Br. J. Surg. 1992, Vol. 79, April, 308-309
N. Bright, P. Hale and R. Mason Department of Surgery, United Medical and Dental Schools of Guy's Hospital, St Thomas' Street, London S E l 9RT, UK Correspondence to: Mr R. Mason
Poor palliation of colorectal malignancy w i t h the neodymium yttrium-aluminium-garnet laser The neodymium yttrium-aluminium-garnet ( N d Y A G ) laser was used to palliate the symptoms of 38 patients with rectal carcinoma unsuitable for radical surgery. All patients with small tumours ( n = 6 ) reported resolution of their symptoms. In contrast, those with large tumours frequently showed little improvement ( n = 18) and alternative surgical management was necessary in 12 patients. The overall early mortality rate ( < 1 month after first treatment) was 21 per cent. The NdYAG laser offers good palliation and may even cure small colorectal tumours in patients who are unsuitable for surgery. For large circumferential tumours, those associated with obstruction and those close to or involving the anal sphincters, however, the results are poor and better symptom control may be achieved by other means.
Recent reports have suggested that the neodymium yttriumaluminium-garnet (NdYAG ) laser can offer good long-term palliation to those patients with colorectal malignancy considered unfit for surgery 1-4. Such palliation should relieve obstruction and control the symptoms of bleeding, tenesmus and mucus discharge as quickly as possible and with minimum discomfort to the patient. This study was designed to determine whether such optimism is confirmed and to determine which patients derive most benefit from this treatment.
Patients and methods Thirty-eight consecutive patients with colorectal malignancy proven by biopsy were studied and followed up to death or for a minimum of 18 months. There were 19 men and 19 women aged 52-93 (mean 75) years. Primary malignancy occurred in 26 patients and 12 had recurrent tumour. Ten patients refused surgery and 12 were considered unfit for operation because of coexisting medical problems, including severe cardiac failure and chronic obstructive airway disease. In 16 patients, including the 12 with recurrent tumour, involvement of other pelvic structures or metastases meant that the disease was inoperable. All turnours were graded, at the time of initial assessment, for the degree of luminal obstruction ( I , endoscope passes with ease; 2, endoscope passes with difficulty; 3, endoscope would not pass but a lumen is visible; 4, no visible lumen), length and the percentage of bowel circumference involved. This enabled the tumours to be grouped into small (lumen grade 1, < 5 cm long, 1 2 5 per cent Circumference involved) and large (grades 2-4, 2 5 c m long, a 2 5 per cent circumference involved). The distance of the lower margin from the anal verge for all tumours is shown in Table I . Most tumours were situated in the rectum, but seven were > 15 cm from the anal margin. All treatments were performed under sedation with intravenous diazepam. Between 2000 and 10000 J per session were administered using a NdYAG laser. Initially, treatment was repeated until a good lumen was achieved and then, where necessary, was given monthly. All patients were followed up regularly. Treatment was considered successful if the patient's symptoms of obstruction, tenesmus, bleeding and mucus discharge improved so that they could return home and remain free of symptoms.
