at an advanced stage, 5-year survival is very low in the majority of cases. The following factors are considered for palliative treatment.

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1. Comorbid conditions: Cardiac diseases, bad chest
2. Blood spread metastasis: Para-aortic lymph nodes
3. Contiguous organ: Trachea, aorta, pericardium invasion (CT scan)
4. Diagnostic laparoscopy: Peritoneal spread, omental nodules, ascites
5. CT scan or laparoscopic ultrasound: Lymph nodes metastasis: Para-aortic lymph nodes, supraclavicular lymph nodes

Palliation is done to relieve dysphagia or to control bleeding lesions or for feeding purposes. Palliation to control pain.

1. Intubation: The choice of the intubation material is self-expanding metallic stent. Two types are available—covered and noncovered. The stent is deployed by endoscopy under fluoro¬scopic guidance. It is collapsed during insertion and once confirmed radiologically by position, it is expanded. Minimal dilatation of the oesophagus (8 mm) is required to place the stent. On the other hand, the plastic tubes which were used earlier, required more than 8 mm dilatation and there was always a risk of perforation. If the patient is expected to survive beyond 3 months, SEM stent can be considered. Complications include aspiration, feeling of tightness in the chest, bleeding, food blockage, etc. This is the choice in cases of tracheo-oesophageal fistula due to carcinoma oesophagus.
2. Laser therapy: Endoscopic laser treatment is used to core the tumour and widen the lumen to relieve dysphagia. Principle is thermal destruction of the tumour. The procedure has to be repeated. Laser used is Nd:YAG laser or diode laser. Infiltrative lesions are not suitable for laser treatment but exophytic lesions are ideal—less than 6 cm. Success rates are 80-90% in relieving dysphagia. Perforation, fever, chest pain, fistula are complications.
3. Photodynamic therapy: It is used in early carcinomas—mucosal lesions wherein patients are not willing for surgical procedures including endoscopic mucosal resection. In this procedure, a photosensitiser (porfimer sodium) is given. It will be taken by dysplastic cells and malignant cells. Perforation, fever, sunburn, pleural effusion are the complications.
4. Radiotherapy, brachytherapy: It is intraluminal radiation (RT) with short penetration distance 1500 cGy radiation is given. No systemic side effects. Palliative external beam radiation to doses of 50 to 60 Gy is successful in 50 to 70% of patients.
5. Feeding gastrostomy or jejunostomy: In very late advanced cases, where all other treatment feels.

Causes of Death in Carcinoma Oesophagus

• Cancer cachexia
• Complications such as bronchopleural fistula, aspira-tion pneumonia, haematemesis due to erosion of aorta, perforation of the growth and mediastinitis.

Summary of Treatment of Carcinoma Oesophagus

• Majority of oesophageal cancers are advanced at the time of diagnosis.
• 5-year survival rates after curative resections are around 10%.
• The best results are obtained after surgery—radial oesophagectomy. Curative resections are major surgeries and should be undertaken by an experienced surgeon. Curative resections can be attempted at all levels of carcinoma oesophagus (upper, middle and lower) provided vital structures are not involved (assessment by CT scan and endosonogram).
• Chemoradiotherapy may cure the disease in selected patients—these are squamous cell cancers.
• Palliation: Radiotherapy, chemotherapy, dilatation and stenting also can give palliation. As majority of the patients with carcinoma oesophagus have dys-phagia, all the methods of palliation are aimed at relieving dysphagia. Endoscopy followed by dilata-tion using guidewire is a simple procedure with rate of complications such as perforation around 2-3%. However, the results are only for a few weeks. Self- expandable metal stents are regularly used nowadays as a palliation.
• Endoscopic laser therapy relieves obstruction and bleeding. It can be carried out as an outpatient treatment but needs multiple sittings.
• Radiotherapy alone has been tried for squamous cell carcinoma of the oesophagus—dose is 6,000 cG units. No survival advantage is seen with this method.
• Combination chemotherapy using cisplatin and 5- fluorouracil with radiotherapy has been tried in patients who are not fit for surgery. Paclitaxel achieves high response rate in metastatic oesophageal cancer and it also acts as a radiation sensitiser.
• Endoscopic intraluminal brachytherapy is used in, cases of recurrent tumour growing inside the lumen and causing obstruction.