Photodiagnosis and Photodynamic Therapy (2005) 2, 197—200
Photodynamic therapy for Barretts’ adenocarcinoma associated with an Angelchik device John T. Jenkins BSc (Hons), MBChB a,∗, Arlette Charles b, Kenneth G. Mitchell b, Grant M. Fullarton a a b
Department of Surgical Gastroenterology, Gartnavel General Hospital, Glasgow, UK Department of Surgery, Royal Alexandra Hospital, Paisley, UK
Available online 29 September 2005 KEYWORDS Angelchik; Barrett’s oesophagus; Photodynamic therapy; Endoscopy; Palliation
Summary We present a novel case of an elderly patient with a Barrett’s adenocarcinoma in the presence of an Angelchik prosthesis. We aim to draw attention to issues relating to metaplastic Barretts’ oesphagus and its adenocarcinoma complications and highlight relevant issues in multimodal endoscopic management and palliation using photodynamic therapy in the presence of the device. © 2005 Elsevier B.V. All rights reserved.
Introduction The Angelchik device has been used in the treatment of gastro-oesophageal reflux disease (GORD). The prosthesis is a ring-shaped silicone shell filled with vulcanized silicone gel that is implanted surgically around the distal oesophagus and secured in position with a radiopaque silicone marking strap [1] (Fig. 1). First used in the late 1970s, prosthesis implantation was felt to be quicker and less complicated than alternative anti-reflux procedures of the time. The device controlled reflux and induced a reconsideration of the pathophysiology of reflux. Theories exist that it may have functioned by pre∗ Corresponding author at: Department of Surgery, Crosshouse Hospital, Kilmarnock, Scotland, UK. Tel.: +44 141 211 3000; fax: +44 141 357 4725. E-mail address: [email protected] (J.T. Jenkins).
venting proximal gastric distension, consequently lessening transient lower oesophageal sphincter relaxation, or effacement and weakening of the lower oesophageal sphincter, or both mechanisms [2]. Long-term follow-up revealed an unacceptably high rate of surgical revision and its use has largely been relegated to surgical history. Many reports describe complications, including dysphagia, migration, obstruction, fistulation and erosion that necessitated prosthesis removal [3,4]. However, few have reported on how the prosthesis can complicate treatment of coincidental oesophageal conditions and, in particular, oesophageal malignancy [5] and whether modifications to treatment techniques are necessary in the presence of the device. This is the first reported case of endoscopic management of an oesophageal adenocarcinoma in Barretts’ oesophagus in the presence of an Angelchik device using photodynamic therapy.
1572-1000/$ — see front matter © 2005 Elsevier B.V. All rights reserved. doi:10.1016/S1572-1000(05)00091-8
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Figure 2 Barretts’ adenocarcinoma associated with Angelchik device.
Figure 1 Angelchik prosthesis in situ.
