Oesophagus Cancer : wich treatment ? Personal experience using a Multidisciplinary Therapeutic Approach.

BachGround :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 / / References : 1. Palliative therapy for patients with unresecable esophageal. Freeman R.K.,Ascioti A.J.,Muhidara R.J. Surg Clin North Am 2012 Oct;92(5):1337-51 2. The use of self-expandable metallic stents for palliative treatment of inoperable esophageal cancer. Eroghu A.,Turkylmaz A.,Subasi M.,Kareoglanoghu N Dis Esophagus 2010 Jan;23(1):64-90 3. Advanced esophageal carcinoma recanalization. Molna’rova’ A Klin Onkol 2008;21(5):309-312 4. Inoperable esophageal cancer and out come of palliative care. Besharat S.,Jabbari A.,Semnani S.,Keshtkar A.,Marjanis World J GastroEnterol 2008 June 21;14(23):3725-8 5. Causes and treatment of recurrence dysphagia after self-expanding metallic stent placement for palliation of esophageal carcinoma. Homs MY.,Steyerberg E.W.,Knipers E.J.,Van der Goost A.,Haringsma J.,Van Blankenstein M.,Siersema P.D. Endoscopy 2004 Oct;36(10):880-6 6. Endoscopic Laser Surgery in Flogistic Disease and non operable cancer of oesophagus. Fiorito R.,Bellanova G.,Milito G.,Filingeri V.,Venditti D.,Casciani C.U. Atti 7mo Congresso Nazionale della Societa’ Italiana di Chirurgia Endoscopica;Urbino 9-11 Sett/2001 7. Neoplasie inoperabili del cardias : degenerazione e dislocamento di self expanding covered stents dopo RadioTerapia. Fiorito R. , Moraldi A. , Pocek M.,Sergiacomi G.L.,Bellanova G.,Filingeri V.,Casciani C.U. Atti 101°Congresso Societa’ Italiana di Chirurgia; Catania 10-13 Ott./1999 Abstrac book p.129-130 8. Palliation of inoperable oesophageal carcinoma treated by self expanding stents. Guemes A.,De Gregorio M.A., Salinas J.C., Torcal J.,Sousa R.,Burdio F.,Fernandez J.and Lozano R. Br J Surg 1998;85,supp.2:182-184 9. Restenting malignant oesophageal strictures LaGattolla N.R.F., Rowe H., Anderson H.,Dunk A.A Br J Surg 1998;85:261-263 10. Management of malignant oesophageal obstruction with self-expanding metallic stents. Cowling M.G., Hale A., Grundy A. Br J Surg 1998;85:264-266 11. Advances in the surgical treatment of oesophageal cancer. Sugimachi K. Br J Surg 1998;85:289-290 12. Palliative treatment of neoplastic oesophageal strictures by self-expanding metallic stents. Pocek M., Iascone C., Fiorito R. Atti 6 th World Congress of the International Society for Disease of the oesophagus; Milan Aug.23-29/1995:vol.I ,pag.501-504 13. Esophageal cancer and palliation of dysphagia. Massey S. Clin J Oncol Nurs 2011 June:15(3):327-

Clinical-radiological correlation in immunocompromised host [Correlazione clinico-radiologica nella patologia polmonare da immunosoppressione]

Lung is the most involved site by infective manifestations in immunodepressed patients. In these patients the variability of pathogenic and opportunistic agents is expressed in the lungs with interstitial and alveolar changes, which are not pathognomonic. CT is the appropriate method to study lung parenchyma. CT by means of fast scans and high resolution algorithms (HRCT) allows an accurated and detailed reppresentation of the lung parenchyma, detecting the secondary lobe, the anatomic and functional unit of the lung and its pathological changes. Our study aim to show the clinical-radiological correlation among the various types pulmonary infections in immunocompromised host

Clinical-radiological correlation in immunocompromised host [Correlazione clinico-radiologica nella patologia polmonare da immunosoppressione]

Lung is the most involved site by infective manifestations in immunodepressed patients. In these patients the variability of pathogenic and opportunistic agents is expressed in the lungs with interstitial and alveolar changes, which are not pathognomonic. CT is the appropriate method to study lung parenchyma. CT by means of fast scans and high resolution algorithms (HRCT) allows an accurated and detailed reppresentation of the lung parenchyma, detecting the secondary lobe, the anatomic and functional unit of the lung and its pathological changes. Our study aim to show the clinical-radiological correlation among the various types pulmonary infections in immunocompromised host

