Palliation of Esophageal Cancer

Key Points

• Self-expanding metal stents provide rapid relief from dysphagia.
• Lasers control bleeding and relieve proximal esophageal obstruction.
• Thermal Nd:YAG laser provides rapid palliation
• Cryospray ablation is a promising new tool
• PDT laser provides the best hemostasis.
• All endoscopic therapies are complementary.

The American Cancer Society estimates that 21,560 new esophageal cancers will be diagnosed in 2023 and 16,120 patients with esophageal cancer will die from the disease.[1][2] Esophageal cancer is the sixth leading cause of cancer related mortality worldwide with approximately 600,000 new cases annually and more than 80% of cases occur in developing countries.[1] Although the overall survival from esophageal cancer has improved over the last decade, the long-term prognosis remains poor with a 5-year survival of 21% for all stages combined.^[3] Survival rates are better with early stage disease but less than half of the patients will be eligible for potentially curative resection at the time of presentation.^[4] For patients who are candidates for resection the majority will undergo neoadjuvant therapy. Based on outcomes between 2012 and 2016 in the SEER database 5 year survival for localized disease is 47% but for regional disease and distant disease the survival rates drop to 26% and 6% respectively.[4] Most often patients present with dysphagia and weight loss; thus, the majority of patients may be candidates for palliative interventions to improve their swallowing, allow adequate oral intake, and reduce the risk of aspiration pneumonia. An ideal palliative treatment will allow a rapid return to oral intake and can be easily applied with low morbidity and a minimal hospital stay.

Palliation of dysphagia is usually reserved for advanced stage, patients not candidates for curative treatment, or recurrence of disease. Patients with dysphagia at diagnosis but with minimal nutritional deficits, who are candidates for chemotherapy or chemoradiation therapy, usually respond to therapy and will not need initial interventions for dysphagia. Chemotherapy can palliate dysphagia but the time to relief of dysphagia is weeks to a month or more. A significant number of patients however with a very tight stricture (Figure 1) - will need endoscopic interventions to improve oral intake and nutritional status as the first step in their treatment algorithm to support them through their induction therapy prior to definitive and potentially curative surgical therapy. Likewise patients with localized esophageal cancer who have peristent localized disease after chemoradiothrepy and who are not physiologic candidates for esophagectomy may also require endoscpic intervertions for locally recurrent disease. Most endoscopic therapies vary considerably in their durability but share in common a fairly brisk initial improvement in dysphagia. After improvement in oral nutrition, performance may improve and other therapies may be tolerated.

Figure 1A

Radiologic (a) and endoscopic (b) appearance of a tight malignant stricture involving the distal esophagus.

Figure 1B

Radiologic (a) and endoscopic (b) appearance of a tight malignant stricture involving the distal esophagus.

In this chapter we review all the commonly employed methods for endoscopic palliation of malignant dysphagia. In general, these methods deliver rapid relief and allow intake of a soft to regular diet with some modifications depending on the individual. Some limitations in oral diet are still required, but most patients will be able to avoid the need for feeding tubes. While endoscopic or surgical feeding tubes will afford nutritional support they are considered poor palliation as they do not allow for any oral intake and the patient may not even have the opportunity to clear their own saliva. The durability of the relief of dysphagia is variable, depending on the method used and the progression of the disease at the locoregional level. Many patients who live longer than a few months will need some form of reintervention to maintain relief. On a rare occasion, in a patient with very good performance status with incurable disease, esophagectomy may be indicated for palliation when other interventions fail. A study comparing outcomes of patients who underwent esophageal bypass surgery versus stent insertion between April 2016 and 2021 examined diet resumption, length of hospital stay as well as post-operative complications. Post operative respiratory compications, post operative length of stay, and interval until initiation of systemic cancer therapy was all longet in the surgical group. In-hospital mortality was 9.3% in the surgical bypass group and 0% in the stent group.[5] Choosing a palliative option has become a complex and dynamic decision-making process given the number of variables to consider. The extent of disease, the cost-effectiveness, the durability of the approach, and the predicted life expectancy of the patient should be considered when deciding upon an appropriate palliative option. Local expertise also is a factor in decision making.