Case report An 87-year-old retired slater presented with worsening dysphagia. His medical history included hiatus hernia and GORD complicated by Barretts’ oesophagus and peptic oesophageal structuring that previously required endoscopic dilatation. An Angelchik prosthesis was implanted (Mentor Corp. Goleta, California, USA) 17 years earlier (1986) with good symptomatic response. Rigid oesophagoscopy and dilatation was performed in 1996 for a symptomatic benign stricture at 35 cm with regular acid suppression, using a proton pump inhibitor, provided from that time. He was treated for hypertension, previous stroke and an asymptomatic atrial septal defect. Medications were Omeprazole, Amlodipine and Pravastatin. Examination found evidence of previous surgery but no additional abnormalities. Oesophago-gastro-duodenoscopy (OGD) identified a long circumferential segment of Barretts’ oesophagus with a long impassable stricture from 33 cm (Fig. 2). Biopsies confirmed adenocarcinoma within an area of intestinal metaplasia. Worsening symptoms meant that endoscopic radial expansion balloon dilatation was required which provided moderate improvement although the lesion remained impassable. Staging investigations confirmed localized disease however, the patients’ age and comorbidities precluded resection. He was initially treated using photodynamic therapy (PDT). Photofrin (porfirmer sodium) 2 mg/kg activated by 630 nm laser (Diomed 630
PDT, UK) on day 2 (and 4 on the first treatment) using a power setting of 300 J/cm2 with a 5 cm diffuser laser fibre (Diomed, UK). His symptoms markedly improved and he was palliated well for approximately 6 months until repeat balloon dilatation was performed for dysphagia allowing access to the stomach (Fig. 3). Further PDT was administered for exophytic tumour re-growth at this time with good symptomatic response. He remained without significant dysphagia for a further 3 months, when oesophageal dilatation and laser re-canalization (Nd:YAG; Ceramoptec, D53121 Bonn, Germany) was required. Thermal laser was used owing to concerns regarding oesophageal wall necrosis with repeat PDT due to obvious oesophageal wall constriction by the prosthesis. Five further oesophageal dilatations and four further laser sessions (1500 J, 2800 J, 2500 J, 2700 J)
Figure 3 Retroflexed scope view of Angelchik device.
Photodynamic therapy for Barretts’ adenocarcinoma associated with an Angelchik device for dysphagia were required over the following 8 months. Unfortunately, his dysphagia worsened and radiologically-guided oesophageal stenting was required. A 20 mm 13.5 cm BoubellaTM stent (UK Medical Ltd., Sheffield, UK) was inserted without immediate complication. The Boubella stent is a self-expanding covered stainless steel stent featuring an anti-reflux valve, flexible articulations and anti-migration design that can dilate stenoses and resist increased constriction due to its expansion force. Within 12 h of the procedure his condition declined resulting from significant upper GI bleeding. He responded to volume and blood replacement and the bleeding settled with conservative management. Barium swallow confirmed a patent functioning stent with no evidence of oesophageal perforation. The stomach was noted to be full of fluid, presumed to be blood. Unfortunately, he deteriorated with respiratory difficulties secondary to aspiration pneumonia and a large left sided pleural effusion that was resistant to thoracentesis. He succumbed 8 days following oesophageal stenting, approximately 18 months after diagnosis.
Discussion This novel report highlights several issues associated with difficulties in treatment of an oesophageal lesion in the presence of the Angelchik prosthesis but describes effective multimodal endoscopic palliation including photodynamic therapy. Many prostheses were used in the 1980s and although many were subsequently removed, a significant population remains with prosthesis in situ. Experience with this case suggests that endoscopic management is feasible. Richardson [5] reported a single case of Barretts’ adenocarcinoma complicating oesophageal resection owing to significant inflammatory reaction around the prosthesis. No other reports have addressed this issue or have addressed endoscopic management of oesophageal malignancy in the presence of the prosthesis. PDT has been used for palliation and was preferentially used in this patient owing to concerns regarding thermal damage with standard thermal laser. Concerns over the potential incendiary characteristics of silicone in the Angelchik device with thermal laser use prompted the use of photodynamic therapy. The incendiary characteristics of silicone medical devices have previously been assessed in vitro with different thermal lasers, including Nd-YAG. In
199
particular, silicone coated endotracheal stents have been assessed and ambient oxygen concentrations of greater than 40%, radiopaque stents, the presence of blood, metal, higher power output and shorter laser probe distances are related to shorter times to ignition, with radiopaque blood-covered stents being the most easily ignited [6]. Data are not present outlining the effects of different lasers upon the Angelchik device. We also aimed to avoid potential problems encountered after stenting particularly reflux, aspiration and significant haemorrhage. Evidence indicates that PDT is less likely to produce significant complications [7]. A recently reported randomised trial comparing brachtherapy and stenting for oesophageal cancer palliation identified significantly greater total complication and major complication risks in patients palliated with stenting [8]. Haemorrhage was significantly more likely after stenting. Unfortunately, this patient suffered aspiration pneumonia, probably related to reflux symptoms, and haemorrhage following stent insertion.
