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Oesophagus Cancer : wich treatment ? Personal experience using a Multidisciplinary Therapeutic Approach.
Full text linkBachGround :Actually the oesophageal and cardias carcinoma is a high morbility and mortality disease too.The main reason is a underestimated disphagic disease with a delayed clinical evaluation. The result is a very low quality of life and severe mortality.
The purpose of this study was to reduce the high grade of the disphagia and improve the quality of life in patients affected by oesophagus cancer stenosis using a MultiDisciplinary Therapeutic Approach.
Materials & Methods :In our last Universitary Endoscopic Ambulatory,during 10 years, we observed 135 patients affected by oesophageus disease .The grave or severe disphagia was the more frequent symptom.Sometime,there were other symptoms linked to disphagia (tab.1). The 89% cases arrived to our evaluation without an adeguate clinical-endoscopic-radiological documentation.All had previously been treated with anti H2 and pro-kinetic drugs for several months.We observed 1)Primitive Neoplasm (78/120 p.=65%) 2)Secondary Neoplasm(12/120 p.= 10%) 3)Neoplastic Recurrences (17/120 p.=14.5%) 4)Flogistic Disease (5/120p.=4.16%) 5)Achalasia (5/120p.=4.16) 6)Barrett’s Disease (3/120p.=2.5%) (tab.2-3).Male/female ratio was 2.5/1.Various risk factors were classified (smoke=60%,Alchohol intake over 1000cc/die=60%,Obesity=25%,Barrett =2.5%)(tab.4)
All the patients were valued with accurate clinical evaluation using a Multianalises Score System (tab.5-6-7-8-)
In evaluating operability,we considered several parameters concerning the General Clinical Status and the Neoplasm Stage (TNM) (tab.9-10-11)
Surgical treatment was established for only a few patients (15/135) which might gain advantages one-step open-surgical oesophagectomy,alone or combined to chemo-radio therapy,in according to international leterature.
The others 120 patients with disphagia (III°rd level=80 p.,
IV°th level = 40 p.) were valued no-responders to classic open-VLS Surgery (tab.12-13).They were treated with ELS (Endoscopic Laser Surgery) alone or combined to others treatments (EGDS Savary Dilatation,Endoprosthesis,
X-Rays Therapy).
Flexible fibre CO2 Laser and single-use pinches were employed to perform this kind of treatment.The Endoscopic Laser Energy was administered with a continuous power flow (20-40 Watts) and mixed Technique.We used a specific treatment to single patient and disease.The single dose ranged 800-2000 Joules.The procedure was cyclically repeated every 15-60 days.The Total Dose ranged 2000-6000 Joules.In general ,we prefered the EGDS Savary Dilatation before the LES and positionating self expanding covered or non-covered stents (102)after ELS according Radiologist collegues.
If necessary ,RadioTherapy (mean dose 39 Gy) was associated too.
Results : we obtained a total recanalisation in flogistic disphagia disease.We obtained an important recanalisation in the first 12 months in the 85% of the neoplastic stenosis and an enough recanalisation in the 60% of the cases between 12-24 months from the first treatment.After 24 months ,we obtained an useful canalisation only in the 30% of the cases(tab.14).We registered some complications link to the treatment.(tab.15).The only one intra-operative death was in a 78 y.old patient affected by cardiomegaly.Probably ,the cause was an arrest hearth because of the fatality laser energy propagation.So,the mortality for this laser-surgery treatment was lower than 1% and also the morbidity was reduced when compared to the other centers ‘dates.We registered oesophagus Iatrogenous perforations (3) too.These healed spontaneously after specific therapy (2) using thoracic drainage,antibiotic drugs,total parenteral nutrition).It has been necessary to place only one covered endoprosthesis. Our protocol provided a 3-years follow-up with long term survival ranging 30-900 days.
Conclusions :ELS could be considered the main treatment to inoperable oesophageal cancer.According our dates we think that the Treatment don’t influence the survival ,reduces absolutely the disphagic symptoms and improve the quality of life. The Cost/Benefit is profitable too.(tab.16)
Tab.1 Symptom %
Dysphagia 78
Epigastric pain 6
Heatburn 3
Weight loss only 3
Odinophagia 2
Vomiting/Regurgitation 2
Fatigue 2
GastroIntestinal bleeding 1
Nausea 1
Indigestion 1
Sore throat 1
Tab.2 Patology
Diagnosis n.patients %
Primitive Cancer 78 65
Secondary Cancer 12 10
K. Recurrences 17 14.5
Flogistic disease 5 4.16
Achalasia 5 4.16
Barrett’esophagus 3 2.5
Tab.3 Primitive Cancer
n.patients %
Cervical esoph. 10/78 12.8
Thoracic 17/78 21.7
Cardias 51/78 66.5
Tab.3 Secondary Cancer
n.patients %
Cervical esoph.
