Research Of Endoscopic Therapy For Aged Patients With Malignant Esophageal Dysphagia And Expression Of Survivin, Fas And FasL

PART 1STENTS PLACEMENT UNDER ENDOCOPY FOR AGED PATIENTS WITH MALIGNANT ESOPHAGEAL DYSPHAGIAObjective: It is to explore the treatment measures of stent placement under endoscopy and its clinical effectiveness for the aged patients with severely obstructive esophageal carcinoma missed operation and radiotherapy.Methods: Between February 2000 and December 2003 Forty-two aged patients with esophageal carcinoma received the endoscopic therapy with nitinol covered Self-expanding metallic stent (SEMS) placement only. A novel approach was used to facilitate dilation of complex non-traversable esophagel strictures prior to stenting by a flexible guidewire for vascular intervention combined with a transpositional device made by us. The etiology of obstruction of the esophagus was squamous cell carcinoma in 42 patients (28 male, 14 female, age range75~89 years, mean 77.21+2.58 years). The site of obstruction was in the upper (n = 7), in the middle (n = 21) and in the lower esophagus (n - 14).Results: Stents were placed successfully in all 42 patients, leading to an improved oral intake (100%) . During the follow-up period the rate of Restenosis from four and six months after treatment was 29. 73% (11/37) versus 47. 06% (8/17) , and the rate of dysphagia due to tumor overgrowth was 27. 27% (3/11) and 50% (4/8) respectively. The median survival time was 5.91 + 1.64 months.Conclusion: Placement of covered self-expanding metallic stents under endoscopy is a safe and effective modality that improves the quality of life for patients with inoperable malignant esophageal strictures, however, it could not control the local mass overgrowth and prolong the overall survival of these patients missed radiochemaltherapy. The method by exchange of a flexible vascular guidewire with a more rigid wire using a transpositional device made by us was useful in the process of stenting for complex, tight esophageal strictures.PART 2TREATMENT WITH MTC AND LOCAL INJECTION COMBINED WITHSTENTING FOR AGED PATIENTS SUFFERINGFROM ESOPHAGEAL CARCINOMAObjective: The aim of this study was to evaluate the efficacy and safety of endoscopic therapy with covered self-expanding metallic stent (SEMS) in the management of malignant esophageal obstruction or stenosis, and to explore the effectiveness of the method combied with microwave tissue coagulation (MTC) and local injection to control regional tumor in aged patients suffering from esophageal carcinoma missed operation and radiotherapy.Methods: From February 2000 to December 2003 forty-six aged patients with esophageal carcinoma received the endoscopic therapy of microwave tissue coagulation combied with local injection prior to nitinol covered memory metallic stent placement. The etiology of obstruction of the esophagus was squamous cell carcinoma in all 46 patients (27 male, 19 female, age range 75~92 years, mean 78 + 3.21 years). The site of obstruction was in the upper (n = 9), in the middle (n = 25) and in the lower esophagus (n = 12).Results: Stenting was successful in 46 patients with no complications, and the dysphagia was alleviated in 100%. There were no serious complications in the process of treatment. During the follow-up period five (12. 20%) patients developed dysphagia again 6 months after stenting and there was not restenosis due to tumor overgrowth in this period. The rate of Restenosis from 12 months after treatment was 61. 11% (11/18). There was a significant differience of restenosis betwwen 6and 12 months, KO. 01. The Survival rate of six and twelve months was 89. 13% (41/46) and 39. 13% (18/46) respectively. The median survival time was 10.07 + 4.74 months.Conclusion: MTC and local injection prior to stent placement was useful to control the overgrowth of local primary esophageal carcinoma and effective to reduce the chance of metastasis. The difficult problem of no effective measures to treat patients after stent placement was solved successfully. With the survival time prolonged the rate of restenosis became higher. It is better to try endoscopic therapy on the aged patients with malignant esophageal obstrctions missed operation and radiotherapy. The quality of the life of these patients could be improved and the period of the life could be prolonged.PART 3EXPRESSION OF SUEVIVIN, FAS AND FASL AND THEIR CLINICAL SIGNIFICANCE IN ESOPHAGEAL CARCINOMAObjective: The aim was to investigate the prognostic significance of survivin, Fas and FasL gene expression in esophageal squamous cell carcinoma, and the relationship of these genes with tumour cell grade, clinical stages and lymph node metastasis was yet to be explored, which might be a good marker in the process of treatment for aged patients with inoperable esophageal carcinoma.Methods: Specimens obtained by endoscopy from 88 aged patients with severely obstructive oesophageal squamous cell carcinoma missed operation and radiotherapy were used for immunohistochemical evaluation of Survivin, Fas and FasL genes. Another 54 specimens were acquired from postoperative cases.Results: The positive rate of Survivin, Fas and FasL expression in esophageal cancer tissue was 73.86%, 46.59% and 54.55% in endospic treatment group respectively. The median survival time for patients with higher survivin and FasL expression was less than that for patients with lower expression, PiO. 05. The expression of survivin and Fas genes was not correlation with tumor cell grade in this study, but there was a negative relationship existing between the expression of FasL and the grade of esophageal squamous cell carcinoma. In resection group, Expression of Survivin, Fas and FasL in esophageal cancer tissue was 68.52%, 40.74% and 55.56% respectively, and there was a positive relationship existing between the expression of Survivin , FasL and clinical stages, lymphatic invasion of cancer cells.Conclusion: The imraunohistochemical results suggest that high expression of survivin and FasL may provide unfavorable prognosis in patients with esophageal cancer, which might be a good marker for esophageal tumors to be less responsive to chemotherapy.