Enzymatic dissection for palliative treatment of esophageal carcinoma: an experimental study
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《血管的通路杂志》
1 Yuzuncu Yil University, Medical School, Thoracic Surgery Department, Maras Street, Van, Turkey
2 Yuzuncu Yil University, Medical School, Physiology Department, Maras Street, Van, Turkey
3 Yuzuncu Yil University, Medical School, Pathology Department, Maras Street, Van, Turkey
4 Yuzuncu Yil University, Medical School, General Surgery Department, Maras Street, Van, Turkey
Abstract
Patients with esophageal carcinoma generally lose their chance of curable surgical treatment when symptoms become evident. At this stage chemoradiotherapy and palliative treatment methods are the only options. We investigated the potential use of enzymatic treatment in tissue loosening to improve the esophageal passage especially in patients with advanced esophageal carcinoma. Specimens were prepared from resection materials (one adenocarcinoma, two squamous cell carcinomas) which were removed from three consecutive patients. They were treated with pancreatin at 2.5%, 5% and 10% of concentrations. Macroscopic and histopathologic examinations were performed to evaluate the effect. At 2.5% enzyme concentration no macroscopically change was observed in adenocarcinoma while mild softening occurred in the tissue samples of squamous cell carcinoma. Histopathologic examination revealed tissue and cell necrosis destruction at 5 and 10% concentrations in the latter samples. We observed clear destruction of squamous cell carcinoma tissue in both macroscopically and microscopically with in vitro enzyme application. This procedure, not only helps to open esophageal passage, but may also delay the growth of tumour and support the chemoradiotherapy. Enzymatic tumoral dissection (tumourolysis) is a promising method to alleviate the symptoms of esophageal carcinoma.
Key Words: Esophagus; Cancer; Surgery; Stents; Palliative treatment
1. Introduction
Although esophageal carcinomas are not so common in the world, there are endemic areas like China, Japan, Korea, Iran, South Africa and Porto-Rico [1]. It is also endemic in Turkey especially in regions along the ancient Silk Road. The most frequent symptom is progressive dysphagia. Patients generally apply to a physician at a stage when they cannot swallow solid foods anymore; which means an inoperable tumour of an advanced stage. Fifty-two of 186 cases with esophageal carcinoma diagnosed at our clinic between 1996 and 2004 were not even palliatively operable. Ninety of the remaining patients had a chance of curative surgery, only 12% of whom had a 3-year survival. There are some reports that give resection rate between 30.8% and 63.9% in esophageal carcinoma [1]. Surgery alone or surgery after chemo-radiotherapy has been discussed [2–4]. There is a clear need for adjuvant methods, which could protect patients from malnutrition and provide at least temporary comfort, alongside radical treatment procedures. For this reason, esophageal stent, ethanol injection, photodynamic therapy, endoluminal laser therapy, bipolar electro-coagulation, brachytherapy and chemotherapy applications are currently used [5–11]. In this study, we investigated the potential use of enzymatic treatment in tissue loosening to improve the esophageal passage especially in patients with advanced esophageal carcinoma.
2. Material and method
An in vitro experimental study was done with specimens of one adenocarcinoma and two squamous cell carcinomas of the three patients who were operated consecutively in our clinic. For enzymatic treatment, pancreatin (Sigma) was selected for its diverse content (amylase, trypsin, lipase, ribonuclease, protease). The study was planned in two steps. In the first step, cubic pieces were prepared in approximately 0.4x0.6 cm dimensions from the tumoral tissues. Similar samples from intact tissue that encompassed the whole esophageal wall and smaller ones (1x5 mm) that contained only mucosal layer were also removed. 0.25 ml pancreatin solution (2.5%) in phosphate buffered saline (PBS) was injected with an insulin injector into each cubic piece which were then left in an incubator at 37 °C for 5, 10, 20 and 30 min. Mucosal tissue samples were covered with 300 μl of enzyme solution and incubated for similar durations.
