GIT J Club

1. Kurdistan Board GEH/GIT Surgery
weekly J Club 2018:
Supervised by:
Professor Dr.Mohamed Alshekhani
MBChB-CABM,FRCP,EBGH

2. Abstract:
• 50% diagnosed with EC present with unresectable or metastatic disease.
• The aims: control dysphagia & other cancer-related symptoms, improve
QOL&prolong survival.
• Modestly improved outcomes achieved in the treatment of patients with
inoperable non-metastatic cancer who are medically not fit for surgery or
have unresectable, locally advanced disease.
• Concurrent chemoradiotherapy offers the best outcomes in these patients.
• In distant metastatic EC, several double-agent or triple-agent
chemotherapy regimens are first-line treatment options.
• Long-term results of trials using additional targeted therapies published,
affecting contemporary clinical practice & future research directions.
• For the local trt of malignant dysphagia, various options emerged&SEMS
placement is currently the most widely applied method &antireflux/
irradiation stents developed.

3. Introduction:
• EC is diagnosed in 450,000 patients yearly worldwide& >400,000 patients
die from this disease every year.
• EC is the eighth most common cancer worldwide & the sixth leading cause
of cancer-related mortality.
• It has two histological subtypes: EAC&ESCC.
• ESCC is the predominant tumour type in Asia, Africa, South America.
• In Europe &USA, where EAC is predominant, the incidence of EC has
been rising more rapidly than that of any other cancer but have plateaued.
• ESCC are more prevalent in the upper & middle third of the oesophagus,
whereas EAC commonly arise from the distal third or EGJ.
• Although surgery is cornerstone of curative trt, 50–60% are unsuitable for
surgery at presentation BZ of tumour ingrowth into unresectable adjacent
structures (T4b disease), extensive upper mediastinal or cervical lymph
node metastases or distant metastases (M1 disease), or medically not fit for
surgery from comorbidities or poor performance status.

4. Introduction:
• For this majority with unresectable or metastatic EC, effective palliative
interventions aim at relieving dysphagia (required in 70–90%)& other
cancer-related symptoms, improving qua QOL &prolonging survival.
• Various treatment options emerged for the local treatment, including self-
expandable stent placement, intraluminal brachytherapy, external beam
radiotherapy (EBRT), neodymium-doped yttrium aluminium garnet (Nd-
YAG) laser therapy,PDT&chemotherapy.
• The introduction/optimization of definitive concurrent chemoradiotherapy
(CRT), 5-year survival increased from 0–14% to 20–25% in these patients,
indicating a shift from palliative care towards more curative intent.
• By contrast, despite the development of newer &more active
chemotherapy, the median survival for patients with metastatic disease at
presentation is only around 1 year.
• New targeted agents & immunotherapy published, affecting contemporary
clinical practice & future research directions.

5. MDT management:
• A study in the Netherlands found large & statistically significant
differences between hospitals of diagnosis with regard to the proportion of
patients referred for treatment with curative intent, ranging from 33- 67%
• The authors concluded that these differences were most likely explained by
the fact that local non-expert MDTs were less proficient in defining the
best treatment options for patients than regional expert MDTs.
• The finding that patients in several local hospitals had worse overall
survival than those at a reference hospital supported this hypothesis.

15. Conclusion:
• Treatment for unresectable or metastatic EC is best by an MDT.
• Concurrent CRT is the preferred option for patients with unresectable,
locally advanced EC&the focus of ctrials on concurrent CRT is on
radiation dose escalation & substituting conventional CF for less toxic
&more effective compounds.
• In patients with distant metastatic disease & an adequate performance
status, palliative combination chemotherapy is recommended, as it
improves survival compared with best supportive care or single-agent CT.
• Combination therapy containing a fluoropyrimidine & a platinum
compound is recommended in this scenario.
• Triple combination therapy, with addition of a taxane, to increase response
but triple therapies only moderately improve survival compared with the
use of double-agent therapy with increased treatment-associated toxicity.
• Targeted trts with trastuzumab(in tumours overexpress HER2)&
ramucirumab become part of 1st-line &2nd-line treatment, respectively.
• Immunotherapy&biomarkers may identify those more likely to respond

16. Conclusion:
• No absolute superiority of any particular local intervention for the
palliation of malignant dysphagia exists.
• SEMS placement relieves dysphagia more rapidly than other modalities,
particularly preferred in patients with severe dysphagia or a short life
expectancy.
• Covered stents are superior in terms of resisting tissue ingrowth&
overgrowth compared with partially covered or uncovered stents at the
price of increased rates of stent migration.
• Despite improving dysphagia more slowly than oesophageal stenting, high-
dose rate brachytherapy provides an alternative treatment with fewer
complications & additional benefits in terms of QOL & survival.
• Owing to the equivocal evidence, routine use of antireflux stents cannot be
recommended.
• Novel irradiation stents have advantages of immediate dysphagia relief
&the longer-term benefits of brachytherapy.
• Combining different interventions needs randomized trials.