title: Self-Expandable Metal Stents in Esophageal Cancer in a High HIV Prevalence Area: A Survival Analysis and Evaluation of Prediction Scores.
abstract: BACKGROUND
  Esophageal cancer (EC) and human immunodeficiency virus (HIV) are common in parts of South Africa. Squamous cell carcinoma of the esophagus in KwaZulu-Natal, South Africa presents generally in advanced stages and is mostly palliated by the deployment of self-expandable metal stent (SEMS). This study analyses these relationships between coexistent HIV infection, SEMS deployment, and survival scores.
  
  
  METHODS
  Information on patients managed with SEMS between October 2013 and December 2014 was retrieved from a prospective database of EC and followed up until April 2015. Data collected included demographics, HIV status, clinical presentation, prognostic indicators, management, and survival. Prognostic factors were calculated in relation to outcome.
  
  
  RESULTS
  One hundred five patients with EC had median ages of 61 (SD±11.4) and median body mass index of 17.45. Squamous cell carcinoma of the esophagus was diagnosed in 90 patients and adenocancer in 7 patients. Tumors were located in the proximal (10), middle (64), and distal (29) esophagus. Stage IV EC had a significant shorter survival of fewer than 3 months compared with stage III cancer (P=0.009). A C-reactive protein >150 mg/L was 3.6 times more likely to predict survival of fewer than 3 months than a value <50 mg/L (P=0.035). A proximal stent position significantly predicted shorter survival (P=0.035). The Steyerberg prognostic score proved ineffective in predicting survival of <3 months in our setting. Of the 84 patients tested for HIV, 23 were positive. Thirteen patients were on highly active antiretroviral therapy surviving significantly longer than those without this medication (P=0.036).
  
  
  CONCLUSIONS
  Stage IV cancer and C-reactive protein >150 predicted survival of <3 months significantly better than the Steyerberg prediction score or other markers. Highly active anti-retroviral therapy had a positive impact on survival; however, SEMS placement in the proximal esophagus was associated with shorter survival.
authors.affiliation: *Department of Surgery, Inkosi Albert Luthuli Central Hospital †Department of Surgery ‡SAMRC/UKZN Gastrointestinal Cancer Research Centre, University of KwaZulu-Natal, Durban §Department of Surgery, Grey's Hospital, Pietermaritzburg ∥Department of General Surgery, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa ¶Department of Hepatogastroenterology, VU University Medical Centre Amsterdam, The Netherlands.
authors.forename: Emil
authors.initials: E
authors.lastname: Loots
authors.forename: Frank
authors.initials: F
authors.lastname: Anderson
authors.forename: Damian L
authors.initials: DL
authors.lastname: Clarke
authors.forename: Chris J J
authors.initials: CJ
authors.lastname: Mulder
authors.forename: Thandinkosi E
authors.initials: TE
authors.lastname: Madiba
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004938:Esophageal Neoplasms / Q000150:complications / Q000401:mortality / Q000601:surgery*; D005260:Female; D015658:HIV Infections; D015528:HIV Seroprevalence; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D012189:Retrospective Studies; D000069322:Self Expandable Metallic Stents; D013019:South Africa / Q000453:epidemiology; D015996:Survival Rate / Q000639:trends