(from laringeal K.) 7/12 58.2
Cardias
(from lung-mediastinic K.) 5/12 39.7
Tab.4 Risk Factors
Smoke 70 %
Alcohol 60 %
Obesity 30 %
Barrett’s esophagus 2.5 %
Tab.5 Clinical Evaluation
General Status
Pulmonary Function
Cardio-Vascular Function
Hepatic Function
Renal Function
Neurological Function
Diabetes
Tumor Stage
Tab.6 Clinical Evaluation - General Status
Sex
Age
Karnofsky Index
Alcohol Abuse
Tobacco Abuse
Weight loss
Dispepsia
Mental Cooperation
Blood examination
Tab.7 Clinical Evaluation - Pulmonary/Renal Function
Vital Capacity V.C
Focal Expiratory Volume FEV 1
Peak Flow
PaO2 mm/Hg
PaCO2 mm/Hg
Creatinine Clearance mg/ml
Tab.8 Clinical Evaluation - Cardiac/Hepatic Function
ECG
X-rays Chest
Cardiologist Visit
Serum Albumin
Bilirubin
P.T- P.T.T
Aminopyrine Breath Test
Cirrhosis
Tab.9 Clinical Evaluation - Mental cooperation / Risk
Karnofsky Index > 80 & good cooperation / Normal
Karnofsky Index < 80 & good cooperation/ Compromised
Karnofsky Index < 80 & bad cooperation/Severely impaired
Tab.10 Clinical Evaluation - Cardiac Function / Risk
Normal Normal
Compromised Increased
Severely impaired Highest
Tab.10 Clinical Evaluation -Pulmonary Function / Risk
VC > 90% PaO2 >70 mm/Hg Normal
VC < 90% PaO2< 70 mm/Hg Compromised
Tab.11 Clinical Evaluation –Hepatic Function / Risk
ABT > 0.4 Normal
ABT < 0.4 no Cirrhosis Compromised
Cirrhosis Severely Impaired
Tab.12 Conditions for inoperable patients
III th Stage Neoplasm T3 N2 M0-1
Age over 75
Cardio-Vascular disease
Coagulopaties
Weight loss
Immuno Compromised
Tab.13 Pre-Operative Disphagia
Patients III grade IV grade
120 80 40
Tab.14 Post-Operative Disphagia
grade % n.patients Follow-up/months
I 85 102/120 <12
I 60 72/120 >12 <24
II 30 36/120 >24
Tab.15 Intra-Peri Operative Complications
n.patient %
Exitus 1/120 0.83
Iatrogenous perforation 3/120 2.5
Re – Stricture (after RadioTherapy) 2/120 1.66
Tab.16 Cost effectiveness in the management of oesophageal K.
Surgery RadioTherapy Laser Stents No Treatm.
Median Cost $ 8070 4720 3520 2450 1390
Range 2540-39780 3364-
6687 2530-
6340 1647-
5550 1132-
2348
Cost /month Survival
457
364
342
/
/
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Palliative Treatment of Neoplastic Esophageal Strictures by Self-Expanding Metallic Stent
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counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
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No full textTo understand the level of acceptance, awareness and usefulness of informed consent, a group of 119 patients (59 men and 60 women) from different types of hospitals were given a questionnaire which required only 'YES or NO' answers, both before and after surgery. The questionnaire concerned the patient's knowledge about pathology, operative risks, approval, anxiety caused, understanding of information received and consent given, and also if he would inform a relative in the same condition. From the analysis of the results it was established that: the more information a patient has about his illness and operation risks, the more he will want to have; the less he knows the less he will want to know, and he will also have more faith in the doctors. Some patients would not inform a relative with a similar pathology. To conclude, informed consent, instead of being a right of the patient is progressively becoming more a right of the doctor. It does not have any real effect on the patient's choice but is useful, as it represents a moment of personalised attention from medical personnel, though the patient may not completely understand the information received. There are few advantages in strictly medical terms but informed consent has increased malpractice litigation
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