Conclusion This report indicates that although the Angelchik device provided symptomatic relief from GORD, Barretts’ oesophagus persisted to become complicated by adenocarcinoma, suggesting that the Angelchik device does not protect against degeneration to adenocarcinoma. We also find that multimodal endoscopic palliation can be used in the setting of the silicone-containing Angelchik prosthesis and we suggest that photodynamic therapy, when available, is a preferable option to thermal laser and stenting. Oesophageal cancer teams should have the resources and skills to use a range of available methods of therapy in addition to conventional methods.
References [1] Mentor Corporation. Angelchik anti-reflux prosthesis. Product information. Goleta (Calif.) 1984. [2] Maddern GJ, Myers JC, McIntosh N, et al. The effect of the Angelchik prosthesis on esophageal and gastric function. Arch Surg 1991;126:1418—22. [3] Ritchie PD, Milkins R, Fleming EL, Nott R. The Angelchik prosthesis: results and complications. Aust NZ J Surg 1987;57:621—5. [4] Varshney S, Kelly JJ, Branagan G, Somers SS, Kelly MJ. Angelchik prosthesis revisited. World J Surg 2002;26:129—33. [5] Richardson JD. Angelchik prosthesis complicates treatment of adenocarcinoma in Barretts’ esophagus. Arch Surg 1991;126:784—5.
200 [6] Scherer TA. Nd-YAG laser ignition of silicone endobronchial stents. Chest 2000;117:1449—54. [7] Litle VR, Luketich JD, Christie NA, et al. Photodynamic therapy as palliation for esophageal cancer: experience in 215 patients. Ann Thorac Surg 2003;76:1687—93.
J.T. Jenkins et al. [8] Homs MYV, Steyerberg EW, Eijkenboom WMH, et al. Single dose brachtherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial. Lancet 2004;364:1497— 504.
Photodynamic therapy for Barretts’ adenocarcinoma associated with an Angelchik device John T. Jenkins BSc (Hons), MBChB a,∗, Arlette Charles b, Kenneth G. Mitchell b, Grant M. Fullarton a a b
Department of Surgical Gastroenterology, Gartnavel General Hospital, Glasgow, UK Department of Surgery, Royal Alexandra Hospital, Paisley, UK
Available online 29 September 2005 KEYWORDS Angelchik; Barrett’s oesophagus; Photodynamic therapy; Endoscopy; Palliation
Summary We present a novel case of an elderly patient with a Barrett’s adenocarcinoma in the presence of an Angelchik prosthesis. We aim to draw attention to issues relating to metaplastic Barretts’ oesphagus and its adenocarcinoma complications and highlight relevant issues in multimodal endoscopic management and palliation using photodynamic therapy in the presence of the device. © 2005 Elsevier B.V. All rights reserved.
Introduction The Angelchik device has been used in the treatment of gastro-oesophageal reflux disease (GORD). The prosthesis is a ring-shaped silicone shell filled with vulcanized silicone gel that is implanted surgically around the distal oesophagus and secured in position with a radiopaque silicone marking strap [1] (Fig. 1). First used in the late 1970s, prosthesis implantation was felt to be quicker and less complicated than alternative anti-reflux procedures of the time. The device controlled reflux and induced a reconsideration of the pathophysiology of reflux. Theories exist that it may have functioned by pre∗ Corresponding author at: Department of Surgery, Crosshouse Hospital, Kilmarnock, Scotland, UK. Tel.: +44 141 211 3000; fax: +44 141 357 4725. E-mail address: [email protected] (J.T. Jenkins).
venting proximal gastric distension, consequently lessening transient lower oesophageal sphincter relaxation, or effacement and weakening of the lower oesophageal sphincter, or both mechanisms [2]. Long-term follow-up revealed an unacceptably high rate of surgical revision and its use has largely been relegated to surgical history. Many reports describe complications, including dysphagia, migration, obstruction, fistulation and erosion that necessitated prosthesis removal [3,4]. However, few have reported on how the prosthesis can complicate treatment of coincidental oesophageal conditions and, in particular, oesophageal malignancy [5] and whether modifications to treatment techniques are necessary in the presence of the device. This is the first reported case of endoscopic management of an oesophageal adenocarcinoma in Barretts’ oesophagus in the presence of an Angelchik device using photodynamic therapy.
