Colon Cancer 3
What’s the best technique? Well, obviously one that can be accomplished quickly, conveniently for the patients where they are not tied to an endoscopy center repeatedly, the lowest cost, and the lowest morbidity and mortality. Palliative management, a number of guidelines; we’ve got to confirm the diagnosis. The location, length, other characteristics of the tumor are important to define. Is this primarily an exophytic tumor or rather is this extrinsic compression from a tumor outside the esophagus perhaps? Is there a fistula present, and has adjuvant therapy being contemplated?
This is an example of an esophageal tumor, primarily exophytic as you can gauge by the roughened tissue within the midportion of the esophagus. This was a squamous cell malignancy. Now how should we manage this tumor? If you look at the relatively ancient literature, back in 1845 there was a Frenchman who used a decalcified elephant tusk – basically a hunk of ivory – the center was bored out and he placed that into the esophageal tumor unsuccessfully, unfortunately. Ten years later an Englishman named Sir Charles Simmond used a piece of carved boxwood, a six-inch piece of wood. Jammed it into an esophageal tumor and the patient did well for about three months.
So those are the first reported cases of so-called endoscopic intervention, but our therapy has actually evolved since then. In the modern era it is important to at least consider now radiation therapy. There are special protocols designed to shrink tumors rapidly over a short period of time, such as over ten fractions, but importantly, the response rate is quite variable especially for the responses for adenocarcinomas. The time to see tumors shrink is also quite variable. It can take as long as six weeks, even in the responders, before you’ll get a significant effect – although the duration is usually around the time of five or six months where the benefit will be maintained. Importantly, stricture formation in patients who have radiation therapy can be a significant complication where endoscopic therapy is again called upon.
Since the advent of the fiberoptic endoscope, a number of interventional technologies have evolved, and listed here in the order in which they appeared. Dilation therapy, simply using a bougie or a balloon dilator is simple, quite easy to perform, but as you would imagine, the benefit is quite short-lived and typically, repeated dilatations are necessary. Aggressive dilatation can result in a dilatation in up to a quarter of the patients. Injection therapy is also quite simple, technically. You basically inject absolute alcohol or some other solutions into a kind of fleshy, soft, exophytic tumor where it works the best, and you may see some fluffage which occurs with that. But again, as you can imagine, with extensive fibrotic circumferential tumors this therapy doesn’t work very well.