INTRODUCTION — Esophageal cancer is often diagnosed at an advanced and/or incurable stage. Although surgical palliation may be considered in patients without metastatic disease who are good operative risk, locally unresectable or medically poor-risk patients may achieve palliation of dysphagia from nonoperative methods. Palliation of dysphagia can often be achieved by radiation, with or without chemotherapy. (See "Management of locally advanced, unresectable and inoperable esophageal cancer".)
However, improvement in swallowing may not occur for several weeks, and not all patients can tolerate these treatments. These individuals can be plagued by symptoms of esophageal obstruction, fistulae, dysphagia, odynophagia, aspiration, poor nutrition, and weight loss.
Symptomatic patients who are not candidates for chemoradiotherapy, or who have recurrent dysphagia following definitive chemoradiotherapy may benefit from palliative endoscopic maneuvers. While a variety of endoscopic methods have been described, esophageal stenting is probably most commonly used [1]. Guidelines from the American Society for Gastrointestinal Endoscopy recommended esophageal stenting as the preferred method for palliation of dysphagia and fistulas in patients with esophageal cancer [2]. The degree of palliation with any of these methods is typically incomplete, underscoring that more effective approaches are still needed. As a general rule, palliative approaches for inoperable esophageal cancer should be based upon patient and tumor characteristics, goals of care, and patient and clinician preferences [2,3].
This topic will provide an overview of the endoscopic options available for the palliation of esophageal cancer. The use of expandable stents in treating esophageal obstruction is discussed in detail elsewhere. (See "Endoscopic stenting for palliation of malignant esophageal obstruction".)
ENDOSCOPIC STENTING — Patients with advanced stages of esophageal cancer or those who are poor surgical candidates can be offered stenting as a palliative treatment for dysphagia. Stenting can also be used for palliation of patients with postoperative tumor recurrence [4]. This topic is discussed in detail elsewhere. (See "Endoscopic stenting for palliation of malignant esophageal obstruction".)
ESOPHAGEAL DILATION — Esophageal dilatation with either through-the-scope balloon or wire-guided polyvinyl bougies can provide temporary relief of dysphagia until more definitive treatment can be accomplished. Most malignant strictures can be safely dilated to 16 or 17 mm in several sessions [5]. However, repeat dilatation is usually required every two to four weeks. Esophageal dilation is also associated with risk of perforation, especially if performed by blind Maloney dilation during radiotherapy [6-9]. In clinical practice, dilation of malignant esophageal strictures is uncommonly performed given the short-term benefit and associated risks.(See "Complications of endoscopic esophageal stricture dilation".)
PHOTODYNAMIC THERAPY
General principles — Photodynamic therapy (PDT), a tissue ablative technique, uses a photosensitizing agent in combination with endoscopic low power laser exposure. Only one photosensitizing agent, porfimer sodium (Photofrin), is available in the United States. Porfimer sodium is a hematoporphyrin derivative, which is approved for the palliation of esophageal cancer. PDT with porfimer sodium is thought to have a direct toxic effect on malignant cells via the production of singlet oxygen, which damages the microvasculature of the tumor and renders it ischemic [10]. (See "Endobronchial photodynamic therapy in the management of airway disease in adults", section on 'Principles of photodynamic therapy'.)
Porfimer sodium accumulates in malignant tissue after intravenous injection, and the area is then exposed to an endoscopically placed low power laser diffuser with monochrome light (630 nm), which initiates a photochemical reaction that results in tumor necrosis. The malignant tissue can be repeatedly treated in order to provide optimal tissue ablation.
Patients with advanced disease — With the widespread availability of self-expandable metal stents (SEMS) for esophageal cancer, PDT is less commonly utilized as initial therapy for palliation of malignant dysphagia. For patients with SEMS, PDT can be used to treat stent occlusion related to tissue ingrowth or overgrowth. (See "Endoscopic stenting for palliation of malignant esophageal obstruction", section on 'Stent occlusion'.)
PDT has also been studied in combination with argon plasma coagulation (APC). (See 'Argon plasma coagulation' below.)
Studies suggest that PDT provides palliation from dysphagia for patients with advanced esophageal cancer and that PDT with a second-generation photosensitizer has shown promise for patients with local failure after chemoradiotherapy [11-14]. In a study including 121 patients with esophageal cancer and local failure following chemoradiotherapy, salvage PDT using talaporfin sodium was associated with higher rates of local complete response compared with PDT using porfimer sodium (69 versus 58 percent) [13]. Adverse events including skin phototoxicity, esophageal stricture, and esophageal fistula were less common in the talaporfin sodium group. (See 'General principles' above.)
