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Fiberoptic flexible sigmoidoscopy and pelvic masses
Letters to the Editor
agus and esophagogastric junction. These latter cancers have been strongly associated with Barrett's esophagus, leading to surveillance strategies in an effort to detect high-grade dysplasia and cancer at a curative stage. In high-incidence areas for squamous cell cancer, screening cytology and endoscopy have been initiated as public health measures in a similar effort to detect early cancer. The most accurate clinical staging of esophageal cancer has been achieved using CT for distant metastases (M), with EUS for primary tumor depth of invasion (T) and regional lymph node (N) disease. The value of EUS for esophageal cancer staging is in selecting patients for stage-based management. Malignant esophageal strictures are usually advanced stage III or IV disease, but some patients may have bulky tumors that are stage IIA with a much better prognosis after surgical resection. Surgery with curative intent or multimodality surgical adjuvant treatments can be applied in selected patients with stage III disease, while such efforts are not indicated for patients with stage IV. Limitations in using EUS relate to low availability outside major centers. There are new instruments specifically designed for staging malignant strictures. For example, the Olympus MH-908 is a non-optical instrument, 7.9 mm in diameter, with a bougie-shaped tip that passes over a guidewire. Complete tumor staging, including evaluation of the celiac axis, can be accomplished in almost all patients. Palliation of malignant dysphagia can be achieved in most patients. Dilation using guidewires is almost always possible, but improvement is transient. Ablative methods include alcohol injection, Nd:YAG laser, and photodynamic therapy, listed in the order of increasing expense, better control and overall results. The placement of esophageal stents, however, has emerged as the treatment of choice for palliation. In the United States, most gastroenterologists favor covered expandable metal stents, which can be deployed successfully with very low complication rates. Some specialists still favor the placement of plastic prostheses, noting the markedly lower cost; but in most series, including the two randomized trials with metal stents, insertion of plastic tubes was associated with a significant incidence of perforation and mortality. Covered stents provide the best palliation for airway fistulas. Long-term stent complications, however, continue to be a problem in about a third of patients. The complication rates appear to be higher in patients who have received prior radiation therapy. The ideal esophageal stent has not yet been developed. With so many unsatisfactory aspects of diagnosis and therapy, patients should be encouraged to enter clinical trials designed to test methods to improve the situation. Hopefully, such efforts will lead to better VOLUME 49, NO. 6, 1999
affordable management strategies for esophageal cancer, resulting in more uniform practice patterns around the globe. For a detailed discussion, please refer to the Guidelines of Esophageal Cancer just published in the January 1999 issue of the American Journal of Gastroenterology with the endorsement of all the major American gastroenterology societies. DR. CHARLESJ. LIGHTDALE New York, New York
Fiberoptic flexible sigmoidoscopy and pelvic masses To the Editor: Lawitz and Kadakia 1 recently reported on the utility of preoperative fiberoptic flexible sigmoidoscopy in the evaluation of patients with suspected gynecologic malignancies. They stated that "the role of pre-operative FFS {fiberoptic flexible sigmoidoscopy} has not been previously evaluated" in the patient with suspected gynecologic malignancy. Peller and Wong2 reported on 134 patients with known pelvic masses who underwent preoperative FFS. One hundred four of these patients were ultimately diagnosed with a gynecologic malignancy. The mean age of the patients was 49 years. Eight percent (11 of 134) had extrinsic compression noted on FFS. One of these patients had serosal involvement at surgery and required a sigmoid resection, but perioperatively there was no difference in surgical approach. Neoplastic processes (one patient with a sigmoid carcinoma and three patients with tubular adenomas) occurred in 3% of the patients. All patients with adenomas or colon cancer were older than 50 years of age. Our conclusion is in agreement with Lawitz and Kadakia, that routine preoperative FFS did not alter the surgical management of patients with pelvic masses. We also concluded that FFS should be performed in all patients with pelvic masses over the age of 50.
Thomas Peller, MD, FACP Southside Medical Clinic Eau Claire, Wisconsin
REFERENCES 1. Lawitz E, Kadakia S. Utility of preoperative fiberoptic flexible sigmoidoscopy in the evaluation of patients with suspected gynecologicmalignancy. Gastrointest Endosc 1998;47:350-3. 2. Peller T, Wong RKH. Routine flexible sigmoidoscopy and barium enema does not alter operative management and is not cost effective in the evaluation of pelvic masses [abstract]. Gastroenterology 1992;102:A23.