Results The results are summarized in Table 2. All six patients with small tumours did well with good control of their symptoms. Two patients died from other causes (myocardial infarction and coexisting carcinoma of the bronchus) before a n accurate assessment could be made. Of the four cases that were assessable, three had no evidence of disease on biopsy and one had residual disease but no symptoms. Based on a presentation given to the British Society of Gastroenterology, April 1990 and published in abstract,form as Gut 1990; 31: A604
308
The 32 patients with large tumours (25cm long, 2 25 per cent circumference involved) included all those with recurrent tumour. The survival rate in this group was poor. Sixteen died within 3 months of referral and only four survived for > 6 (mean 4 ) months. The median lumen grade was 4 with a range of 1-4. All have undergone one to 13 (median three) treatments. The total energy given during treatment varied from 2341 to 96 349 (mean 24 760) J. Only 25 of these patients could be assessed: six died within 1 month of treatment and one patient had a large cavitating lesion that was unsuitable for laser therapy. Eleven patients have been referred for surgery: the major indication was colonic obstruction, present at the time of referral and not relieved with the laser (five patients), or developing during treatment (two patients). Colostomy was performed in two patients for persistent diarrhoea and in two for relief of rectovaginal fistula. Three patients showed no improvement in symptoms and continued passing eight to 12 mucus bowel actions per day. One patient was made worse by treatment and a further two showed initial improvement but relapsed during treatment. Eight patients have shown sustained improvement with a reduction in bleeding and in the number of bowel motions; the tumours in six of these patients were > 10 cm from the anus and in the remaining two were 5-10 cm from the anal verge. Table I
Site of tumours treated with NdYAG laser
Distance of lower margin from anal verge fcm)
No. of small tumours
No. of large tumours
20
11
12 2 2
Table 2 Oufcome of laser treatment in 38 palients No. of small tumours (n = 6 ) Complete resolution Residual disease, symptoms controlled N o improvement, symptomatic treatment No improvement, surgery Unassessable Unsuitable for laser treatment
0007-1323/92/040308-02
No. of large tumours ( n = 32)
3 1
0
0
6
0 2 0
11 6
8
f> 1992 Butterworth-Heinemann Ltd
1
NdYAG laser treatment for colorectal malignancy:
N. Bright et al.
study should not have been treated at all, as the benefit provided during their last few weeks of life was minimal. The results achieved for small tumours in this series agree with The NdYAG laser provides an alternative to open surgery those reported by other workers','. While many of these in unfit patients and is particularly valuable for treating smaller, tumours may be amenable to treatment by other, less costly non-obstructing tumours in the colon and upper rectum. Larger means, particularly when they occur below the peritoneal tumours and those in the lower rectum are better palliated by reflection, the NdYAG laser offers an alternative to other surgical techniques. A defunctioning colostomy can safely colonoscopic diathermy and open operation for more proximal be performed under local anaesthesia and often gives significant tumours. relief of symptoms, particularly when they are related to For large carcinomas the results presented here are worse obstruction. Consideration should also be given to local than those reported by others, who describe a favourable excision, diathermy or transanal endoscopic resection, but these symptomatic outcome in up to 75 per cent of cases and survival are not suitable for lesions above the peritoneal reflection. up to 24 This would appear to contradict an earlier report in which we described early functional improvement3. This discrepancy is due to the larger number of patients referred References with colonic obstruction and failure to maintain continence in patients with luminal patency. We feel that two factors 1. Loizou LA, Grigg D, Boulos PB, Bown SG. Endoscopic Nd:YAG contribute to loss of continence: involvement of the sphincters laser treatment of rectosigmoid cancer. Gut 1990; 31: 812-16. 2. Brunetaud JM, Maunoury V, Durcotte P, Cochelard D, Cortot A , with tumour and loss of rectal compliance secondary to Paris JC. Palliative treatment of rectosigmoid carcinoma by laser involvement by tumour and fibrosis. As 50 per cent of these endoscopic photoablation. Gasrroenterology 1987; 92: 663-8. patients had tumours within 10 cm of the anus, and 87 per cent 3. Houghton AD, Allen A, Mason R, McColl I. Laser treatment to had tumours within 15 cm, the poor functional results for large rectal malignancies. Surg Res Commun 1989; 6 : 271-3. tumours reported here are not surprising. 