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Stenting in the Neoadjuvant Setting
LETTERS
Stenting in the Neoadjuvant Setting
3. Mariette C, Gronnier C, Duhamel A, et al. Self-expanding covered metallic stent as a bridge to surgery in esophageal cancer: impact on oncologic outcomes. J Am Coll Surg 2015;220:287e296.
Gregory L Falk, MBBS Lindfield, Australia
Disclosure Information: Nothing to disclose.
I read with a little concern the excellent study by Philips and colleagues1 on the efficacy of gastro-esophageal stenting. Although quality of life and swallowing were enhanced in this group, there was a high rate of stent migration (63%), and this therapy is recognized only for palliative cases. So these data are quite applicable to the palliative group and are reassuring. There are no data available for the use of stenting as a bridge to curative resection with neoadjuvant therapy. Our concerns were first raised when an early and unusual pattern of recurrence of esophageal carcinoma was found in a number of patients, and cure on the basis of histopathology would have been expected. In several other patients, stents were seen in the mediastinum, indicating cancer perforation and incurability. With this experience, we reviewed the very scant literature. One can only theorize that stenting a tumor in the esophagus or cardio-esophageal junction leads to micro-cracking of the exterior of the tumor and potential for dissemination. Jones and Griffiths2 indicated that stenting in the neoadjuvant setting can lead to significant complications and can compromise the opportunity for surgical cure. In a collected series, Mariette and colleagues3 demonstrated a negative effect of stenting on oncologic outcomes in the neoadjuvant situation. On the basis of such concerns, a moratorium needs to be called on stenting in the neoadjuvant situation until adequate randomized data show it to be effective and able to produce equivalent oncologic outcomes to those of current techniques. REFERENCES 1. Philips P, North DA, Scoggins C, et al. Gastric-esophageal stenting for malignant dysphagia: results of prospective clinical trial evaluation of long-term gastroesophageal reflux and quality of life-related symptoms. J Am Coll Surg 2015;221: 165e173. 2. Jones CM, Griffiths EA. Should oesophageal stents be used before neo-adjuvant therapy to treat dysphagia in patients awaiting oesophagectomy? Best evidence topic (BET). Int J Surg 2014;12:1172e1180.
ª 2015 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.
Stenting and Curative Resection In Reply to Falk Robert CG Martin II, Louisville, KY
MD, PhD, FACS
Thank you very much for your kind comments regarding our study on the use of gastroesophageal stenting in patients with gastroesophageal (GE)-junction adenocarcinoma. Respectfully, we would like to inform you that there actually is a wealth of data on the use of stenting as a bridge to curative resection while patients are on neoadjuvant therapy that has been published in the literature. One of the larger studies was published by our division, by Brown and colleagues,1 which demonstrated the surgical safety and more importantly, the lack of increased operative time and operative complexity in patients who had undergone neoadjuvant chemotherapy and/or radiation therapy while having an esophageal stent in place. This study was further expanded, and a much larger study, which is currently the largest series outlining the use of neoadjuvant stenting, was again carried out by our Division of Surgical Oncology. These demonstrated the significant improvement in quality of life and efficacy with the use of neoadjuvant stenting in patients with potentially resectable GE-junction adenocarcinoma.2 A third review, again performed by our Division of Surgical Oncology by Bower and coauthors,3 demonstrated the significant improvement in overall nutritional parameters in patients who underwent neoadjuvant stenting in comparison with patients who had enteral feeding tubes in place or who attempted to maintain their nutrition with simple oral intake. These are just the studies that have been published from our division; multiple other manuscripts have been published on the use of stenting as a bridge to curative resection with neoadjuvant therapy.4-7 More importantly, with the studies mentioned above as well as the other studies, there has not been any type of report of “micro-cracking,” and therefore, a worsening
1093
http://dx.doi.org/10.1016/j.jamcollsurg.2015.08.426 ISSN 1072-7515/15
Stenting in the Neoadjuvant Setting
3. Mariette C, Gronnier C, Duhamel A, et al. Self-expanding covered metallic stent as a bridge to surgery in esophageal cancer: impact on oncologic outcomes. J Am Coll Surg 2015;220:287e296.
Gregory L Falk, MBBS Lindfield, Australia
Disclosure Information: Nothing to disclose.
I read with a little concern the excellent study by Philips and colleagues1 on the efficacy of gastro-esophageal stenting. Although quality of life and swallowing were enhanced in this group, there was a high rate of stent migration (63%), and this therapy is recognized only for palliative cases. So these data are quite applicable to the palliative group and are reassuring. There are no data available for the use of stenting as a bridge to curative resection with neoadjuvant therapy. Our concerns were first raised when an early and unusual pattern of recurrence of esophageal carcinoma was found in a number of patients, and cure on the basis of histopathology would have been expected. In several other patients, stents were seen in the mediastinum, indicating cancer perforation and incurability. With this experience, we reviewed the very scant literature. One can only theorize that stenting a tumor in the esophagus or cardio-esophageal junction leads to micro-cracking of the exterior of the tumor and potential for dissemination. Jones and Griffiths2 indicated that stenting in the neoadjuvant setting can lead to significant complications and can compromise the opportunity for surgical cure. In a collected series, Mariette and colleagues3 demonstrated a negative effect of stenting on oncologic outcomes in the neoadjuvant situation. On the basis of such concerns, a moratorium needs to be called on stenting in the neoadjuvant situation until adequate randomized data show it to be effective and able to produce equivalent oncologic outcomes to those of current techniques. REFERENCES 1. Philips P, North DA, Scoggins C, et al. Gastric-esophageal stenting for malignant dysphagia: results of prospective clinical trial evaluation of long-term gastroesophageal reflux and quality of life-related symptoms. J Am Coll Surg 2015;221: 165e173. 2. Jones CM, Griffiths EA. Should oesophageal stents be used before neo-adjuvant therapy to treat dysphagia in patients awaiting oesophagectomy? Best evidence topic (BET). Int J Surg 2014;12:1172e1180.
ª 2015 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.
Stenting and Curative Resection In Reply to Falk Robert CG Martin II, Louisville, KY
MD, PhD, FACS
Thank you very much for your kind comments regarding our study on the use of gastroesophageal stenting in patients with gastroesophageal (GE)-junction adenocarcinoma. Respectfully, we would like to inform you that there actually is a wealth of data on the use of stenting as a bridge to curative resection while patients are on neoadjuvant therapy that has been published in the literature. One of the larger studies was published by our division, by Brown and colleagues,1 which demonstrated the surgical safety and more importantly, the lack of increased operative time and operative complexity in patients who had undergone neoadjuvant chemotherapy and/or radiation therapy while having an esophageal stent in place. This study was further expanded, and a much larger study, which is currently the largest series outlining the use of neoadjuvant stenting, was again carried out by our Division of Surgical Oncology. These demonstrated the significant improvement in quality of life and efficacy with the use of neoadjuvant stenting in patients with potentially resectable GE-junction adenocarcinoma.2 A third review, again performed by our Division of Surgical Oncology by Bower and coauthors,3 demonstrated the significant improvement in overall nutritional parameters in patients who underwent neoadjuvant stenting in comparison with patients who had enteral feeding tubes in place or who attempted to maintain their nutrition with simple oral intake. These are just the studies that have been published from our division; multiple other manuscripts have been published on the use of stenting as a bridge to curative resection with neoadjuvant therapy.4-7 More importantly, with the studies mentioned above as well as the other studies, there has not been any type of report of “micro-cracking,” and therefore, a worsening
1093
http://dx.doi.org/10.1016/j.jamcollsurg.2015.08.426 ISSN 1072-7515/15