Generally, cancer of the esophagus and gastroesophageal junction carries with it a poor prognosis. The expected 5-year survival with esophageal cancer is 40%, 21%, and 4%, for localized, regional, and distant disease, respectively.¹ Approximately 50% of patients presenting with esophageal cancer are not candidates for surgical resection at the time of diagnosis.² Unfortunately, these patients frequently have symptoms, particularly dysphagia, that require palliation. Therefore, the first objective of treatment is to adequately assess their symptoms. Establishing the extent of dysphagia (Table 91-1), and assessing accompanying pain, bleeding, aspiration, and other symptoms will assist in determining the best therapies required for effective palliation.

There are many different treatment modalities available for the palliation of esophageal cancer. Endoscopic intervention is the most common means and includes dilation, ablative techniques, local injection, and endoluminal stents. Similarly radiation, chemoradiation, and chemotherapy are used for symptomatic relief in unresectable patients. Surgery is used palliatively as a means for obtaining enteric access. Due to the poor prognosis and significant morbidity, radical palliative resection is rarely, if ever, indicated and mentioned only for completeness.

Endoscopic procedures are becoming increasingly common in the management of advanced malignancy. The primary indication is dysphagia without complete obstruction. The goal of therapy is restoration of the esophageal lumen with return or improvement of enteral intake.

Dilation

Endoscopic dilation offers a temporary relief of symptoms. Generally, the therapeutic effects of dilation last a couple of days to 2 weeks.² This method of palliation is used primarily to allow access for other modalities or in patients with short-term life expectancies. The benefits of esophageal dilation are its low cost and immediate effectiveness. There are several modes of esophageal dilation including mercury-weighted rubber bougies (Maloney dilators), hydrostatic and pneumatic endoscopic balloon dilators, and wire-guided poly-vinyl bougies (Savary dilators). To date, there are no large trials comparing the types of esophageal dilation. Hernandez and colleagues published a report comparing the types of dilation used and their associated complications. In their series of 142 patients, four patients experienced a perforation during dilation. All four patients were dilated blindly with a Mahoney dilator and had complex strictures defined by having one or more of the following: asymmetry, diameter of less than or equal to 12 mm, malignancy, caustic esophagitis, sclerotherapy for esophageal varices, surgically altered anatomy, or associated esophageal diverticulae.³ However, while there is a reported perforation risk of approximately 5%, dilation remains an acceptable short-term palliative therapy for malignant esophageal strictures.⁴

Ablative Techniques

There are many ablative techniques available for palliation of malignant strictures. Energy types that are used include: electrocoagulation, argon plasma coagulation (APC), photodynamic therapy (PDT), Nd:YAG laser ablation, or endoscopic spray cryotherapy.

Electrocoagulation offers heat destruction of tumor cells and bipolar electrocautery (BICAP) is the method often used. Benefits include a relatively lower cost than that of laser therapy or PDT and short onset to effect. Perforation, fistula formation, and bleeding are reported complications. Delayed hemorrhage has been demonstrated up to 2 weeks following the procedure.⁵ Generally, more than one treatment is required to obtain restoration of the esophageal lumen.⁵

Argon plasma coagulation is another method for topical destruction of inoperable esophageal strictures with an 85% overall response rate.⁶ APC involves the passage of argon gas through the endoscope while the probe is held a short distance away from the lesion. Monopolar current is then conducted through the gas and allows for heat destruction of the lesion. There are two types of APC used: forced and pulse. In a recent series comparing the two, response rates and complications were found to be similar with a shorter treatment time in the forced group.⁶ The most common complication seen with APC is bleeding.⁶

Photodynamic therapy has also been used for palliation of esophageal cancer with 91% improvement in dysphagia scores 4 weeks following treatment.⁷ It involves the systemic injection of a photosensitizing agent followed by light activation with the designated wavelength as determined by the photosensitizing agent selected. Activation of the photosensitizing agent results in the formation of oxygen-free radicals, which precipitate destruction of the tumor cells. Treatment results in the topical ablation of the tumor. The photosensitizer is primarily taken up by the tumor cells allowing for a selective destruction of tumor tissue. One of the advantages to this approach is the ability to treat large areas. Generally, patients require more than one treatment to reach desired effect, but results are seen quickly following treatment. The complications of this approach are photo sensitivity, perforation, fistula, stricture formation, and pleural or pericardial effusion. The photo sensitivity can be profound, requiring patients to avoid direct sunlight for up to 8 weeks.^8–10 In a selected group of patients, Lindenmann et al¹¹ reported an extension in median survival from 17.3 months to 50.9 months when PDT was used as a first-line therapy in patients with inoperable esophageal cancer. The disadvantages to this therapy include the need for repeated therapies, cost of the procedure, and equipment required.

