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Combination therapy offers best palliation for malignant dysphagia

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Argon plasma coagulation (APC) in combination with another method of esophageal recanalization is better than APC alone as palliative therapy in patients with malignant dysphagia, researchers from Poland report in the June 24th online American Journal of Gastroenterology.

“The combination therapy using argon plasma coagulation plus brachytherapy seems the best palliative option for patients with malignant dysphagia in whom stenting is not possible or contraindicated,” Dr. Edyta Zagorowicz from Maria Sklodowska-Curie Memorial Cancer Center, Warsaw, Poland told Reuters Health by email. “The combination of argon plasma coagulation plus photodynamic therapy (PDT) seems inferior. The argon plasma coagulation alone is not recommended.”

Dr. Zagorowicz and colleagues investigated whether APC in combination with high dose rate (HDR) brachytherapy, APC in combination with PDT, or APC alone offered the best palliative treatment of dysphagia in a study of 93 patients with esophageal cancer, 82 of which were randomized to one of the 3 treatment arms.

The median dysphagia-free period was longest in the APC plus HDR group (88 days), intermediate in the APC plus PDT group (59 days), and shortest in the APC (control) group (35 days).

The period to dysphagia recurrence did not differ significantly between the combination groups, but both combination groups were significantly better than the control group.

The median interval between repeated rescue recanalization procedures was significantly longer for the APC plus HDR (10.9 weeks) and APC plus PDT (8 weeks) groups than for the APC control group (4.7 weeks), but there was no significant difference in the number of procedures per patient.

Overall survival did not differ significantly between the treatments.

Quality of life improved initially in all 3 treatment groups but declined during the ensuing 30 days. Quality of life remained significantly higher in the APC plus HDR group than in the other 2 treatment groups.

Discomfort related to the recanalization procedure was similar in all groups, and the only major complication was fever, which occurred in 3 patients in the APC plus PDT group.

“We favor argon plasma coagulation (APC) with high dose rate (HDR) brachytherapy as the main palliative approach to patients with malignant obstruction of the esophagus,” Dr. Zagorowicz concluded. “However, there is another method, not studied by us – namely esophageal stenting using a self expanding metal stent (SEMS). This is also a good option providing immediate dysphagia relief.”

“There is still a need for further comparisons using the most modern equipment for brachytherapy and the most modern types of stents,” Dr. Zagorowicz said.

“Endoscopy units dealing with esophageal cancers should aim to have access to and get experience with all available ablation and recanalization methods,” Dr. Zagorowicz said. “Then in each individual patient the best therapeutic option can be chosen.”

Am J Gastroenterol 14 June 2011.