In earlier studies, other adverse events reported with PDT were chest pain and worsening dysphagia [10,15]. Although porfimer sodium is cleared from a variety of tissues within 40 to 72 hours after injection, tumors, the skin, and some organs (ie, liver, spleen) retain the drug for a longer period. Skin photosensitivity may persist for four to six weeks after the treatment; sunscreens are ineffective since they do not block visible light. Agents with less phototoxicity (eg, talaporfin sodium) may be the future of PDT therapy [12,13].
Patients with early-stage disease who are not surgical candidates — Another potential use of PDT is for patients with early-stage disease who pose a high surgical risk or those who refuse surgery [16,17]. In the largest series of 123 such patients who were recommended for nonoperative treatment, the complete response rate at six months was 87 percent with PDT alone or as a component of multimodality therapy, and the five-year disease-specific survival rate was 74 percent [16].
ARGON PLASMA COAGULATION — Argon plasma coagulation (APC) is a technique of monopolar, noncontact, high frequency electrocautery that uses ionized, electrically charged argon gas to cause tissue coagulation and tumor destruction. APC has been used to palliate tumors in a variety of gastrointestinal lumens. In a study of pulsed versus forced APC that included 51 patients with esophageal or esophagogastric junction cancer, an overall response was seen in 85 percent and dysphagia improved in 94 percent of patients [18]. The most common adverse event was bleeding. (See "Argon plasma coagulation in the management of gastrointestinal hemorrhage".)
Outcome data for APC compared with stent placement are limited [19]. In an observational study of 228 patients with inoperable esophageal cancer, APC was associated with longer median survival compared with placement of a self-expandable metal stent (257 versus 102 days), but this difference was likely due to patient selection.
APC has also been studied in combination with brachytherapy and photodynamic therapy (PDT). A randomized trial with 93 patients with malignant dysphagia assigned patients to treatment with APC plus brachytherapy, APC plus PDT, or APC alone [20]. Patients treated with APC alone had shorter median times to first dysphagia recurrence compared with those who also received brachytherapy or PDT (35 versus 88 and 59 days, respectively). There were no differences in overall survival.
CRYOSPRAY ABLATION — Cryospray ablation (cryotherapy) is a noncontact method that uses supercooling (temperatures with nitrogen reaching -196°C) to cause cryonecrosis and has been used to palliate esophageal cancer [21-23]. Cryotherapy involves freezing and thawing cycles. The degree of tissue injury induced by cryotherapy varies depending on the rate and duration of cooling, the number of freeze-thaw cycles, and the distance from the target tissue to the origin of the spray.
In a series of 49 patients with inoperable esophageal cancer, endoscopic cryotherapy using liquid nitrogen spray was associated with improvement in dysphagia. [23]. Major adverse events included benign stricture requiring dilation (one patient) and dilation-related perforation that occurred prior to a cryotherapy session (one patient). The mean number of treatments per patient was 2.4 (range, one to six) and most patients (82 percent) received one to three cryotherapy treatments. In another series of 79 patients with esophageal cancer, a complete intraluminal response was seen in 31 of 49 patients (63 percent) who completed liquid nitrogen spray cryotherapy (30 patients were still receiving cryotherapy at the time of data collection). Benign strictures developed in 10 patients (13 percent), all of whom had undergone previous tumor therapy [22]. The median number of treatments per patient was three (range, 1 to 25).
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Esophageal cancer".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Esophageal cancer (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Indications for endoscopic palliation – Endoscopic interventions may be appropriate for palliation of dysphagia in patients with esophageal cancer in the following settings (see "Management of locally advanced, unresectable and inoperable esophageal cancer"):
•Patients for whom definitive management with radiation or chemoradiotherapy is planned, but who have severe dysphagia at presentation, requiring intervention prior to therapy
•Failure to achieve adequate palliation of dysphagia with initial therapy
•Recurrent dysphagia due to locoregional failure
•Recurrent dysphagia due to benign strictures in patients who are successfully treated with radiation
•Patients are poor candidates for either chemotherapy or radiation therapy
●Endoscopic interventions for malignant dysphagia – There are several endoscopic approaches to providing palliation from malignant dysphagia:
•Placement of an esophageal stent (see 'Endoscopic stenting' above)
•Esophageal dilation (see 'Esophageal dilation' above)
•Photodynamic therapy (see 'Photodynamic therapy' above)
•Argon plasma coagulation (APC) (see 'Argon plasma coagulation' above)
•Cryospray ablation (see 'Cryospray ablation' above)
Stenting is preferable therapy for patients with a malignant stricture and/or fistula. (See "Endoscopic stenting for palliation of malignant esophageal obstruction".)
In the absence of a fistula, optimal therapy remains controversial. The choice of endoscopic palliative method should be based upon anatomical features, patient preferences, and available expertise.