Neodymium Yttrium Aluminium Garnet Laser (Nd:YAG) is another endoscopic modality used to treat esophageal malignancy with a 92% return to regular diet.¹² Targeting is completed via a low power helium-neon laser, and the beam is channeled down a flexible endoscopic fiber. Laser therapy is best for short-segment exophytic tumors. Similar to the other ablative techniques, it requires multiple treatments to reach desired effect. The complications associated with it are perforation and fistula formation. Stricture can be seen if it is not used for exophytic tumors or if used on long-segment tumors. Carter et al¹² reported a series of 141 patients treated with Nd:YAG laser with 92% of patients returned to a semisolid diet or better, and 80% of patients continuing to tolerate a semi-solid diet or better until death. Perforation was reported in 6.4% of cases and tracheoesophageal fistula in 2.8%.^2,12 Two clinical trials have compared Nd:YAG to PDT. Equivalent outcomes were seen for resolution of dysphagia. However, complications were reported more commonly after PDT but the resolution of dysphagia was more long-lasting with PDT.¹³

Endoscopic spray cryotherapy has been used as a topical ablative therapy. Liquid nitrogen is passed through a 7F catheter placed through the side port of a standard endoscope and sprayed onto the tissue in a noncontact technique. The liquid nitrogen causes topical destruction of the luminal tumor. Proponents of the technique site are less scarring than that associated with heat-based therapies. Response is quoted as 60% with intraluminal disease. Stricture was the primary associated side effect.¹⁴

Local Injection

Local injection of sclerosing agents into the tumor has also been attempted. Ethanol injection has been reported in many studies. The benefits to this method are the cost, which is significantly decreased compared to other endoscopic methods. The palliative results are temporary, with reports averaging around 30 days between required treatments. Complications associated with this method are mediastinitis from tracking of injections and tracheoesophageal fistula formation.^15–17 Similarly, there are reports of using cisplatin/epinephrine injectable gel with modest results. Patients were given weekly injections for up to 6 weeks. There was a report of tracheoesophageal fistula formation with this method as well.¹⁸

Endoluminal Stents

Esophageal stents are a commonly used method for palliation of esophageal cancer with a 95% reported improvement in dysphagia.¹⁹ Table 91-2 includes a list of commercially available stents in the United States.^20,21 The effect of stenting is immediate and long-lasting. Covered stents are the treatment of choice for tracheoesophageal fistulas. They are more commonly used in the middle and lower esophagus, but more recently, there have been reports of using stents in the cervical esophagus.²² Available stents include rigid plastic stents and self-expanding metal stents (SEMS). Previously, SEMS were uncovered and associated with tumor ingrowth. Presently, most SEMS are completely or partially covered. SEMS are relatively more expensive than the plastic variety, but are felt to be superior due to overall outcomes and complications. Plastic stents are favored if the stent is intended to be temporary and will require removal. SEMS are placed and, as the name suggests, expand over the subsequent 24 to 48 hours. This expansion is associated with increased chest pain following placement of a SEMS. Immediate complications associated with both types of stents are perforation, bleeding, aspiration pneumonia, and severe pain. Both types of stents are also susceptible to delayed complications including migration, severe reflux when placed across the lower esophageal sphincters, obstruction, and recurrence of dysphagia, but SEMS have a lower reported incidence of complications.^23–25. The cost of the rigid plastic stents is lower when compared to SEMS; however, when late complication and reintervention rates are considered, the costs are equivalent.²³ When compared to ablative techniques, palliative results from stents are believed to be longer-lasting, with persistent improvement past 8 weeks.²⁵