1572-1000/$ — see front matter © 2005 Elsevier B.V. All rights reserved. doi:10.1016/S1572-1000(05)00091-8
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Figure 2 Barretts’ adenocarcinoma associated with Angelchik device.
Figure 1 Angelchik prosthesis in situ.
Case report An 87-year-old retired slater presented with worsening dysphagia. His medical history included hiatus hernia and GORD complicated by Barretts’ oesophagus and peptic oesophageal structuring that previously required endoscopic dilatation. An Angelchik prosthesis was implanted (Mentor Corp. Goleta, California, USA) 17 years earlier (1986) with good symptomatic response. Rigid oesophagoscopy and dilatation was performed in 1996 for a symptomatic benign stricture at 35 cm with regular acid suppression, using a proton pump inhibitor, provided from that time. He was treated for hypertension, previous stroke and an asymptomatic atrial septal defect. Medications were Omeprazole, Amlodipine and Pravastatin. Examination found evidence of previous surgery but no additional abnormalities. Oesophago-gastro-duodenoscopy (OGD) identified a long circumferential segment of Barretts’ oesophagus with a long impassable stricture from 33 cm (Fig. 2). Biopsies confirmed adenocarcinoma within an area of intestinal metaplasia. Worsening symptoms meant that endoscopic radial expansion balloon dilatation was required which provided moderate improvement although the lesion remained impassable. Staging investigations confirmed localized disease however, the patients’ age and comorbidities precluded resection. He was initially treated using photodynamic therapy (PDT). Photofrin (porfirmer sodium) 2 mg/kg activated by 630 nm laser (Diomed 630
PDT, UK) on day 2 (and 4 on the first treatment) using a power setting of 300 J/cm2 with a 5 cm diffuser laser fibre (Diomed, UK). His symptoms markedly improved and he was palliated well for approximately 6 months until repeat balloon dilatation was performed for dysphagia allowing access to the stomach (Fig. 3). Further PDT was administered for exophytic tumour re-growth at this time with good symptomatic response. He remained without significant dysphagia for a further 3 months, when oesophageal dilatation and laser re-canalization (Nd:YAG; Ceramoptec, D53121 Bonn, Germany) was required. Thermal laser was used owing to concerns regarding oesophageal wall necrosis with repeat PDT due to obvious oesophageal wall constriction by the prosthesis. Five further oesophageal dilatations and four further laser sessions (1500 J, 2800 J, 2500 J, 2700 J)
Figure 3 Retroflexed scope view of Angelchik device.
Photodynamic therapy for Barretts’ adenocarcinoma associated with an Angelchik device for dysphagia were required over the following 8 months. Unfortunately, his dysphagia worsened and radiologically-guided oesophageal stenting was required. A 20 mm 13.5 cm BoubellaTM stent (UK Medical Ltd., Sheffield, UK) was inserted without immediate complication. The Boubella stent is a self-expanding covered stainless steel stent featuring an anti-reflux valve, flexible articulations and anti-migration design that can dilate stenoses and resist increased constriction due to its expansion force. Within 12 h of the procedure his condition declined resulting from significant upper GI bleeding. He responded to volume and blood replacement and the bleeding settled with conservative management. Barium swallow confirmed a patent functioning stent with no evidence of oesophageal perforation. The stomach was noted to be full of fluid, presumed to be blood. Unfortunately, he deteriorated with respiratory difficulties secondary to aspiration pneumonia and a large left sided pleural effusion that was resistant to thoracentesis. He succumbed 8 days following oesophageal stenting, approximately 18 months after diagnosis.
