International journal of radiation oncology, biology, physics 2017-11-15
Toxicity and Outcomes in Patients With and Without Esophageal Stents in Locally Advanced Esophageal Cancer.
Abstract
Purpose
Esophageal stenting is often considered to relieve dysphagia in patients with locoregionally advanced esophageal cancer. We sought to determine the effects of stenting on the incidence of acute toxicity and oncologic outcomes in patients undergoing chemoradiation therapy (CRT).
Methods and materials
The data from patients treated with curative intent CRT for locoregionally advanced esophageal cancer at the University of Utah were retrospectively analyzed. The χ2 or Fisher exact test was used to compare the demographic and tumor characteristics between patients with and without esophageal stenting before RT. Univariate and multivariate analyses using logistic regression modeling were used to identify the predictors of acute toxicities. A propensity score-matched analysis with shared frailty Cox hazard regression was performed according to stent status to identify the stent effect on survival. Acute toxicities were graded using the Common Terminology Criteria for Adverse Events, version 4.
Results
From 2005 to 2013, 103 consecutive patients received CRT. Of the 103 patients, 28 had a stent in place during CRT. The median dose was 50.4 Gy for all patients. Grade ≥3 acute toxicities were seen in 71% of the stent versus 27% of the no-stent patients (P<.01), including esophagitis (39% vs 20%; P=.05), dehydration (29% vs 13%; P=.07), and anorexia (14% vs 5%; P=.13). Of the 103 patients, 29% of the stent and 51% of the no-stent patients underwent esophagectomy (P=.05). The only significant predictor for acute toxicity on multivariate analysis was esophageal stenting (odds ratio 8.1; P<.01). After propensity score matching, the stent patients had a worse median overall survival compared with the no-stent patients (11.5 vs 22.0 months; hazard ratio 2.3; P=.016).
Conclusions
In patients undergoing CRT with curative intent, esophageal stenting was associated with significantly increased grade ≥3 acute toxicities, fewer patients proceeding to esophagectomy, and worse overall survival.
Related Questions
For a patient with T3N1M0 esophageal adenocarcinoma, who suffered esophageal perforation necessitating metallic stent placement, would you favor a neoadjuvant chemoradiation or perioperative chemotherapy approach?
In situations of esophageal perforation, the main concern will be the dissemination of disease particularly in the thoracic cavity, i.e. pleura. Therefore, I favor a systemic therapy approach upfront. Should the patient have a good response to systemic therapy, then chemoradiation could be considere...
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 ...
In the case of a thoracic esophageal cancer that will require extensive volume coverage, >2/3 of the esophagus, do you prophalactically prescribe a feeding tube or observe?
I am not a big fan of stents and working with the University of Utah team we published on this issue (Francis et al., IJROBP 2017). For a series of 103 consecutive patients treated with definitive or neoadjuvant chemoradiation (CRT), of whom 28 had a stent in place during the chemoRT, we found that ...