4. Walfisch S, Stern H, Ball S. Use of Nd-YAG laser ablation in Circumferential involvement and the presence of complete colorectal obstruction and palliation in high-risk patients. Dis or partial colonic obstruction are both said to be associated Colon Rectum 1989; 32: 1060-4. with a poor response to laser therapy, although some authors Eckhauser ML, Imbeno AL, Mansour EG. The role of 5. have advocated laser therapy as a means of recanalizing the pre-resectional laser recanalization for obstructing carcinomas of the colon and rectum. Surgery 1989; 106: 710-17. colon before resection4.*. Three-quarters of the patients with 6. Brunetaud JM, Maunoury V, Cochelard D, Boniface B, Cortot A, large tumours in this series had 2 7 5 per cent circumferential Paris JC. Endoscopic laser treatment for rectosigmoid villous involvement and five were referred with colonic obstruction. adenoma: factors affecting the results. Gasiroenterology 1989; 97: The patients in this study were extremely frail, as 212-1. demonstrated by their poor overall survival rate. Indeed, eight 7. Brunetaud JM, Maunoury V, Cochelard D, Boniface B, Cortot A, died before an accurate assessment of response could be made. Paris JC. Parameters affecting laser palliation in patients with The poor survival of these patients suggests that they had more advanced digestive cancers. Laser Surg Med 1989; 9: 169-73. advanced disease than those in some other s e r i e ~ ' . ~ * ~ . ~ . ~ . Paper accepted 25 November 1991 Indeed, it could be argued that some of the patients in this
Discussion
Announcement Inter nat io na I Hepato - B iIia ry - Pancreatic Association Frank Glenn Travelling Fellowship 1992 The International Hepato-Biliary-Pancreatic Association invites applications for the above travelling Fellowship. A stipend of SFr 5000 is available to subsidize a young investigator in the field of hepatobiliary and pancreatic disorders. The applicant must be sponsored by a member of the Association. The stipend may be used to support a laboratory project and/or to subsidize travel expenses which are deemed appropriate to the field of investigation. Applicants must be under 40 years of age and should have an established record of at least one or several papers concerning liver, biliary or pancreatic disease. Applications should be made in writing and should include the following: 1. a copy of the applicant's curriculum vitae; 2. a summary of 1-2 pages of a research protocol describing how the stipend is to be used; 3. a letter of nomination from a member of the IHBP Association or your Department Chairman. Applications should be sent to: D r Haile T. Debas, University of California, San Francisco, Department of Surgery, San Francisco, CA 94143-0104, USA by 30 April 1992. Telephone: (415) 476-1236. Facsimile: (415) 476-1734.
Br. J. Surg.. Vol. 79, No. 4, April 1992
309
N. Bright, P. Hale and R. Mason Department of Surgery, United Medical and Dental Schools of Guy's Hospital, St Thomas' Street, London S E l 9RT, UK Correspondence to: Mr R. Mason
Poor palliation of colorectal malignancy w i t h the neodymium yttrium-aluminium-garnet laser The neodymium yttrium-aluminium-garnet ( N d Y A G ) laser was used to palliate the symptoms of 38 patients with rectal carcinoma unsuitable for radical surgery. All patients with small tumours ( n = 6 ) reported resolution of their symptoms. In contrast, those with large tumours frequently showed little improvement ( n = 18) and alternative surgical management was necessary in 12 patients. The overall early mortality rate ( < 1 month after first treatment) was 21 per cent. The NdYAG laser offers good palliation and may even cure small colorectal tumours in patients who are unsuitable for surgery. For large circumferential tumours, those associated with obstruction and those close to or involving the anal sphincters, however, the results are poor and better symptom control may be achieved by other means.
Recent reports have suggested that the neodymium yttriumaluminium-garnet (NdYAG ) laser can offer good long-term palliation to those patients with colorectal malignancy considered unfit for surgery 1-4. Such palliation should relieve obstruction and control the symptoms of bleeding, tenesmus and mucus discharge as quickly as possible and with minimum discomfort to the patient. This study was designed to determine whether such optimism is confirmed and to determine which patients derive most benefit from this treatment.