Pectoralis muscle flap repair reduces paradoxical motion of the chest wall in complex sternal wound dehiscence

The aim of the study was to test the hypothesis that in patients with chronic complex sternum dehiscence, the use of muscle flap repair minimizes the occurrence of paradoxical motion of the chest wall (CWPM) when compared to sternal rewiring, eventually leading to better respiratory function and clinical outcomes during follow-up

Pectoralis Muscle Flap Repair Reduces Paradoxical Motion of the Chest Wall in Complex Sternal Wound Dehiscence

The aim of the study was to test the hypothesis that in patients with chronic complex sternum dehiscence, the use of muscle flap repair minimizes the occurrence of paradoxical motion of the chest wall (CWPM) when compared to sternal rewiring, eventually leading to better respiratory function and clinical outcomes during follow-up

Vascular radiology and physics of fluids [Radiologia vascolare e fisica dei fluidi.]

In the cardiovascular system, morphology and functionality are closely related. The observation that atherosclerotic lesions appear with different incidence in the various sites and prefer bifurcations, suggested that vascular architecture might be an important pathogenic factor. Vascular geometry deals with the evaluation of the "form" element from a theoretical point of a view, pointing out the angles and diameters which can make the arterial system physiologically more efficient. The key element of the system is the bifurcation: depending on whether bifurcations are considered as a single entity or as a whole, either "local" or "global" geometry is employed. The morphology of the bifurcation directly affects blood flow patterns, influencing both blood flow velocity and wall shear stress. Experimental studies evidenced that high blood flow velocities and low wall shear stress have, respectively, a preventive or favorable role in atheroma development. By observing these altered flow sites, the areas which are most likely to develop atherosclerotic damage have been detected in the various bifurcations; the areas correspond to angiographic and autoptic findings. Based on their experience, the authors discuss the contribution that the different imaging techniques can give to the study of vascular geometry

Computed tomography detection of gastrointestinal neoplasms

Gastrointestinal (GI) tract neoplasms can be detected, evaluated and staged by computed tomography (CT), especialy from high-resolution examinations, but routine CT scanning may occasionally discover GI neoplasms in patients with non-specific symptoms. We therefore evaluated the sensitivity and main signs of CT examinations resulting from routine sessions. In 46 out of 1560 patients who underwent abdominal CT, it was possible to obtain a diagnosis of primitive gastric or colo-rectal tumour by means of barium X-ray and/or endoscopy. The sensitivity rate of CT obtained from the present study was 86% in gastric tumours and 87% in colonic tumours. In gastric lymphoma, infiltrating carcinoma of stomach and rectal carcinoma, the sensitivity rate was 100%. The CT diagnosis of GI neoplasms was based on diffuse or local thickening of the gut on a solid dishomogenous mass showing contrast enhancement. The prevalence of various patterns depends on site of origin and on macroscopic features of the neoplasia. In conclusion the results suggest that abdominal CT, even if performed with a method not specifically devoted to GI tract, has high sensitivity rates and then a high probability of detecting GI neoplasms when unsuspected at time of the examination. In our series 11% of GI neoplasms were initially diagnosed by routine CT examination

Vascular radiology and physics of fluids [Radiologia vascolare e fisica dei fluidi.]

In the cardiovascular system, morphology and functionality are closely related. The observation that atherosclerotic lesions appear with different incidence in the various sites and prefer bifurcations, suggested that vascular architecture might be an important pathogenic factor. Vascular geometry deals with the evaluation of the "form" element from a theoretical point of a view, pointing out the angles and diameters which can make the arterial system physiologically more efficient. The key element of the system is the bifurcation: depending on whether bifurcations are considered as a single entity or as a whole, either "local" or "global" geometry is employed. The morphology of the bifurcation directly affects blood flow patterns, influencing both blood flow velocity and wall shear stress. Experimental studies evidenced that high blood flow velocities and low wall shear stress have, respectively, a preventive or favorable role in atheroma development. By observing these altered flow sites, the areas which are most likely to develop atherosclerotic damage have been detected in the various bifurcations; the areas correspond to angiographic and autoptic findings. Based on their experience, the authors discuss the contribution that the different imaging techniques can give to the study of vascular geometry