Does an esophageal stent impact your radiation treatment plan for a patient with non-metastatic GE junction adenocarcinoma?

While the presence of a stent might not directly affect my radiation dose and volumes, due to numerous other considerations, it would certainly affect my overall treatment plan. I highly encourage avoiding a stent in the setting of radiation due to toxicity concerns in addition to the complications noted by @Dr. First Last, MD. Working with the University of Utah team, we published a series involving a series of 103 patients treated with definitive or neoadjuvant chemoRT, of whom 28 had a stent in place during the chemoRT (Francis et al., PMID 28864404). We found that Grade 3 toxicities were significantly more likely in the stented patients both overall and for esophagitis, and anorexia and dehydration were numerically worse in stented patients. Interestingly, the only significant predictor for acute toxicity on multivariate analysis was esophageal stenting. The most common complications from stenting itself included pain (39%), stent migration (32%), and reflux (14%). This has led us to avoid placing stents in the definitive setting, instead favoring J-tubes if potentially operable and PEG tubes if surgery is not planned. Although the aforementioned data is from the curative intent setting, it does advise caution involving both RT & stents in the palliative setting as well. Of note, in a prior study we also evaluated how self-expanding stents (SESs) may affect esophageal cancer radiation planning target volumes (PTVs) and dose delivered to surrounding organs at risk (OARs) in a series of ten patients were evaluated for whom an SES was placed before radiation (Francis et al., PMID 23835387). The lung V5, lung V10, and heart V40 constraints were achieved more often using plan evaluations based on pre-stent CT scans. Esophageal SES placement increases the dose delivered to the lungs, heart, and liver. Since the publication of this data, our team has been very successful in avoiding RT in the presence of a stent, and we have only offered it a handful of times.

If a patient does have a stent placed here at UVM, the disease is almost always locoregionally advanced in a way that is borderline metastatic equivalent. Depending on the patient's goals of care, in an otherwise healthy patient starting with chemo to address both the esophageal cancer causing dysphagia as well as the advanced disease is often our preferred plan, with analgesics as needed for the odynophagia and dietary modifications in consultation with a dietician. Typically, we provide 2-3 months of chemotherapy (sometimes with concurrent immunotherapy) or perhaps a CALGB 80803 6 weeks of chemo approach, and the dysphagia resolves to the point where the stent can be removed, and if PET/CT shows continued non-metastatic disease we then offer concurrent chemoRT (preferred dosing is 50.4 Gy/28 fx if definitive & 41.4/23 fx if neoadjuvant.) While this induction approach is not clearly supported by NCCN guidelines, it is often very effective and it is supported by the American Radium Society Gastrointestinal Committee Appropriate Use Criteria guidelines on esophageal adenocarcinoma (Anker et al., PMID 32858113).

Regarding the time course & durability of improving dysphagia for RT vs. stents, a retrospective review of 63 inoperable patients (Hanna et al., PMID 22514498) found that the interval to improvement of dysphagia was slower with RT than with stents as would be expected (50% vs 85% at 2 weeks) but the response was more durable with RT (90% vs 80% at 10 weeks).

Of note, palliative care/hospice should often be discussed in addition to or instead of stenting. In rare situations where the patient has near complete esophageal obstruction and is at risk for aspiration, then a stent might help prevent life-threatening aspiration pneumonia but the lumen needs to be patent enough to place a stent. If a standard scope is too large with which to place the stent, a pediatric scope might be possible which has a smaller diameter, and as a last resort placing a stent over 1-2 mm guidewire might be possible under fluoroscopic guidance. As always, the bottom line is an individualized, multidisciplinary approach is essential in these difficult situations.

In general, I try and avoid stents. While it does not impact my treatment planning, I do have concerns for perforation or stent migration. So the management of these patients can be more involved given the risk for a series of complications. 

I agree with Drs. @Dr. First Last, @Dr. First Last, and @Dr. First Last.

I also did some literature search. Based on some published study results, esophageal stenting can indeed impact the radiation treatment plan for patients with non-metastatic GE junction adenocarcinoma. These studies indicate several key findings:

1. Complications after Stent Placement:

• Radiation therapy after esophageal stent placement in patients with locally advanced esophageal cancer can lead to severe complications, including bleeding, pneumonia, and even death (Yakami et al., PMID 14663644, Chen et al., PMID 21628012).
• Airway complications, particularly esophagorespiratory fistula, are common after esophageal stent placement, with a higher frequency observed in patients undergoing radiation therapy (Park et al., PMID 22268193, Chen et al., PMID 21628012).

• Patients who undergo radiation therapy before stent placement experience earlier airway complications and shorter survival periods compared to those who undergo radiation therapy after stent placement (Park et al., PMID 22268193, Chen et al., PMID 21628012).
• Esophageal stenting before chemoradiation therapy (CRT) for locoregionally advanced esophageal cancer is associated with significantly increased grade 3 acute toxicities, decreased rates of esophagectomy, and worse overall survival (Int J Radiation Oncol Biol Phys, 2017, 884e894).

• Different esophageal stent materials and mesh density designs have varying effects on radiation dose perturbation, with polymer-based and biodegradable stents showing negligible backscatter and metal alloy stents exhibiting significant backscatter (Abu Dayyeh et al., PMID 23254405, Chen et al., PMID 21628012).
• Self-expanding stents (SESs) increase the lumenal diameter of the esophagus, leading to larger gross tumor volumes (GTV), and resulting in higher radiation doses to organs at risk (OARs) such as the lungs and heart (Francis et al., PMID 23835387).
• The presence of a metallic esophageal stent during radiation therapy results in dose perturbations and overdose in the esophageal wall (Lu et al., PMID 29728468).

The overall implications of these studies suggest that esophageal stenting, especially in the context of radiation therapy, is associated with increased complications, such as fistula formation and airway complications. The timing of stent placement in relation to radiation therapy may impact the occurrence of complications and patient outcomes. Alternative treatment approaches and careful consideration of the risks and benefits are recommended to optimize outcomes and minimize risks. The collective evidence from these studies strongly indicates that esophageal stenting can significantly influence the radiation treatment plan for patients with non-metastatic GE junction adenocarcinoma.

Clinically, I usually don’t like to deliver definitive chemoradiation to patients with a stent.

I agree with Dr. @Dr. First Last and Dr. @Dr. First Last. I would only add that a stent across the GE junction is frequently very poorly tolerated, with severe reflux that is refractory to medication. Additionally, the further the stent extends into the stomach, the more likely it is to migrate. 

At the end of the 1990s, the Digestive Disease Ce meter and Rad Onc MUSC spearheaded a trial STent or palliative RT (20 Gy 5 Fx). It was sponsored by Boston Scientific. A lot of balking at 20 Gy, but MST was 4 mos. Only 30 patients were entered. I reported at ASTRO but the GI fold and BS didn’t want to publish that survival was marginally better with 20 Gy, palliation of swallowing a bit better with Nytenol Stents. Crossover allowed. Nytenol Stents do not migrate. 

Excellent thread here on esophageal stenting. 

I reserve stenting as the last resort for palliation, especially if there are no radiotherapy options. 

For curative intent chemorads patients - supporting them with G-tube, TPN, and hydration is more critical and getting them through the treatment. Stents cause more issues than benefits. 

In palliative setting, single fraction of brachytherapy has shown to be more effective, both clinically and financially than stenting.