Patients and methods Thirty-eight consecutive patients with colorectal malignancy proven by biopsy were studied and followed up to death or for a minimum of 18 months. There were 19 men and 19 women aged 52-93 (mean 75) years. Primary malignancy occurred in 26 patients and 12 had recurrent tumour. Ten patients refused surgery and 12 were considered unfit for operation because of coexisting medical problems, including severe cardiac failure and chronic obstructive airway disease. In 16 patients, including the 12 with recurrent tumour, involvement of other pelvic structures or metastases meant that the disease was inoperable. All turnours were graded, at the time of initial assessment, for the degree of luminal obstruction ( I , endoscope passes with ease; 2, endoscope passes with difficulty; 3, endoscope would not pass but a lumen is visible; 4, no visible lumen), length and the percentage of bowel circumference involved. This enabled the tumours to be grouped into small (lumen grade 1, < 5 cm long, 1 2 5 per cent Circumference involved) and large (grades 2-4, 2 5 c m long, a 2 5 per cent circumference involved). The distance of the lower margin from the anal verge for all tumours is shown in Table I . Most tumours were situated in the rectum, but seven were > 15 cm from the anal margin. All treatments were performed under sedation with intravenous diazepam. Between 2000 and 10000 J per session were administered using a NdYAG laser. Initially, treatment was repeated until a good lumen was achieved and then, where necessary, was given monthly. All patients were followed up regularly. Treatment was considered successful if the patient's symptoms of obstruction, tenesmus, bleeding and mucus discharge improved so that they could return home and remain free of symptoms.
Results The results are summarized in Table 2. All six patients with small tumours did well with good control of their symptoms. Two patients died from other causes (myocardial infarction and coexisting carcinoma of the bronchus) before a n accurate assessment could be made. Of the four cases that were assessable, three had no evidence of disease on biopsy and one had residual disease but no symptoms. Based on a presentation given to the British Society of Gastroenterology, April 1990 and published in abstract,form as Gut 1990; 31: A604
308
The 32 patients with large tumours (25cm long, 2 25 per cent circumference involved) included all those with recurrent tumour. The survival rate in this group was poor. Sixteen died within 3 months of referral and only four survived for > 6 (mean 4 ) months. The median lumen grade was 4 with a range of 1-4. All have undergone one to 13 (median three) treatments. The total energy given during treatment varied from 2341 to 96 349 (mean 24 760) J. Only 25 of these patients could be assessed: six died within 1 month of treatment and one patient had a large cavitating lesion that was unsuitable for laser therapy. Eleven patients have been referred for surgery: the major indication was colonic obstruction, present at the time of referral and not relieved with the laser (five patients), or developing during treatment (two patients). Colostomy was performed in two patients for persistent diarrhoea and in two for relief of rectovaginal fistula. Three patients showed no improvement in symptoms and continued passing eight to 12 mucus bowel actions per day. One patient was made worse by treatment and a further two showed initial improvement but relapsed during treatment. Eight patients have shown sustained improvement with a reduction in bleeding and in the number of bowel motions; the tumours in six of these patients were > 10 cm from the anus and in the remaining two were 5-10 cm from the anal verge. Table I
Site of tumours treated with NdYAG laser
Distance of lower margin from anal verge fcm)
No. of small tumours
No. of large tumours
20
11
12 2 2
Table 2 Oufcome of laser treatment in 38 palients No. of small tumours (n = 6 ) Complete resolution Residual disease, symptoms controlled N o improvement, symptomatic treatment No improvement, surgery Unassessable Unsuitable for laser treatment
0007-1323/92/040308-02
No. of large tumours ( n = 32)
3 1
0
0
6
0 2 0
11 6
8
f> 1992 Butterworth-Heinemann Ltd
1
NdYAG laser treatment for colorectal malignancy:
N. Bright et al.
study should not have been treated at all, as the benefit provided during their last few weeks of life was minimal. The results achieved for small tumours in this series agree with The NdYAG laser provides an alternative to open surgery those reported by other workers','. While many of these in unfit patients and is particularly valuable for treating smaller, tumours may be amenable to treatment by other, less costly non-obstructing tumours in the colon and upper rectum. Larger means, particularly when they occur below the peritoneal tumours and those in the lower rectum are better palliated by reflection, the NdYAG laser offers an alternative to other surgical techniques. A defunctioning colostomy can safely colonoscopic diathermy and open operation for more proximal be performed under local anaesthesia and often gives significant tumours. relief of symptoms, particularly when they are related to For large carcinomas the results presented here are worse obstruction. Consideration should also be given to local than those reported by others, who describe a favourable excision, diathermy or transanal endoscopic resection, but these symptomatic outcome in up to 75 per cent of cases and survival are not suitable for lesions above the peritoneal reflection. up to 24 This would appear to contradict an earlier report in which we described early functional improvement3. This discrepancy is due to the larger number of patients referred References with colonic obstruction and failure to maintain continence in patients with luminal patency. We feel that two factors 1. Loizou LA, Grigg D, Boulos PB, Bown SG. Endoscopic Nd:YAG contribute to loss of continence: involvement of the sphincters laser treatment of rectosigmoid cancer. Gut 1990; 31: 812-16. 2. Brunetaud JM, Maunoury V, Durcotte P, Cochelard D, Cortot A , with tumour and loss of rectal compliance secondary to Paris JC. Palliative treatment of rectosigmoid carcinoma by laser involvement by tumour and fibrosis. As 50 per cent of these endoscopic photoablation. Gasrroenterology 1987; 92: 663-8. patients had tumours within 10 cm of the anus, and 87 per cent 3. Houghton AD, Allen A, Mason R, McColl I. Laser treatment to had tumours within 15 cm, the poor functional results for large rectal malignancies. Surg Res Commun 1989; 6 : 271-3. tumours reported here are not surprising. 4. Walfisch S, Stern H, Ball S. Use of Nd-YAG laser ablation in Circumferential involvement and the presence of complete colorectal obstruction and palliation in high-risk patients. Dis or partial colonic obstruction are both said to be associated Colon Rectum 1989; 32: 1060-4. with a poor response to laser therapy, although some authors Eckhauser ML, Imbeno AL, Mansour EG. The role of 5. have advocated laser therapy as a means of recanalizing the pre-resectional laser recanalization for obstructing carcinomas of the colon and rectum. Surgery 1989; 106: 710-17. colon before resection4.*. Three-quarters of the patients with 6. Brunetaud JM, Maunoury V, Cochelard D, Boniface B, Cortot A, large tumours in this series had 2 7 5 per cent circumferential Paris JC. Endoscopic laser treatment for rectosigmoid villous involvement and five were referred with colonic obstruction. adenoma: factors affecting the results. Gasiroenterology 1989; 97: The patients in this study were extremely frail, as 212-1. demonstrated by their poor overall survival rate. Indeed, eight 7. Brunetaud JM, Maunoury V, Cochelard D, Boniface B, Cortot A, died before an accurate assessment of response could be made. Paris JC. Parameters affecting laser palliation in patients with The poor survival of these patients suggests that they had more advanced digestive cancers. Laser Surg Med 1989; 9: 169-73. advanced disease than those in some other s e r i e ~ ' . ~ * ~ . ~ . ~ . Paper accepted 25 November 1991 Indeed, it could be argued that some of the patients in this
Discussion
Announcement Inter nat io na I Hepato - B iIia ry - Pancreatic Association Frank Glenn Travelling Fellowship 1992 The International Hepato-Biliary-Pancreatic Association invites applications for the above travelling Fellowship. A stipend of SFr 5000 is available to subsidize a young investigator in the field of hepatobiliary and pancreatic disorders. The applicant must be sponsored by a member of the Association. The stipend may be used to support a laboratory project and/or to subsidize travel expenses which are deemed appropriate to the field of investigation. Applicants must be under 40 years of age and should have an established record of at least one or several papers concerning liver, biliary or pancreatic disease. Applications should be made in writing and should include the following: 1. a copy of the applicant's curriculum vitae; 2. a summary of 1-2 pages of a research protocol describing how the stipend is to be used; 3. a letter of nomination from a member of the IHBP Association or your Department Chairman. Applications should be sent to: D r Haile T. Debas, University of California, San Francisco, Department of Surgery, San Francisco, CA 94143-0104, USA by 30 April 1992. Telephone: (415) 476-1236. Facsimile: (415) 476-1734.
Br. J. Surg.. Vol. 79, No. 4, April 1992
309
