Introduction

First-line FOLFIRINOX or gemcitabine plus nab-paclitaxel (GNP) have improved the survival outcomes of patients with advanced pancreatic cancer (APC) and nano-liposomal irinotecan (nal-IRI) plus 5-FU/leucovorin is proven as the second-line agents.

Aims & Methods

The current study aims to assess the efficacy of third-line palliative chemotherapy in APC.
Medical records were retrospectively reviewed in a single tertiary hospital between 2012 and 2021. We enrolled patients with APC who experienced progression after the second-line chemotherapy following the first-line FOLFIRINOX or GNP. To define the efficacy of the third-line chemotherapy, Cox-regression analysis was performed. To identify the clinical factors affecting the survival, multivariable logistic regression analysis was also performed.

Results

Total 141 patients were enrolled. The median age at diagnosis was 61.8 years (range 36.0 – 86.0), and males were 54.9% (n=78). The first-line chemotherapy regimen was FOLFIRINOX (95, 67.4%) and GNP (46, 32.6%). The second-line chemotherapy regimen was FOLFIRINOX (38, 27.0%), GNP (74, 52.5%), and others (29, 20.4%). Regarding the third-line regimen, TS-1 and nal-IRI plus 5-FU/leucovorin were 69 (27.0%) and 53 (37.6%). The median overall survival (OS) from diagnosis was 18.0 months (95% confidence interval (CI), 15.3 – 20.7). The median OS and median progression-free survival after the third-line treatment were 14.6 (95% CI, 12.1 – 17.0) and 7.3 weeks (95% CI, 6.3– 8.3). About the best tumor response during the third-line chemotherapy, there was no complete response, 2 (1.4%) with a partial response, 41 (29.1%) with stable disease, and 80 (56.7%) with progressive disease. Consequently, the disease control rate in the third-line treatment was 30.5%. Of the patients with the third-line chemotherapy, the following clinical factors affected OS; ECOG of 2 at third-line chemotherapy (HR: 2.64, 95% CI: 1.58-4.42; p <0.001), serum CA19-9 level ≥ 1,000 U/ml before the third-line chemotherapy (HR: 1.67, 95% CI: 1.11-2.52; p=0.014), duration of the second-line chemotherapy < 19 weeks (HR: 1.51, 95% CI: 1.03-2.21; p=0.034), and peritoneal seeding before the third-line chemotherapy (HR: 1.53, 95% CI: 1.03-2.25; p=0.033).

Conclusion

The current study suggested that proceeding with the third-line chemotherapy could be recommended in some patients. There is no difference in survival rate according to the type of the third-line chemotherapy regimen. ECOG 0 or 1, CA 19-9 <1,000U/ml, duration of second-line chemotherapy ≥ 19 weeks, and no peritoneal seeding showed significantly more benefit from the third-line therapy.

References

1. Conroy T, Desseigne F, Ychou M, Bouche O, Guimbaud R, Becouarn Y, Adenis A, Raoul JL, Gourgou-Bourgade S, de la Fouchardiere C, Bennouna J, Bachet JB, Khemissa-Akouz F, Pere-Verge D, Delbaldo C, Assenat E, Chauffert B, Michel P, Montoto-Grillot C, Ducreux M, Groupe Tumeurs Digestives of U, Intergroup P. FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. N Engl J Med 2011; 364(19): 1817-1825
2. Von Hoff DD, Ervin T, Arena FP, Chiorean EG, Infante J, Moore M, Seay T, Tjulandin SA, Ma WW, Saleh MN, Harris M, Reni M, Dowden S, Laheru D, Bahary N, Ramanathan RK, Tabernero J, Hidalgo M, Goldstein D, Van Cutsem E, Wei X, Iglesias J, Renschler MF. Increased survival in pancreatic cancer with nab-paclitaxel plus gemcitabine. N Engl J Med 2013; 369(18): 1691-1703
3. Walker EJ, Ko AH. Beyond first-line chemotherapy for advanced pancreatic cancer: an expanding array of therapeutic options? World J Gastroenterol 2014; 20(9): 2224-2236
4. Wang-Gillam A, Hubner RA, Siveke JT, Von Hoff DD, Belanger B, de Jong FA, Mirakhur B, Chen LT. NAPOLI-1 phase 3 study of liposomal irinotecan in metastatic pancreatic cancer: Final overall survival analysis and characteristics of long-term survivors. Eur J Cancer 2019; 108: 78-87

Introduction

A 28-year-old woman with Type I diabetes presented with severe dysphagia after pregnancy. Endoscopy showed a “blind” esophagus, with complete esophageal obstruction (Fig. 1). An endoscopic approach was unsuccessful in finding an access for the guidewire and no evidence of contrast medium passage was seen. Endoscopic ultrasound was used to study the esophageal layers and try to see behind the stricture. The wall was thickened (10 mm), with prevalence of the submucosa.

