White Russell E, Parker Robert K, Fitzwater John W, Kasepoi Zachariah, Topazian Mark
Tenwek Hospital, Bomet, Kenya; Department of Surgery, Brown Medical School, Rhode Island Hospital, Providence, RI, USA.
Lancet Oncol. 2009 Mar;10(3):240-6. doi: 10.1016/S1470-2045(09)70004-X. Epub 2009 Feb 18.
Therapies for inoperable oesophageal cancer include chemoradiotherapy and placement of a self-expanding metal stent (SEMS). Few data are available regarding SEMS as sole therapy for patients with inoperable disease who have not already received, or are unfit for, chemoradiotherapy. The aim of this study was to determine survival, adequacy of palliation, and complications after SEMS placement as sole therapy for inoperable oesophageal cancer in a resource-limited setting.
Data were prospectively gathered on all patients with oesophageal cancer treated with SEMS between Jan 1, 1999, and May 20, 2008, at a hospital in Kenya where chemoradiotherapy is unavailable. Dysphagia scores, morbidity, mortality, and survival were assessed. Follow-up was done during clinic visits, home visits, and by mobile phone.
1000 stents were placed in 951 patients. Long-term follow-up was obtained for 334 patients (35%) with a median survival of 250 days (IQR 130-431, 95%CI 217-301). Mean dysphagia scores improved from 3.3 (SD 0.6) pre-SEMS (n=697) to 1.0 (SD 1.3) for patients (n=78) still alive and 1.8 (SD 1.2) at time of death (n=165). Survival of 17 patients with follow-up who had perforation during tumour dilation (treated with SEMS) was 283 days (IQR 227-538) similar to the 317 patients with follow-up data who did not have a perforation (245 days, 124-430). 20 patients with a tracheo-oesophageal fistula lived a median of 142 days (IQR 73-329). Early complications occurred in 6% (54 of 951 patients) and late complications occurred in 19% (62 of 334 patients). SEMS-related mortality was 0.3% (three of 951).
SEMS effectively palliate inoperable oesophageal cancer. Survival may be longer than previously reported when SEMS are placed in all patients with inoperable oesophageal cancer, as in our study, rather than those failing or unfit for chemoradiotherapy. SEMS seem to be an appropriate technology for palliation of oesophageal cancer in resource-limited settings. Given the proportion of patients lost to follow up, these findings merit further confirmation.
不可切除食管癌的治疗方法包括放化疗和置入自膨式金属支架（SEMS）。对于尚未接受过放化疗或不适合放化疗的不可切除疾病患者，关于SEMS作为单一治疗的数据很少。本研究的目的是确定在资源有限的环境中，将SEMS作为不可切除食管癌的单一治疗后的生存率、缓解程度和并发症情况。
前瞻性收集了1999年1月1日至2008年5月20日期间在肯尼亚一家无法进行放化疗的医院接受SEMS治疗的所有食管癌患者的数据。评估吞咽困难评分、发病率、死亡率和生存率。通过门诊随访、家访和电话进行随访。
951例患者共置入1000个支架。对334例患者（35%）进行了长期随访，中位生存期为250天（IQR 130 - 431，95%CI 217 - 301）。仍存活患者（n = 78）的平均吞咽困难评分从SEMS置入前的3.3（SD 0.6）（n = 697）改善至1.0（SD 1.3），死亡时（n = 165）为1.8（SD 1.2）。17例在肿瘤扩张时发生穿孔（接受SEMS治疗）且有随访的患者的生存期为283天（IQR 227 - 538），与317例有随访数据且未发生穿孔的患者（245天，124 - 430）相似。20例气管食管瘘患者的中位生存期为142天（IQR 73 - 329）。早期并发症发生率为6%（951例患者中的54例），晚期并发症发生率为19%（334例患者中的62例）。SEMS相关死亡率为0.3%（951例中的3例）。
SEMS能有效缓解不可切除食管癌。正如我们研究中那样，当对所有不可切除食管癌患者置入SEMS时，生存期可能比之前报道的更长，而不是仅针对放化疗失败或不适合放化疗的患者。在资源有限的环境中，SEMS似乎是缓解食管癌的合适技术。鉴于失访患者的比例，这些发现值得进一步证实。