In the second step, cubic specimens (0.5x1 cm) were dissected from squamous cell carcinoma (6 pieces) and healthy esophageal wall (3 pieces) including mucosal layer and weighed (Table 1). Five or 10% pancreatin solution was injected into the cancer tissue samples (3 samples for each concentration) as described earlier. All of the healthy esophageal specimens were injected with the 10% solution. Specimens were incubated at 37 °C for 10, 20 and 30 min.
The materials were fixed in 10% neutral-buffered formalin and embedded in paraffin. Four-micrometer-thick sections were cut and stained with hematoxyline and eosin.
3. Results
Tissue softenening was macroscopically evident in the squamous cell carcinoma sample that was treated with 2.5% pancreatin solution and incubated for 30 min while no change was observed in the adenocarcinoma specimen. No sign of necrosis or tissue destruction was detected histopathologically in any cancer specimen. There was no macroscopically or histopathological alterations in healthy mucosal pieces.
The specimens of squamous cell carcinoma which were treated with 5% and 10% of pancreatin solution and incubated for 20 and 30 min showed signs of softening, which were accompanied by extensive cell necrosis and tissue destruction (Table 2) (Fig. 1). Dosage interval was calculated as 12.5–25 mg/gr. No significant destruction was observed in healthy mucosal layer except mild desquamation (Fig. 2).
4. Discussion
The probability of curable surgical treatment of esophageal carcinoma is too low [1]. This is due to both insidious progression of tumour and the ignorance of early symptoms by patients. Non-surgical treatment methods have been researched. There are different data and reports about complete pathological response [2–4]. However, malnutrition problem that is caused by tumoral obstruction of esophageal passage has been considered important at least as well as radical treatment of carcinoma. For this reason, many different invasive and non-invasive procedures have been investigated and have found application fields. Esophageal stent, endoluminal laser therapy (ELLT), photodynamic therapy, argon beam or electro-coagulation methods can be listed as chief procedures [5–9]. Ethanol injection has been used as another method [10]. There are some difficulties in stent application. The most important one is that it cannot be applied easily at all levels of esophagus. Chest pain, bleeding, perforation, aspiration and fistula development are early complications [5,6,8]. Perforation and fistula development rates have been reported as 10–20% in some series [5,6]. Mortality (30 day) is between 7 and 26% [8,12–14]. Stent migration has been observed more than expected. Especially in stents placed at cardia, 25–32% migration rates were reported [12]. The most important problem is the obstruction of the stent with growing tumour at late period [13].
Another palliative treatment method is ELLT [8]. Disadvantages of this procedure are the requirement for multiple applications and dilatation during operation, which brings about risk of perforation. It has been reported that there was no significant difference between ELLT and stent application in curing dysphagia in comparative studies [8]. Cure rates of dysphagia have been stated as 80–90% in photodynamic therapy, argon beam or electro-coagulation therapy [5,7]. Although perforation rates are lower than the other procedures, requirement for multiple treatment sessions is an important disadvantage. Brachytherapy is another method for palliative treatment of advanced esophageal carcinoma. With this, cure rates for dysphagia are between 75–90%, but high esophageal stricture risk is a disadvantage of this procedure. However, better survival rates can be achieved by this method compared with stent, ELLT and electro-coagulation applications [11].
It is clear that different treatment methods have to be developed for palliative treatment of dysphagia in patients with advanced esophageal carcinoma. Each of the acceptable treatment methods for this purpose has advantages and disadvantages. We investigated the effectiveness of enzymatic dissection procedure to improve the quality of life for the patients with advanced esophageal carcinoma by relieving dysphagia during chemoradiotherapy. Enzymatic treatment has been used for different diseases like fibrinolytic treatment of pleural empyema and enzymatic anterior capsulotomy in cataract surgery. Cinal et al. reported use of collegenase for anterior capsulotomy in rabbit eye [15].
We found out that pancreatin caused tumour necrosis especially in squamous cell carcinoma. In this study, healthy esophageal mucosa was not affected except mild desquamation of epithelium. In our opinion, this is an important advantage because perforation and fistula are the most common complications of palliative treatment methods. If required the activity of the enzyme solution can be blocked by EDTA, which provides a means of control during treatment for physician. Lower cost of the application is another advantage compared with high costs of stent (1000$–1500$). It may also support chemoradiotherapy by leading to tumoral necrosis.
In conclusion, this study shows that pancreatin solution can be used for palliative treatment of advanced esophageal carcinoma. However, both experimental animal studies and clinical investigation on voluntary patients have to be performed for further exploration.
References
Bains MS, Shields TW. Squamous cell carcinoma of the esophagus. In: Shields TW, Locicero III S, Ponn RB. eds. General Thoracic Surgery. Philedelphia: Lipincott Williams and Wilkins, 2000:1905–1934. 5th ed.
Jones DR, Detterbeck FC, Egan TM, Parker LA, Bernard SA, Tepper JE. Induction chemoradiotherapy followed by esophagectomy in patients with carcinoma of the esophagus. Ann Thorac Surg 1997;64:185–192.
Malhaire JP, Labat JP, Lozac'h P, Simon H, Lucas B, Tobart P, Volant A. Preoperative concomitant radiochemotherapy in squomous cell carcinoma of the esophagus: results of a study of 56 patients. Int J Radiat Oncol Biol Phys 1996;34:429–437.
Bains MS, Stojadinovic A, Minsky B, Rusch V, Turnbull A, Korst R, Ginsberg R, Kelsen DP, Ilson DH. A phase II trial of preoperative combined-modality therapy for localized esophageal carcinoma: Initial results. J Thorac Cardiovasc Surg 2002;124:270–277.
Lee SH. The role of oesophageal stenting in the non-surgical management of oesophageal strictures. Br J Rad 2001;74:891–900.
Park HS, Do YS, Suh SW, Choo SW, Lim HK, Kim SH, Shim YM, Park KC, Choo IW. Upper gastrointestinal tract malignant obstruction: Initial results of palliation with a flexible covered stent. Radiology 1999;210:865–870.
Maier A, Tomaselli F, Matzi V, Rehak P, Pinter H, Smolle-Jüttner FM. Photosensitization with hematoporphyrin derivative compared to 5-Aminolaevulinic Acid for photodynamic therapy of esophageal carcinoma. Ann Thorac Surg 2001;72:1136–1140.
Konigsrainer A, Riedman B, De Vires A, Ofner D, Spechtenhauser D, Aigner F, Fritsch E, Margreiter R. Expandable metal stents versus laser combined with radiotherapy for palliation of unresectable esophageal a prospective randomized trial. Hepatogastroenterology 2000;47:724–727.
Heindorf H, Wojdemann M, Bisgaard T, Svendsen LB. Endoscopic palliation of inoperable cancer of the oesophagus or cardia by argon electrocoagulation. Scand J Gastroenterol 1998;33:21–23.
Payne-James JJ, Spiller RC, Misiewicz JJ, Silk DB. Use of ethanol-induced tumor necrosis to palliate dysphagia in patients with esophagogastric cancer. Gastrointest Endosc 1990;36:43–46.
Sur RK, Donde B, Levin VC, Monnell A. Fractionated high dose rate intraluminal brachytherapy in palliation of advanced esophageal cancer. Int J Radiat Oncol Biol Phys 1998;40:447–453.
Acunas B, Rozanes I, Akpinar S, Tunaci A, Tunaci M, Acunas G. Palliation of malignant esophageal strictures with self-expanding Nitinol stents: draw-backs and complications. Radiology 1996;199:648–652.
Adam A, Ellul J, Watkinson AF, Tan BS, Morgan RA, Saunders MP, Mason RC. Palliation of inoperable esophageal carcinoma: a prospective randomised trial of laser therapy and stnet placement. Radiology 1997;202:344–348.
Bartelsman JF, Bruno MJ, Jensema AJ, Haringsma J, Reeders JW, Tygat GN. Palliation of patients with esophageal neoplasms by insertion of covered expandable modified Gianturco-Z endoprosthesis: experiences in 153 patients. Gastrointest Endosc 2000;51:134–138.
Cinal A, Ozturk G, Demirok A, Ozdemir M, Ozen S, Ozbek H, Yasar T, Simsek S. Enzymatic anterior capsulotomy in cataract surgery: An experimental rabbit study. J Cataract Refract Surg 2004;30:1385–1386.(Ahmet Feridun Isik, Gurka)
2 Yuzuncu Yil University, Medical School, Physiology Department, Maras Street, Van, Turkey
3 Yuzuncu Yil University, Medical School, Pathology Department, Maras Street, Van, Turkey
4 Yuzuncu Yil University, Medical School, General Surgery Department, Maras Street, Van, Turkey
Abstract
Patients with esophageal carcinoma generally lose their chance of curable surgical treatment when symptoms become evident. At this stage chemoradiotherapy and palliative treatment methods are the only options. We investigated the potential use of enzymatic treatment in tissue loosening to improve the esophageal passage especially in patients with advanced esophageal carcinoma. Specimens were prepared from resection materials (one adenocarcinoma, two squamous cell carcinomas) which were removed from three consecutive patients. They were treated with pancreatin at 2.5%, 5% and 10% of concentrations. Macroscopic and histopathologic examinations were performed to evaluate the effect. At 2.5% enzyme concentration no macroscopically change was observed in adenocarcinoma while mild softening occurred in the tissue samples of squamous cell carcinoma. Histopathologic examination revealed tissue and cell necrosis destruction at 5 and 10% concentrations in the latter samples. We observed clear destruction of squamous cell carcinoma tissue in both macroscopically and microscopically with in vitro enzyme application. This procedure, not only helps to open esophageal passage, but may also delay the growth of tumour and support the chemoradiotherapy. Enzymatic tumoral dissection (tumourolysis) is a promising method to alleviate the symptoms of esophageal carcinoma.
Key Words: Esophagus; Cancer; Surgery; Stents; Palliative treatment
1. Introduction
Although esophageal carcinomas are not so common in the world, there are endemic areas like China, Japan, Korea, Iran, South Africa and Porto-Rico [1]. It is also endemic in Turkey especially in regions along the ancient Silk Road. The most frequent symptom is progressive dysphagia. Patients generally apply to a physician at a stage when they cannot swallow solid foods anymore; which means an inoperable tumour of an advanced stage. Fifty-two of 186 cases with esophageal carcinoma diagnosed at our clinic between 1996 and 2004 were not even palliatively operable. Ninety of the remaining patients had a chance of curative surgery, only 12% of whom had a 3-year survival. There are some reports that give resection rate between 30.8% and 63.9% in esophageal carcinoma [1]. Surgery alone or surgery after chemo-radiotherapy has been discussed [2–4]. There is a clear need for adjuvant methods, which could protect patients from malnutrition and provide at least temporary comfort, alongside radical treatment procedures. For this reason, esophageal stent, ethanol injection, photodynamic therapy, endoluminal laser therapy, bipolar electro-coagulation, brachytherapy and chemotherapy applications are currently used [5–11]. In this study, we investigated the potential use of enzymatic treatment in tissue loosening to improve the esophageal passage especially in patients with advanced esophageal carcinoma.
2. Material and method
An in vitro experimental study was done with specimens of one adenocarcinoma and two squamous cell carcinomas of the three patients who were operated consecutively in our clinic. For enzymatic treatment, pancreatin (Sigma) was selected for its diverse content (amylase, trypsin, lipase, ribonuclease, protease). The study was planned in two steps. In the first step, cubic pieces were prepared in approximately 0.4x0.6 cm dimensions from the tumoral tissues. Similar samples from intact tissue that encompassed the whole esophageal wall and smaller ones (1x5 mm) that contained only mucosal layer were also removed. 0.25 ml pancreatin solution (2.5%) in phosphate buffered saline (PBS) was injected with an insulin injector into each cubic piece which were then left in an incubator at 37 °C for 5, 10, 20 and 30 min. Mucosal tissue samples were covered with 300 μl of enzyme solution and incubated for similar durations.
In the second step, cubic specimens (0.5x1 cm) were dissected from squamous cell carcinoma (6 pieces) and healthy esophageal wall (3 pieces) including mucosal layer and weighed (Table 1). Five or 10% pancreatin solution was injected into the cancer tissue samples (3 samples for each concentration) as described earlier. All of the healthy esophageal specimens were injected with the 10% solution. Specimens were incubated at 37 °C for 10, 20 and 30 min.