Aims & Methods

A mild insufflation of air, used as ultrasonographic contrast, allowed the endosonographer to see a hyperechoic line that was interpreted as the sub-millimetric remnant of the esophageal lumen (Fig. 2). A 19 G access needle was used to puncture, under EUS guidance, the esophageal wall (Fig. 3) starting from the hyperechoic line inside the esophagus (video 1). After initial resistance, under fluoroscopic view of the needle path, a point of least resistance was felt and the needle tip, inserted for almost 5 cm, was visualized below the diaphragm.

Results

A guidewire was inserted into the needle and under fluoroscopic view was seen creating a loop inside the stomach (Fig.4). A Hurricane RX biliary balloon dilation catheter (6 mm diameter, 4 cm length) was passed through the stricture and the first dilation was performed (Fig.5). In the following weeks, other dilations were performed with Savary bougies and the esophageal lumen was restored (Fig. 6). Forceps biopsies revealed acute and chronic inflammation, with severe fibrosis and no signs of eosinophilic esophagitis or tumor.

Conclusion

After 3 months, the patient could eat normally and a weight increase of 3 kg was observed. Complete esophageal obstruction may arise from both benign and malignant diseases. The treatment must be managed in centers with extensive experience of operative endoscopy, since the approach may be challenging [1-3]. We proposed an alternative, ultrasonographic-guided approach to esophageal restoration.

References

1. Perbtani Yaseen, Alejandro L Suarez, Mihir S Wagh. Endoscopic techniques for complete esophageal obstruction. Endoscopy International Open 2016; 04: E136–E142.
2. Vitali F, Nägel A, Pfeifer L, et al. Endoscopic recanalization of complete esophageal obstruction. Surg Endosc. 2021 Jun;35(6):3184-3188.
3. Bertolini R, Meyenberger C, Putora PM, et al. Endoscopic dilation of complete oesophageal obstructions with a combined antegrade-retrograde rendezvous technique. World J Gastroenterol. 2016 Feb 21;22(7):2366-72.

Introduction

Oesophageal injuries and perforations are transmural ruptures of the oesophagus that subsequently lead to leakage of intraluminal contents into the surrounding mediastinum. This causes local inflammation, a systemic inflammatory response, and eventually the development of sepsis, resulting in significant morbidity and mortality.

Aims & Methods

This study aimed to compare oesophageal self-expandable metal stent (E-SEMS) with endoscopic vacuum therapy (EVT) in oesophageal perforations (EP) treatment. We randomly evaluated 30 patients with traumatic EP. The E-SEMS and EVT groups were assessed for treatment duration, duration of hospitalisation, LOS (length of stay), clinical outcomes, and treatment success.

Results

In both groups, the most common cause of injury was a foreign body 63.3% (19/30), followed by gunshot wounds 30.0% (9/30) and stab wounds 6.7% (2/30). The treatment duration for E-SEMS (45.8±12.9) was significantly longer than EVT (24.42±13.21), p<0.005. Evaluating the clinical results, E-SEMS demonstrated a 93.75% (15/16) discharge rate compared to EVT which showed 71.4% (10/14). Deaths occurred in the E-SEMS and EVT groups at rates of 6.3% (01/16) and 28.6% (04/14) respectively, p=0.1571. Treatment success showed no significant difference between E-SEMS 93.7% (15/16) and EVT 78.6% (11/14), p=0.3155. The costs were calculated at €19,266.08±10,925.00 for E-SEMS and €38,453.17±23,840.40 for EVT, respectively.

Conclusion

E-SEMS had a longer treatment duration compared to EVT. Both therapies showed no significant difference in clinical outcome and treatment success. The overall cost was lower for E-SEMS compared to EVT.

Disclosure

Alessandrino Terceiro de Oliveira, Amanda Cyntia Lima Fonseca Rodrigues, José Wilson da Cunha Parente Júnior, José Ruver Lima Herculano Junior, Jeany Borges e Silva Ribeiro, Orleancio Gomes Ripardo de Azevedo, and Paulo Roberto Cavalcante de Vasconcelos have no conflicts of interest.