title: Management of Dysphagia in Esophageal Adenocarcinoma Patients Undergoing Neoadjuvant Chemotherapy: Can Invasive Tube Feeding be Avoided?
abstract: BACKGROUND
  Neoadjuvant chemotherapy is an accepted standard for locally advanced esophagogastric junction adenocarcinoma. However, the dysphagia frequently associated with this condition may interfere with patient tolerance of this treatment. In many centers, invasive tube feeding, placed either endoscopically, radiographically, or surgically, is used to address this issue, but it can cause significant morbidity. We sought to determine if an approach of goal-directed dietary counseling and appropriately timed neoadjuvant chemotherapy could obviate the need for invasive tube feeding.
  
  
  METHODS
  Patients with locally advanced (cT3 or N+) esophageal and esophagogastric junction adenocarcinoma undergoing neoadjuvant TCF [Taxotere, cisplatin 5-fluorouracil (5-FU)], ECF (epirubicin, cisplatin, 5-FU), or FLOT (docetaxel, oxaliplatin, leucovorin, and 5-FU) at the McGill University Health Center from March 2007 to September 2012 were identified from a prospective database. All received individualized goal-directed dietary counseling, were monitored for signs/symptoms of malnutrition with serial (baseline/presurgery) body mass index, albumin, and completed serial symptom scores (dysphagia), and quality-of-life questionnaires (Functional Assessment in Cancer Therapy with the esophageal subset, FACT-E). We assessed the response of dysphagia and nutritional status to neoadjuvant chemotherapy and the need for invasive tube feeding.
  
  
  RESULTS
  Of 130 patients undergoing neoadjuvant chemotherapy, 78 had severe dysphagia (defined as dysphagia score ≥2 on a 5-point Likert scale), most of whom received TCF (91 %). Overall dysphagia scores improved in 75 (96 %) of 78 patients from a dysphagia score of 3-0, most of which improved after the first cycle of therapy. This was associated with an increase in quality of life (FACT-E scores 117 ± 23 to 140 ± 20). With maintenance of weight (70 ± 22 to 69 ± 24 kg), body mass index (24.5 ± 8 to 23.9 ± 7 kg/m(2)), and serum albumin (40 ± 5 to 37 ± 4 g/L). Only one patient required a stent, and none required jejunostomy or gastrostomy.
  
  
  CONCLUSIONS
  Appropriately timed neoadjuvant chemotherapy with a highly effective regimen rapidly restores normal swallowing, maintains nutritional status, and obviates the need for invasive tube feeding in patients with significant dysphagia from esophageal adenocarcinoma.
authors.affiliation: Department of Surgery, McGill University, Montreal, Canada.
authors.forename: J
authors.initials: J
authors.lastname: Cools-Lartigue
authors.forename: D
authors.initials: D
authors.lastname: Jones
authors.forename: J
authors.initials: J
authors.lastname: Spicer
authors.forename: T
authors.initials: T
authors.lastname: Zourikian
authors.forename: M
authors.initials: M
authors.lastname: Rousseau
authors.forename: E
authors.initials: E
authors.lastname: Eckert
authors.forename: T
authors.initials: T
authors.lastname: Alcindor
authors.forename: M
authors.initials: M
authors.lastname: Vanhuyse
authors.forename: J
authors.initials: J
authors.lastname: Asselah
authors.forename: L E
authors.initials: LE
authors.lastname: Ferri
mesh_terms: D000230:Adenocarcinoma / Q000150:complications* / Q000473:pathology / Q000628:therapy; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects*; D002945:Cisplatin / Q000008:administration & dosage; D003680:Deglutition Disorders / Q000139:chemically induced / Q000517:prevention & control*; D000077143:Docetaxel; D004750:Enteral Nutrition; D015251:Epirubicin / Q000008:administration & dosage; D004938:Esophageal Neoplasms / Q000150:complications* / Q000473:pathology / Q000628:therapy; D004943:Esophagogastric Junction / Q000187:drug effects / Q000473:pathology; D005260:Female; D005472:Fluorouracil / Q000008:administration & dosage; D005500:Follow-Up Studies; D006801:Humans; D002955:Leucovorin / Q000008:administration & dosage; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000009:adverse effects*; D009367:Neoplasm Staging; D009944:Organoplatinum Compounds / Q000008:administration & dosage; D000077150:Oxaliplatin; D011379:Prognosis; D011446:Prospective Studies; D011788:Quality of Life; D043823:Taxoids / Q000008:administration & dosage
chemical_list: D009944:Organoplatinum Compounds; D043823:Taxoids; D000077150:Oxaliplatin; D000077143:Docetaxel; D015251:Epirubicin; D002945:Cisplatin; D002955:Leucovorin; D005472:Fluorouracil