The materials were fixed in 10% neutral-buffered formalin and embedded in paraffin. Four-micrometer-thick sections were cut and stained with hematoxyline and eosin.
3. Results
Tissue softenening was macroscopically evident in the squamous cell carcinoma sample that was treated with 2.5% pancreatin solution and incubated for 30 min while no change was observed in the adenocarcinoma specimen. No sign of necrosis or tissue destruction was detected histopathologically in any cancer specimen. There was no macroscopically or histopathological alterations in healthy mucosal pieces.
The specimens of squamous cell carcinoma which were treated with 5% and 10% of pancreatin solution and incubated for 20 and 30 min showed signs of softening, which were accompanied by extensive cell necrosis and tissue destruction (Table 2) (Fig. 1). Dosage interval was calculated as 12.5–25 mg/gr. No significant destruction was observed in healthy mucosal layer except mild desquamation (Fig. 2).
4. Discussion
The probability of curable surgical treatment of esophageal carcinoma is too low [1]. This is due to both insidious progression of tumour and the ignorance of early symptoms by patients. Non-surgical treatment methods have been researched. There are different data and reports about complete pathological response [2–4]. However, malnutrition problem that is caused by tumoral obstruction of esophageal passage has been considered important at least as well as radical treatment of carcinoma. For this reason, many different invasive and non-invasive procedures have been investigated and have found application fields. Esophageal stent, endoluminal laser therapy (ELLT), photodynamic therapy, argon beam or electro-coagulation methods can be listed as chief procedures [5–9]. Ethanol injection has been used as another method [10]. There are some difficulties in stent application. The most important one is that it cannot be applied easily at all levels of esophagus. Chest pain, bleeding, perforation, aspiration and fistula development are early complications [5,6,8]. Perforation and fistula development rates have been reported as 10–20% in some series [5,6]. Mortality (30 day) is between 7 and 26% [8,12–14]. Stent migration has been observed more than expected. Especially in stents placed at cardia, 25–32% migration rates were reported [12]. The most important problem is the obstruction of the stent with growing tumour at late period [13].
Another palliative treatment method is ELLT [8]. Disadvantages of this procedure are the requirement for multiple applications and dilatation during operation, which brings about risk of perforation. It has been reported that there was no significant difference between ELLT and stent application in curing dysphagia in comparative studies [8]. Cure rates of dysphagia have been stated as 80–90% in photodynamic therapy, argon beam or electro-coagulation therapy [5,7]. Although perforation rates are lower than the other procedures, requirement for multiple treatment sessions is an important disadvantage. Brachytherapy is another method for palliative treatment of advanced esophageal carcinoma. With this, cure rates for dysphagia are between 75–90%, but high esophageal stricture risk is a disadvantage of this procedure. However, better survival rates can be achieved by this method compared with stent, ELLT and electro-coagulation applications [11].
It is clear that different treatment methods have to be developed for palliative treatment of dysphagia in patients with advanced esophageal carcinoma. Each of the acceptable treatment methods for this purpose has advantages and disadvantages. We investigated the effectiveness of enzymatic dissection procedure to improve the quality of life for the patients with advanced esophageal carcinoma by relieving dysphagia during chemoradiotherapy. Enzymatic treatment has been used for different diseases like fibrinolytic treatment of pleural empyema and enzymatic anterior capsulotomy in cataract surgery. Cinal et al. reported use of collegenase for anterior capsulotomy in rabbit eye [15].
We found out that pancreatin caused tumour necrosis especially in squamous cell carcinoma. In this study, healthy esophageal mucosa was not affected except mild desquamation of epithelium. In our opinion, this is an important advantage because perforation and fistula are the most common complications of palliative treatment methods. If required the activity of the enzyme solution can be blocked by EDTA, which provides a means of control during treatment for physician. Lower cost of the application is another advantage compared with high costs of stent (1000$–1500$). It may also support chemoradiotherapy by leading to tumoral necrosis.
