Greater than 50% of patients with esophageal carcinoma are found to be incurable at the time of diagnosis, leaving only palliative options. Self-expanding metal stents (SEMs) are effective for relieving symptoms and complications associated with esophageal carcinoma and improving quality of life. We undertook a retrospective analysis to evaluate the experience of palliative esophageal stenting for symptomatic malignant dysphagia in our institution over a period of 7 years. Between January 1999 and January 2006, 126 patients who received SEMs for malignant dysphagia were identified using an upper gastrointestinal specialist nurse clinician database. Data were obtained from patient case notes, endoscopy, histopathology, radiology, and external agency databases. Of the 126 identified, 36 patients were excluded from the analysis. A number of variables including age, sex, presenting complaints, type of stent, indications of stenting, success or failure of stent insertion, survival rate, and complication rate were analyzed. Of the 90 patients, 55 (61%) were male and 35 (39%) were female. The mean age of patients was 70.79 (range 40-97) years. The predominant presenting complaints were dysphagia (n = 81) and weight loss (n = 48). The indication for stenting was worsening dysphagia in all patients. Tumors were confined to the distal esophagus and esophagogastric junction in 73 patients (81%), and the mid-esophagus in 17 (19%). Adenocarcinoma was identified in 61 patients (67.8%) and squamous cell carcinoma in 29 (32.2%). Stenting numbers were comparable in endoscopic and radiologic groups (47 vs. 43), with successful stent deployment in 89 patients. The 7- and 30-day mortality was 9% (n = 8) and 28% (n = 25), respectively. Comparable numbers of early deaths were seen in both radiologic (n = 13) and endoscopic (n = 12) groups. Causes of early inpatient death included hemorrhage (n = 5), pneumonia (n = 7), exhaustion (n = 2), cardiac causes (n = 3), perforation (n = 1), and sepsis (n = 1). The number of patients with complications was 41 (45.6%), 25 in the surgical group and 15 in the radiologic group; the difference was not significant (P = 0.13). The mean survival time was 92.5 (0-638) days and median survival time was 61 days. A subgroup of patients with complete dysphagia (score 4) gained a mean survival of 59 days. Those patients receiving adjuvant chemotherapy or radiotherapy survived significantly longer than those receiving stenting alone (152.8 days vs. 71.8 days). There is no significant difference in complications or survival when using endoscopic or radiologic methods to deploy SEMs in patients with inoperable esophageal cancer. Mortality is low; however, the morbidity rate is significant. Patients receiving adjuvant chemotherapy or radiotherapy, in addition to stenting, survived significantly longer than those with a stent only.

INTRODUCTION Guidelines for suspected malignant melanoma recommend a prompt, full-thickness excision biopsy allowing diagnosis and assessment of the Breslow thickness. Incisional biopsy is acceptable only for extensive facial lentigo maligna or acral melanoma. Punch, shave and other types of biopsies do not allow pathological staging and are, therefore, not recommended. PATIENTS AND METHODS A total of 100 referrals for histology-proven malignant melanoma were assessed retrospectively over a 1-year period (2005). RESULTS Of the 100 patients included in this study, 52 were male and 48 female. Ages ranged from 18–91 years, with a mean of 63 years. Origin of referrals was: dermatology, 63%; general practitioner (GP), 33%; and other sources in the remaining 4% of cases. Malignant melanoma was suspected in 84% and a benign lesion in remaining 16% of patients. However, only 56% of the patients were seen in our unit within 14 days of the referral as per the 2-week cancer rule. In these 100 patients, various types of biopsy were performed: 50 were referred without biopsy, 17 excision, 20 punch, 3 shave, 1 curettage, and 1 incisional biopsy. The type of biopsy was not recorded in the remaining 3 patients. Of the GP group, 48% were referred without biopsy, 12% had excision and 3% had incisional biopsies. The remaining 30% were punch, shave biopsies, and even curettage, inconsistent with current recommendations. Of the dermatology group, 54% were referred without biopsy, 21% underwent excision biopsy and 22% were punch biopsies. In total, 20 punch biopsies were performed, of which 7 were for lesions on the face ranging from 1.7–25 mm in size. The remaining punch biopsies were for lesions on the trunk or limbs (4–50 mm). Of the 20 punch biopsies performed, Breslow thickness was available in only 9 cases (45%). Sixteen of the punch biopsies were done when malignant melanoma was suspected and lesion otherwise was suitable for excisional biopsy. In the GP group, 3 shave biopsies and 1 curettage were performed, of which malignant melanoma was clinically suspected in one patient. The Breslow thickness was not obtained from any of the shave biopsies or curettage cases. Of the 17 excision biopsies performed, 3 were incompletely excised (2 by dermatology and 1 by GP). CONCLUSIONS A significant proportion of biopsies are inappropriate and inconsistent with the malignant melanoma guidelines. Punch biopsies are performed even when malignant melanoma is clinically suspected and excision biopsy is feasible. Only a small proportion of patients appear to be seen on an urgent basis within 14 days of referral. Such factors can lead to a delay in diagnosis, subsequent definitive treatment and adversely affect patient outcome. This study identifies a need to provide feedback and education to sources of malignant melanoma referrals.

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