Endoscopic palliation of esophageal cancer
- John R Saltzman, MD, FACP, FACG, FASGE, AGAF
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
- Section Editor — Therapeutic and Diagnostic Endoscopy
- Professor of Medicine
- Harvard Medical School
Esophageal cancer is often diagnosed at an advanced incurable stage. (See "Epidemiology, pathobiology, and clinical manifestations of esophageal cancer".) 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 excellent palliation of swallowing from nonoperative means. 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 are plagued by symptoms of esophageal obstruction or fistulae, dysphagia, 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 . In a 2013 guideline, the American Society for Gastrointestinal Endoscopy recommended esophageal stenting as the preferred method for palliation of dysphagia and fistulas in patients with esophageal cancer . The degree of palliation with any of these methods is typically incomplete, underscoring that better 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 "Use of expandable stents in the esophagus".)
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 . However, repeat dilatation is usually required every three to four weeks. Esophageal dilation is also associated with a small risk of perforation, especially if performed by blind Maloney dilation during radiotherapy [5-8].
- Jacobson BC, Hirota W, Baron TH, et al. The role of endoscopy in the assessment and treatment of esophageal cancer. Gastrointest Endosc 2003; 57:817.
- ASGE Standards of Practice Committee, Evans JA, Early DS, et al. The role of endoscopy in the assessment and treatment of esophageal cancer. Gastrointest Endosc 2013; 77:328.
- Shenfine J, McNamee P, Steen N, et al. A randomized controlled clinical trial of palliative therapies for patients with inoperable esophageal cancer. Am J Gastroenterol 2009; 104:1674.
- Boyce HW Jr. Palliation of Dysphagia of Esophageal Cancer by Endoscopic Lumen Restoration Techniques. Cancer Control 1999; 6:73.
- Heit HA, Johnson LF, Siegel SR, Boyce HW Jr. Palliative dilation for dysphagia in esophageal carcinoma. Ann Intern Med 1978; 89:629.
- Cassidy DE, Nord HJ, Boyce HW. Management of malignant esophageal strictures: Role of esophageal dilation and peroral prosthesis. Am J Gastroenterol 1981; 75:173.
- Lundell L, Leth R, Lind T, et al. Palliative endoscopic dilatation in carcinoma of the esophagus and esophagogastric junction. Acta Chir Scand 1989; 155:179.
- Hernandez LV, Jacobson JW, Harris MS. Comparison among the perforation rates of Maloney, balloon, and savary dilation of esophageal strictures. Gastrointest Endosc 2000; 51:460.
- Haddad NG, Fleischer DE. Endoscopic laser therapy for esophageal cancer. Gastrointest Endosc Clin N Am 1994; 4:863.
- Mellow MH, Pinkas H. Endoscopic laser therapy for malignancies affecting the esophagus and gastroesophageal junction. Analysis of technical and functional efficacy. Arch Intern Med 1985; 145:1443.
- Dallal HJ, Smith GD, Grieve DC, et al. A randomized trial of thermal ablative therapy versus expandable metal stents in the palliative treatment of patients with esophageal carcinoma. Gastrointest Endosc 2001; 54:549.
- Adam A, Ellul J, Watkinson AF, et al. Palliation of inoperable esophageal carcinoma: a prospective randomized trial of laser therapy and stent placement. Radiology 1997; 202:344.
- Chung SC, Leong HT, Choi CY, et al. Palliation of malignant oesophageal obstruction by endoscopic alcohol injection. Endoscopy 1994; 26:275.
- Moreira LS, Coelho RC, Sadala RU, Dani R. The use of ethanol injection under endoscopic control to palliate dysphagia caused by esophagogastric cancer. Endoscopy 1994; 26:311.
- Ramakrishnaiah VP, Ramkumar J, Pai D. Intratumoural injection of absolute alcohol in carcinoma of gastroesophageal junction for palliation of dysphagia. Ecancermedicalscience 2014; 8:395.
- Monga SP, Wadleigh R, Sharma A, et al. Intratumoral therapy of cisplatin/epinephrine injectable gel for palliation in patients with obstructive esophageal cancer. Am J Clin Oncol 2000; 23:386.
- Harbord M, Dawes RF, Barr H, et al. Palliation of patients with dysphagia due to advanced esophageal cancer by endoscopic injection of cisplatin/epinephrine injectable gel. Gastrointest Endosc 2002; 56:644.
- Marcon NE. Photodynamic therapy and cancer of the esophagus. Semin Oncol 1994; 21:20.
- McCaughan JS Jr, Ellison EC, Guy JT, et al. Photodynamic therapy for esophageal malignancy: a prospective twelve-year study. Ann Thorac Surg 1996; 62:1005.
- Muto M, Yano T, KAtada C, et al. Salvage photodynamic therapy for locoregional failure after definitive chemoradiotherapy for esophageal cancer (abstract). Proc Am Soc Clin Oncol 2004; 23:355.
- Lightdale CJ, Heier SK, Marcon NE, et al. Photodynamic therapy with porfimer sodium versus thermal ablation therapy with Nd:YAG laser for palliation of esophageal cancer: a multicenter randomized trial. Gastrointest Endosc 1995; 42:507.
- Sibille A, Lambert R, Souquet JC, et al. Long-term survival after photodynamic therapy for esophageal cancer. Gastroenterology 1995; 108:337.
- Corti L, Skarlatos J, Boso C, et al. Outcome of patients receiving photodynamic therapy for early esophageal cancer. Int J Radiat Oncol Biol Phys 2000; 47:419.
- Eickhoff A, Jakobs R, Schilling D, et al. Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction: effectiveness of the new pulsed APC versus forced APC. Endoscopy 2007; 39:637.
- Rupinski M, Zagorowicz E, Regula J, et al. Randomized comparison of three palliative regimens including brachytherapy, photodynamic therapy, and APC in patients with malignant dysphagia (CONSORT 1a) (Revised II). Am J Gastroenterol 2011; 106:1612.
- Cash BD, Johnston LR, Johnston MH. Cryospray ablation (CSA) in the palliative treatment of squamous cell carcinoma of the esophagus. World J Surg Oncol 2007; 5:34.
- Greenwald BD, Dumot JA, Abrams JA, et al. Endoscopic spray cryotherapy for esophageal cancer: safety and efficacy. Gastrointest Endosc 2010; 71:686.
- Siersema PD, Schrauwen SL, van Blankenstein M, et al. Self-expanding metal stents for complicated and recurrent esophagogastric cancer. Gastrointest Endosc 2001; 54:579.
- ESOPHAGEAL DILATION
- LASER THERAPY
- ABSOLUTE ALCOHOL INJECTION
- INTRATUMORAL INJECTION OF CISPLATIN/EPINEPHRINE GEL
- PHOTODYNAMIC THERAPY
- Palliation of dysphagia in advanced disease
- Inoperable patients with early stage disease
- ARGON PLASMA COAGULATION
- CRYOSPRAY ABLATION
- ENDOSCOPIC STENTING
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS