Comparative Study of Esophageal Self-expandable Metallic Stent Insertion and Gastrostomy Feeding for Dysphagia Caused by Lung Cancer

Jihye Kim; Yang Won Min; Hyuk Lee; Byung-Hoon Min; Joon Haeng Lee; Poong-Lyul Rhee; Jae J. Kim

doi:10.4166/kjg.2018.71.3.124

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Kim, Min, Lee, Min, Lee, Rhee, and Kim: Comparative Study of Esophageal Self-expandable Metallic Stent Insertion and Gastrostomy Feeding for Dysphagia Caused by Lung Cancer

Original Article

Korean J Gastroenterol 2018;71(3):124-131.

Published online: 4 October 2018

DOI: https://doi.org/10.4166/kjg.2018.71.3.124

Comparative Study of Esophageal Self-expandable Metallic Stent Insertion and Gastrostomy Feeding for Dysphagia Caused by Lung Cancer

Jihye Kim, Yang Won Min, Hyuk Lee, Byung-Hoon Min, Joon Haeng Lee, Poong-Lyul Rhee, Jae J. Kim

Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Correspondence to: Yang Won Min, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea. Tel: +82-2-3410-3409, Fax: +82-2-3410-6983, E-mail: yangwon.min@samsung.com

Received 26 October 2017 Accepted 14 December 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

Dysphagia is encountered in a large proportion of patients with lung cancer and is associated with malnutrition and a poor quality of life. This study compared the clinical outcomes of self-expandable metallic stent (SEMS) insertion and percutaneous gastrostomy (PG) feeding for patients with lung cancer and dysphagia.

Methods

A total of 261 patients with lung cancer, who underwent either SEMS insertion (stent group) or PG (gastrostomy group) as an initial treatment procedure for dysphagia between July 1997 and July 2015 at the Samsung Medical Center, were reviewed retrospectively, and 84 patients with esophageal obstruction were identified. The clinical outcomes, including the overall survival, additional intervention, complications, and post-procedural nutritional status in the two groups, were compared.

Results

Among the 84 patients finally analyzed, 68 patients received SEMS insertion and 16 had PG. The stent group had less cervical obstruction and more mid-esophageal obstruction than the gastrostomy group. The Kaplan-Meier curves revealed similar overall survival in the two groups. Multivariate analysis showed that the two modalities had similar survival rates (PG compared with SEMS insertion, hazard ratio 0.682, p=0.219). Fifteen patients (22.1%) in the stent group received additional intervention, whereas there was no case in the gastrostomy group (p=0.063). The decrease in the serum albumin level after the procedure was lower in the gastrostomy group than in the stent group (−0.20±0.54 g/dL vs. −0.65±0.57 g/dL, p=0.013)

Conclusions

SEMS insertion and PG feeding for relieving dysphagia by lung cancer had a comparable survival outcome. On the other hand, PG was associated with a better nutritional status.

Keywords: Self expandable metallic stents, Gastrostomy, Esophageal stenosis, Lung cancer, Dysphagia

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Fig. 1.

Flow chart of patient selection. RT, radiotherapy.

Fig. 2.

Kaplan-Meier curves for the overall survival in lung cancer patients who received either esophageal stent or percutaneous gastrostomy for malignant dysphagia.

Fig. 3.

Subgroup analysis of the overall survival according to the 7th AJCC staging in NSCLC patients. (A) Kaplan-Meier curves for the overall survival in NSCLC stage III patients who received either esophageal stent or percutaneous gastrostomy for malignant dysphagia. (B) Kaplan-Meier curves for the overall survival in NSCLC stage IV patients who received either esophageal stent or percutaneous gastrostomy for malignant dysphagia. AJCC, American Joint Committee on Cancer; NSCLC, non-small cell lung cancer.

Table 1.

Comparison of Baseline Characteristics in Lung Cancer Patients Who Received either Esophageal Stent or Percutaneous Gastrostomy for Malignant Dysphagia

Variables	Stent group (n=68)	Gastrostomy group (n=16)	p-value
Age (years)	62.4±11.5	58.5±6.3	0.069
Sex			0.214
Male	47 (69.1)	14 (87.5)
Female	21 (30.9)	2 (12.5)
BMI (kg/m²)	20.0±2.68	20.2±3.05	0.725
Weight (kg)	51.0 (33.7–78.9)	54.4 (38.2–70.6)	0.197
Albumin (g/dL)	3.63±0.52	3.43±0.62	0.198
Histology			0.552
Adenocarcinoma	27 (39.7)	6 (37.5)
Squamous cell carcinoma	27 (39.7)	8 (50.0)
Small cell lung cancer	6 (8.8)	2 (12.5)
Others	8 (11.8)	0 (0)
Stage by AJCC 7th			0.611
NSCLC stage III	15 (22.1)	5 (31.3)
NSCLC stage IV	47 (69.1)	9 (56.3)
SCLC ^a	6 (8.8) ^a	2 (12.5)
Location of stenosis			0.021
Cervical	1 (1.5)	2 (15.5)
Upper thoracic	6 (8.8)	2 (12.5)
Mid thoracic	49 (72.1)	6 (37.5)
Lower thoracic	12 (17.6)	6 (37.5)
Stenotic length			0.530
Near total obstruction	5 (7.4)	1 (6.3)
≤3 cm	24 (35.3)	5 (31.3)
>3 cm and ≤6 cm	26 (38.2)	9 (56.3)
>6 cm	13 (19.1)	1 (6.3)
CTx or RTx after procedure
No	33 (48.5)	5 (31.3)	0.270
Yes	35 (51.5)	11 (68.8)
CTx only	16	6
RTx only	9	3
CTx and RTx	10	2

Values are presented as the mean±standard deviation, median (range) or n (%).

BMI, body mass index; AJCC, American Joint Committee on Cancer; NSCLC, non-small cell lung cancer; SCLC, small cell lung cancer; CTx, chemotherapy; RTx, radiotherapy.

^a Among the SCLC patients, only one patient of stent group was limited stage and the others were extended stage.

Table 2.

Prognostic Factors Associated with the Overall Survival in Patients with Dysphagia Induced by a Lung Cancer Obstruction

Variables	Univariate analysis		Multivariate analysis
Variables	HR (95% CI)	p-value	HR (95% CI)	p-value
Age (years)	1.021 (0.998–1.044)	0.075	1.008 (0.985–1.031)	0.487
Sex (male)	1.245 (0.766–2.024)	0.376
BMI	0.976 (0.889–1.073)	0.618
Albumin	0.600 (0.410–0.877)	0.008	0.594 (0.393–0.898)	0.014
Histology
NSCLC	1
SCLC	1.351 (0.649–2.816)	0.421
Stage
NSCLC III	1
NSCLC IV	1.172 (0.692–1.984)	0.556
SCLC LD	1
SCLC ED	0.563 (0.058–5.467)	0.621
Location of stenosis
Cervical	1
Upper thoracic	1.279 (0.336–4.864)	0.718
Mid thoracic	1.804 (0.562–5.795)	0.322
Lower thoracic	1.465 (0.426–5.036)	0.544
Stenotic length
≤3 cm	1
>3 cm and ≤6 cm	1.047 (0.63–1.729)	0.858
>6 cm	1.659 (0.868–3.167)	0.125
Near total obstruction	0.806 (0.350–1.857)	0.613
CTx or RTx after procedure
Yes	1		1
No	3.769 (2.332–6.092)	<0.001	3.352 (2.045–5.492)	<0.001
Intervention modality
Stent	1		1
Gastrostomy	0.659 (0.375–1.156)	0.146	0.682 (0.371–1.255)	0.219

HR, hazard ratio; CI, confidence interval; BMI, body mass index; NSCLC, non-small cell lung cancer; SCLC, small cell lung cancer; LD, limited-stage disease; ED, extensive-stage disease; CTx, chemotherapy; RTx, radiotherapy.

Table 3.

Comparison of the Secondary Outcomes in Lung Cancer Patients Who Received either Esophageal Stent or Percutaneous Gastrostomy for Malignant Dysphagia

Variables	Stent group (n=68)	Gastrostomy group (n=16)	p-value
Additional intervention
Need for additional intervention	15 (22.1)	0 (0)	0.063
Number of additional interventions, mean	0.25	0	0.061
Complications
Number of total complications	1 (0–3)	0 (0–1)	0.067
Pneumonia	30 (44.1)	5 (31.3)	0.409
Fistula	9 (13.2)	0 (0)	0.196
Dyspnea	9 (13.2)	0 (0)	0.196
Nutrition
Change in weight after the procedure (kg)	−1.00 (−8.1 to +8.0)	−0.35 (−5.7 to +1.1)	0.658
Change in serum albumin level after the procedure (g/dL)	−0.65±0.57	−0.20±0.54	0.013

Values are presented as the mean±standard deviation, median (range) or n (%).

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