In conclusion, this study shows that pancreatin solution can be used for palliative treatment of advanced esophageal carcinoma. However, both experimental animal studies and clinical investigation on voluntary patients have to be performed for further exploration.
References
Bains MS, Shields TW. Squamous cell carcinoma of the esophagus. In: Shields TW, Locicero III S, Ponn RB. eds. General Thoracic Surgery. Philedelphia: Lipincott Williams and Wilkins, 2000:1905–1934. 5th ed.
Jones DR, Detterbeck FC, Egan TM, Parker LA, Bernard SA, Tepper JE. Induction chemoradiotherapy followed by esophagectomy in patients with carcinoma of the esophagus. Ann Thorac Surg 1997;64:185–192.
Malhaire JP, Labat JP, Lozac'h P, Simon H, Lucas B, Tobart P, Volant A. Preoperative concomitant radiochemotherapy in squomous cell carcinoma of the esophagus: results of a study of 56 patients. Int J Radiat Oncol Biol Phys 1996;34:429–437.
Bains MS, Stojadinovic A, Minsky B, Rusch V, Turnbull A, Korst R, Ginsberg R, Kelsen DP, Ilson DH. A phase II trial of preoperative combined-modality therapy for localized esophageal carcinoma: Initial results. J Thorac Cardiovasc Surg 2002;124:270–277.
Lee SH. The role of oesophageal stenting in the non-surgical management of oesophageal strictures. Br J Rad 2001;74:891–900.
Park HS, Do YS, Suh SW, Choo SW, Lim HK, Kim SH, Shim YM, Park KC, Choo IW. Upper gastrointestinal tract malignant obstruction: Initial results of palliation with a flexible covered stent. Radiology 1999;210:865–870.
Maier A, Tomaselli F, Matzi V, Rehak P, Pinter H, Smolle-Jüttner FM. Photosensitization with hematoporphyrin derivative compared to 5-Aminolaevulinic Acid for photodynamic therapy of esophageal carcinoma. Ann Thorac Surg 2001;72:1136–1140.
Konigsrainer A, Riedman B, De Vires A, Ofner D, Spechtenhauser D, Aigner F, Fritsch E, Margreiter R. Expandable metal stents versus laser combined with radiotherapy for palliation of unresectable esophageal a prospective randomized trial. Hepatogastroenterology 2000;47:724–727.
Heindorf H, Wojdemann M, Bisgaard T, Svendsen LB. Endoscopic palliation of inoperable cancer of the oesophagus or cardia by argon electrocoagulation. Scand J Gastroenterol 1998;33:21–23.
Payne-James JJ, Spiller RC, Misiewicz JJ, Silk DB. Use of ethanol-induced tumor necrosis to palliate dysphagia in patients with esophagogastric cancer. Gastrointest Endosc 1990;36:43–46.
Sur RK, Donde B, Levin VC, Monnell A. Fractionated high dose rate intraluminal brachytherapy in palliation of advanced esophageal cancer. Int J Radiat Oncol Biol Phys 1998;40:447–453.
Acunas B, Rozanes I, Akpinar S, Tunaci A, Tunaci M, Acunas G. Palliation of malignant esophageal strictures with self-expanding Nitinol stents: draw-backs and complications. Radiology 1996;199:648–652.
Adam A, Ellul J, Watkinson AF, Tan BS, Morgan RA, Saunders MP, Mason RC. Palliation of inoperable esophageal carcinoma: a prospective randomised trial of laser therapy and stnet placement. Radiology 1997;202:344–348.
Bartelsman JF, Bruno MJ, Jensema AJ, Haringsma J, Reeders JW, Tygat GN. Palliation of patients with esophageal neoplasms by insertion of covered expandable modified Gianturco-Z endoprosthesis: experiences in 153 patients. Gastrointest Endosc 2000;51:134–138.
Cinal A, Ozturk G, Demirok A, Ozdemir M, Ozen S, Ozbek H, Yasar T, Simsek S. Enzymatic anterior capsulotomy in cataract surgery: An experimental rabbit study. J Cataract Refract Surg 2004;30:1385–1386.(Ahmet Feridun Isik, Gurka)