Response: We appreciate Dr. Pellet's comments on our recently published article in Gastrointestinal Endoscopy. 1 PeUer et al. 2 GASTROINTESTINAL ENDOSCOPY
817
agus and esophagogastric junction. These latter cancers have been strongly associated with Barrett's esophagus, leading to surveillance strategies in an effort to detect high-grade dysplasia and cancer at a curative stage. In high-incidence areas for squamous cell cancer, screening cytology and endoscopy have been initiated as public health measures in a similar effort to detect early cancer. The most accurate clinical staging of esophageal cancer has been achieved using CT for distant metastases (M), with EUS for primary tumor depth of invasion (T) and regional lymph node (N) disease. The value of EUS for esophageal cancer staging is in selecting patients for stage-based management. Malignant esophageal strictures are usually advanced stage III or IV disease, but some patients may have bulky tumors that are stage IIA with a much better prognosis after surgical resection. Surgery with curative intent or multimodality surgical adjuvant treatments can be applied in selected patients with stage III disease, while such efforts are not indicated for patients with stage IV. Limitations in using EUS relate to low availability outside major centers. There are new instruments specifically designed for staging malignant strictures. For example, the Olympus MH-908 is a non-optical instrument, 7.9 mm in diameter, with a bougie-shaped tip that passes over a guidewire. Complete tumor staging, including evaluation of the celiac axis, can be accomplished in almost all patients. Palliation of malignant dysphagia can be achieved in most patients. Dilation using guidewires is almost always possible, but improvement is transient. Ablative methods include alcohol injection, Nd:YAG laser, and photodynamic therapy, listed in the order of increasing expense, better control and overall results. The placement of esophageal stents, however, has emerged as the treatment of choice for palliation. In the United States, most gastroenterologists favor covered expandable metal stents, which can be deployed successfully with very low complication rates. Some specialists still favor the placement of plastic prostheses, noting the markedly lower cost; but in most series, including the two randomized trials with metal stents, insertion of plastic tubes was associated with a significant incidence of perforation and mortality. Covered stents provide the best palliation for airway fistulas. Long-term stent complications, however, continue to be a problem in about a third of patients. The complication rates appear to be higher in patients who have received prior radiation therapy. The ideal esophageal stent has not yet been developed. With so many unsatisfactory aspects of diagnosis and therapy, patients should be encouraged to enter clinical trials designed to test methods to improve the situation. Hopefully, such efforts will lead to better VOLUME 49, NO. 6, 1999
affordable management strategies for esophageal cancer, resulting in more uniform practice patterns around the globe. For a detailed discussion, please refer to the Guidelines of Esophageal Cancer just published in the January 1999 issue of the American Journal of Gastroenterology with the endorsement of all the major American gastroenterology societies. DR. CHARLESJ. LIGHTDALE New York, New York
Fiberoptic flexible sigmoidoscopy and pelvic masses To the Editor: Lawitz and Kadakia 1 recently reported on the utility of preoperative fiberoptic flexible sigmoidoscopy in the evaluation of patients with suspected gynecologic malignancies. They stated that "the role of pre-operative FFS {fiberoptic flexible sigmoidoscopy} has not been previously evaluated" in the patient with suspected gynecologic malignancy. Peller and Wong2 reported on 134 patients with known pelvic masses who underwent preoperative FFS. One hundred four of these patients were ultimately diagnosed with a gynecologic malignancy. The mean age of the patients was 49 years. Eight percent (11 of 134) had extrinsic compression noted on FFS. One of these patients had serosal involvement at surgery and required a sigmoid resection, but perioperatively there was no difference in surgical approach. Neoplastic processes (one patient with a sigmoid carcinoma and three patients with tubular adenomas) occurred in 3% of the patients. All patients with adenomas or colon cancer were older than 50 years of age. Our conclusion is in agreement with Lawitz and Kadakia, that routine preoperative FFS did not alter the surgical management of patients with pelvic masses. We also concluded that FFS should be performed in all patients with pelvic masses over the age of 50.
Thomas Peller, MD, FACP Southside Medical Clinic Eau Claire, Wisconsin
REFERENCES 1. Lawitz E, Kadakia S. Utility of preoperative fiberoptic flexible sigmoidoscopy in the evaluation of patients with suspected gynecologicmalignancy. Gastrointest Endosc 1998;47:350-3. 2. Peller T, Wong RKH. Routine flexible sigmoidoscopy and barium enema does not alter operative management and is not cost effective in the evaluation of pelvic masses [abstract]. Gastroenterology 1992;102:A23.
Response: We appreciate Dr. Pellet's comments on our recently published article in Gastrointestinal Endoscopy. 1 PeUer et al. 2 GASTROINTESTINAL ENDOSCOPY
817