Discussion This novel report highlights several issues associated with difficulties in treatment of an oesophageal lesion in the presence of the Angelchik prosthesis but describes effective multimodal endoscopic palliation including photodynamic therapy. Many prostheses were used in the 1980s and although many were subsequently removed, a significant population remains with prosthesis in situ. Experience with this case suggests that endoscopic management is feasible. Richardson [5] reported a single case of Barretts’ adenocarcinoma complicating oesophageal resection owing to significant inflammatory reaction around the prosthesis. No other reports have addressed this issue or have addressed endoscopic management of oesophageal malignancy in the presence of the prosthesis. PDT has been used for palliation and was preferentially used in this patient owing to concerns regarding thermal damage with standard thermal laser. Concerns over the potential incendiary characteristics of silicone in the Angelchik device with thermal laser use prompted the use of photodynamic therapy. The incendiary characteristics of silicone medical devices have previously been assessed in vitro with different thermal lasers, including Nd-YAG. In
199
particular, silicone coated endotracheal stents have been assessed and ambient oxygen concentrations of greater than 40%, radiopaque stents, the presence of blood, metal, higher power output and shorter laser probe distances are related to shorter times to ignition, with radiopaque blood-covered stents being the most easily ignited [6]. Data are not present outlining the effects of different lasers upon the Angelchik device. We also aimed to avoid potential problems encountered after stenting particularly reflux, aspiration and significant haemorrhage. Evidence indicates that PDT is less likely to produce significant complications [7]. A recently reported randomised trial comparing brachtherapy and stenting for oesophageal cancer palliation identified significantly greater total complication and major complication risks in patients palliated with stenting [8]. Haemorrhage was significantly more likely after stenting. Unfortunately, this patient suffered aspiration pneumonia, probably related to reflux symptoms, and haemorrhage following stent insertion.
Conclusion This report indicates that although the Angelchik device provided symptomatic relief from GORD, Barretts’ oesophagus persisted to become complicated by adenocarcinoma, suggesting that the Angelchik device does not protect against degeneration to adenocarcinoma. We also find that multimodal endoscopic palliation can be used in the setting of the silicone-containing Angelchik prosthesis and we suggest that photodynamic therapy, when available, is a preferable option to thermal laser and stenting. Oesophageal cancer teams should have the resources and skills to use a range of available methods of therapy in addition to conventional methods.
References [1] Mentor Corporation. Angelchik anti-reflux prosthesis. Product information. Goleta (Calif.) 1984. [2] Maddern GJ, Myers JC, McIntosh N, et al. The effect of the Angelchik prosthesis on esophageal and gastric function. Arch Surg 1991;126:1418—22. [3] Ritchie PD, Milkins R, Fleming EL, Nott R. The Angelchik prosthesis: results and complications. Aust NZ J Surg 1987;57:621—5. [4] Varshney S, Kelly JJ, Branagan G, Somers SS, Kelly MJ. Angelchik prosthesis revisited. World J Surg 2002;26:129—33. [5] Richardson JD. Angelchik prosthesis complicates treatment of adenocarcinoma in Barretts’ esophagus. Arch Surg 1991;126:784—5.
200 [6] Scherer TA. Nd-YAG laser ignition of silicone endobronchial stents. Chest 2000;117:1449—54. [7] Litle VR, Luketich JD, Christie NA, et al. Photodynamic therapy as palliation for esophageal cancer: experience in 215 patients. Ann Thorac Surg 2003;76:1687—93.
J.T. Jenkins et al. [8] Homs MYV, Steyerberg EW, Eijkenboom WMH, et al. Single dose brachtherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial. Lancet 2004;364:1497— 504.
