Clinical Effectiveness of Treating Late Stage Esophageal and Esophagocardial Cancer by Electrochemical Therapy XJN Yu-Ling, LU Zhi-Chong, ZHONG Yao-Jie, SONG Qing-Xiang, LIU De-Ruo, SONG Zhi-Yi

China -Japan Friendship Hospital, Beijing 100029, China

Abstract

Three hundred and five cases including 282 cases patients with cancer of esophagus and esophagocardia, 23 patients with postoperative anastomotic stricture were treated by electrochemical therapy (ECT). .This article focuses on 215 cases who had been observed for three to twelve months after treatment. The result included 43 patients with CR (20.0%), 108 PR (50.2%), 33 NC (15.3), 31 PD (14.4%). One hundred and fifty-three cases with CR plus PR represented the total effective rate of 70.2%. In order to alleviate patients‘ suffering and prolong their lifetime, this therapy can provide the patients of late stage cancer of esophagus and esophagocardia, who can‘t undergo surgical therapy, with alleviating their obstructing symptom and improving their taking food and their life quality. Key words: electrochemical therapy late stage cancer of esophagus and esophagocardia

The incidence of esophageal and esophagocardial cancer is high in our country. Most of the patients who don‘t go to see doctor until they had dysphagia, the symptom of late stage cancer. They can‘t undergo surgical therapy. In order to resolve the problem of their taking food, we began, since March of 1992, to treat these patients and those with postoperative anastomotic stricture after esophageal cancer resection using the tube electrode, which was developed by LI Kai-Hua. The result indicate than electrochemical therapy can remove obstruction effectively and improve patients‘ life quality. The method is simple and safe. As there is little harm done and patients recover quickly, it is accepted willingly by the old an weak patients.

Clinical Materials

In order to probe into the effectiveness of ECT, this article summarizes treatment result of 215 patients with late stage cancer of esophagus and esophagocardia and postoperative anastomotic stricture after resection of esophageal cancer. They were treated by ECT and had been observed for three to twelve months after treatment. There are 162 cases of male and 53 of female. The ratio is 3.1: 1. They ranged in age from 45 to 83 years (average 56.5 years). Among the 215 cases 112 cases had been treated separately by means of radiotherapy (32 cases), chemotherapy (28 cases), traditional Chinese medicine (52 cases) without effect. There were surgical explorations done on 13 cases. And 102 patients were old and weak and had poor esophagocardiac and lung function or had distant tumor metastasis. According to WHO tumor classification standard designed in 1978, there were no Ti cases, 35 T2 cases, 121 T3 cases and 59 T4 cases among the group.

Clinical Diagnosis

All patients had taken barium radiography esophagoscopy and biopsy before and after ECT, Among them 123 cases were with squamous cell carcinoma, 33 cases with adenocarcinoma and 59 cases can‘t be classified. The anatomical sites included upper esophagus (36 cases), middle esophagus (81 cases), lower esophagus (41 cases), and esophagocardia (35 cases). There were also 23 cases with postoperative anastomotic stricture after resection of esophageal cancer. Among 192 cases with primary cancer of esophagus the gross pathological types included medullary type (91 cases), stenotic type (53 cases), fungoid type (39 cases), and ulcerous type (9 cases). The lesion length obtained from barium radiograph of esophagus included 3~-5 cm(23 cases), 5.1‘—7.Ocm (118 cases), 7.1—‘9.Ocm (57 cases), and 9.0‘cm (17 cases). Most of the lesions longer than 7 cm were medullary type and those shorter than 7 cm were usually stenotic ~type. The stricture degree of esophageal and esophiagocardiac carcinoma according to the measurement on esophagogram~ included 15 cases with J0 (1 ~-2mm), 61 cases with 110 (S-6 mm) ‚89 cases with 1110 (3~ mm), and 50 cases with W° (1-2 mm). ~Among the group 139 cases (64.4%) withIII or VI  stricture whose lesion belonged to serious obstruction were malnourished ad cachexic

Clinical Symptoms

All patients complained of dysphagia and regurgitating food at different degree. 10 obstruction (dysphagja Occurred when patient taking ordinary food) was found in 15 cases, 110 obstruction (dysphagia occurred-red when patient taking soft food) in 61 cases, 1110 obstruction (dysphagia occurred when patient taking liquid food) in 89 cases, and TV° obstructjon (dysphagia occurred when patients drinking water) in 50 cases. The degree of obstruction was as approximately Same as that of stricture obtained form the measurement on esophagogram The cases with 1V0 obstruction were those presenting serious stricture (1 -2 mm) on esophagogram.. All patients complained of weight loss at different degree including 35 cases with weight loss within 5 kilos, 98 cases with that between 5.1 and 10 kilos, and 82 cases with that between 10 and 15 kilos.

Treating Method

(1)  Selection of equipment: There are several ~types  of cancer ~treatment instrument developed ~ China~, such as general type, micro-processor ~type and computer Con~o11ing ~e. The instrument of all ~types has the function of predetermining voltage ‚current intensity, electric quantity and time. lt also has the monitoring and alarming device to guarantee the accuracy and safety of the therapy.

(2)  Developing the electrode to treat esophageal and esophagocardiac carcinoma• The duct electrode, which was developed by LI Kai-Hua according to the treatment demand required by XIN Yu-Ling, is 70 cm Iong and its outer diameter is O.Scm. Rings of platinum wire (diameter O.3rnm) are wound on the treating end of the tube. Every ring sets a distance of 5 rum from each other and the anodic and cathodic rings are also at a distance from each other. There is also a platinum wire (diameter 1 mm) in the middle of the tube to treat the seriously obstructed esophageal carcinoma. There are side holes in the duct electrode wall to inject drugs.

(3)Preparations~ before treatment: Preparations include routine and electrolyte exams, barium radiography of esophagus~, esophagoscopy and functional examinations~ of esophagocardiac lung, liver and kidney in order to identi1~‘ the pathological type, length and extent of the lesion and patient~‘ nutrition status as well. We give support treatment to weak patients‘ or those with hypo function~ of important organs. lt is necessary to take CT scan to judge tumor invasion to the mediastinum structure such as trachea and aorta. lt is also important to determine the area of tumor on esophageal wall whether it is circular or semi-circular invasion to select appropriate duct electrode and determine current quantity~ applied.

(4) Procedures: Patients take sitting position. Topical anesthesia of 0.1% decaine or 1% lidocaine on mucosa of nasal cavity and pharyngeal site is given. lt is the best way to place the tube electrode through~ nostril, then fix it on the lose. If it is difficult to place it through nostril, do it through oral cavity. While placing the tube electrode, Iet patient swallow to assist the electrode into esophagus. Don‘t let patient breathe deeply lest the tube electrode may be inhaled into trachea.

(5)  The monitoring method indicating the tube electrode in the tumor

A. X-ray monitoring method; After placement of the tube electrode, let the patient swallow watery barium. We can see the stroma of the stricture clearly on the roentgen scope, adjust the electrode direction according to the different shape of the lumen, and insert it into the lesion precisely.

B. Esophagoscopy monitoring method: If we can‘t insert the electrode into the lesion by the roentgenoscope due to the too narrow stricture of the lumen or the varying tumor shape, we can rely on esophagoscopy by which we can catch~ the accurate site, aim at the stroma, adjust the tube electrode, and insert it into the lesion. lathe lumen is too narrow to be inserted, we should first insert platinum wire, which is in the middle of the electrode into the lesion, deliver 100 coulombs for the wire to open a

NC: Tumor size reduces less than one half of its dimension. Patents‘ Symptoms are alleviated. They can take soft food and take care of themselves partly. Their condition can be stable for three months.

PM: Tumor size reduces a little of its dimension. Patients‘ symptoms are not alleviated. They take liquid food and can‘t take care of themselves. They have relapse two months later after treatment.

lt has the best effectiveness (91.3%; 21/23) to treat anastomotic stricture. lt has better effectiveness~ (70.1%; 110/157) to treat esophageal cancer and the effectiveness of treating esophagocardial cancer is the lowest (57.1%; 20/35). The lesion of anastomotic stricture is short and we can exactly insert the electrode into it, so it has the best effectiveness. However, esophagocardial cancer usually invades fundus of stomach and the electrode can‘t cover the tumor totally, so the treatment is not complete and it recurs easily. ECT is very good in alleviating obstructing symptom of late stage esophageal cancer There were 139 cases with JJJ0 or 1V0 serious obstruction among 215 cases before treatment. After ECT the number or the cases decreased to 64 (29.8%), and the number of the cases with 10 and 110 increased to 120(55.8%) from 15(7%) before treatment,. There were 31 cases (14.4%) with obstruction becoming O~ in the group. The alleviating rate of obstruction was 70.0%.

ECT can effectively remove obstruction symptom caused by the stricture of esophageal and esophagocardial cancer. Most of patients were able to take liquid food in one week, soft food in two weeks, and ordinary food in three weeks after treatment. Dysphagia was alleviated obviously. There were no patients with JO and 110 obstruction increased to 64.6% from 35.3% before treatment, patient with III and IV decreased to 29.7% from 64.6% before treatment, respectively.

We analyzed the lesion length change after treatment according to barium radiography of esophagus and found that ECT can shorten the lesion length obviously. For example, there were 32 cases (14.9%) with lesion length shorter than 5c m before treatment, and the number increased to 96 (44.7%) after treatment. There were also 183 cases with that longer than 5 cm (85.1%) before treatment, and the number decreased to 74 (34.4%) after treatment. Forty-five cases‘ lesion disappeared (20.9%) after treatment in the group.

Two-hundred and fifteen cases had been followed up for 3 to 12 months. There were 41 cases (19.1%) had relapse. lt recurred between 3 and 6 months after treatment. The reasons of relapse included (1) all their lesions were longer than 8cm. (2)the current quantity was not enough (each cm lesion got less than 100 coulombs) and (3) among them 16 cases only got one time of ECT and didn‘t get supplementary treatment. Among the 41 cases, 15 patients accepted ECT again: seven patients‘ dysphasia was alleviated and 8 cases failed to respond to it; eleven patients accepted adjuvant radiotherapy; four patients‘ symptoms were alleviated and 7 cases didn‘t obtain any effectiveness. We gave planting dilating ring treatment to 4 patients and 6 patients accepted gastric fistula ion to guarantee their intake of food.

Among the group, 19 cases died within one year. lt included 2 patients with tracheoesophagea! fistula, 2 with esophageal massive hemorrhage, 4 with suffocation (respiratory tract was pressed by mediastinal metastases), 3 with radiation pneumonia, 3 with coronary heart disease, and 5 with unknown reasons. The death rate was 8.8 % within one year.

Complications and their Treatment

Among the group, complications included (1) five cases with esophageal perforation. Their lesion length was 8—9 cm long; all belonged to late stage middle esophageal cancer. As the lesion was longer, the total current quantity was between 900 and 1000 coulombs. The reasons of perforation might have bad something to do with the pathological type (ulcerating type) and larger current quantity. To prevent this complication, we should insert the electrode exactly and deliver the current quantity accurately according to the pathological features. We should avoid either perforation due to delivering the electric quantity greater than required or tumor remained due to delivering the quantity less than required. The treatment for the five perforation cases: We forbid the patients to take food by mouth, and nasal feeding jejunostomy feeding tube was taken to support their nutrition. Three patients with mediastinoesophageal fistula recovered after 2, 4, and 5 months separately. Other two with tracheoesophageal fistula died after leaving hospital voluntarily. (2) Two cases with massive hemorrhage occurred on the fourteenth and fortieth day after treatment separately. These two case~ bad

better treating effectiveness ad their obstruction disappeared completely. As tumor became necrotic and dropped 0ff massively and the patients took ordinary food earlier, it causes rupture of blood Vessels. To prevent massive hemorrhage we should let patients take liquid food within 10 days after treatment and take soft food within 20 days and forbid them to take ordinary food too early. (3) Arrhythrnia is mainly doe to conduction block. We found 5 cases with arrhythrnia and 8 cases with bradycardia (conduction block) in the treatment. They were 9 with lower esophageal cancer and 4 cases with esophagocardial cancer. The lesion site which the electrode was inserted in was dose to the heart lateral wall. As the voltage increased quickly, the current intensity reached 50—~60 mA rapidly. To prevent this complication we should take these measures: (1) At the beginning of the treatment we should slowly increase the

voltage first to 2v—3v, wait for a while, and observe the patient‘s response, then increase it to 4v. The current intensity may be between 20 and 30 mA. lt has the treating effectiveness at the value. When the patient accustoms himself to the condition for a while, we can increase the voltage to 5v or 6v slowly and ~i1c current intensity may reach 30—40 mA. Arrhythinia usually occurs when the voltage is greater than 6v and the current intensity greater than 40 mA. If the patient can‘t endure this voltage and current, we can use voltage of 4 V, current intensity of 30 mA and keep a longer treating time to obtain the same

effectiveness(2) We give the patient intravenous infusion and monitor their electrocardiogram in the treatment, If we find abnormality, we should decreases the voltage to 0 immediately. The rhythm of the heart usually becomes normal automatically when we stop the treatment, because the direct current

doesn‘t injured cardiac muscle directly and it only affects its conduction. After we adjust the rhythm of the heart to normal, we can consider if we continue to give the patient treatment.

Discussion

The incidence of esophageal and esophagocardial cancer is rather high in China. lt is very difficult to detect the disease in the early stage. Most of the patients lost their opportunity for surgical treatment when they went to see doctor and radiotherapy or chemotherapy doesn‘t have excellent effectiveness to middle and lower esophageal an esophagocardial cancer.
There is no very effective method especially to treat those who have seriously obstruction symptom, who haven‘t been able to take food for a long time, and who are very weak. In 1992 we first began to treat these patients by using ECT and obtained success. The effective rate reached 70%. After treatment the patients‘ obstruction symptom disappeared they could take ordinary food and take care of themselves. So this method is an effective means to treat late stage esophageal and esophagocardial cancer, We should select the indications strictly to guarantee the effectiveness, such as the lesion length less than 7cm, no distant metastases, not cachexic, no heart disease and diabetes, etc. Pathological type:  medullary or stenotic type lesions are suitable to be treated. Especially, postoperative anastomotic stricture is also considered to be good indication. If late stage esophagocardial cancer invades fundus of stomach, it usually fails to respond to the treatment.
We should select appropriate electrode according to the Length and shape of the lesion and insert it into the site accurately. Because rings of platinum wire are wound on the treating end, when we treat esophageal cancer of semi-circular invasion, we should seal the part of electrode which contacts normal esophageal wall to protect the normal tissue.
When the tumor length is longer than 7 cm or its thickness is greater than 1.5 cm, it needs several times of treatment. In the first treatment we deliver 500 coulombs of current quantify and ten days late let die patient have esophagoscopy or barium radiography of esophagus. Depending on the result of examination we give the patient the second treatment (about 400 coulombs). Continue to observe die patient‘s response for ten days and we decide whether or not to give die third treatment according to patients‘ condition. Some cases whose lesion length was linger than 10 cm or whose lesion was postoperative anastomotic stricture of scar had four times‘ treatment (die total current quantity reached more than 1000 coulombs) to remove die obstruction completely. The treating quantity required depends on the individual condition. lt is a problem, because there is no accurate method of examination, to pre-determine die individual current quantity required by each different esophageal cancer patient exactly. We can measure die thickness and invasion extent of tumor by means of CT or MRI and it may provides us with some reference data to consider die current quantity delivered. The principle to determine die quantity of each individual lesion according to clinical experience includes both destroying the lesion completely arid not causing esophageal perforation. We should take multiple treatment measures to improve effectiveness of ECT treating esophageal and esophagocardial cancer. Patients who suffer from seriously obstructing esophageal and esophagocardial cancer haven‘t been able to take food for a long time and their constitution is very poor, so we should first removed the obstructing symptom by using ECT to make sure that they can take food and improve their constitution. When we treat the lesion longer than 7 cm, some small cancer focuses may usually remain or metastasize to mediastinal Lymph nodes. Then we need radiotherapy, chemotherapy or traditional Chinese medicine as supplement to improve the effectiveness.