INTRODUCTION — Esophageal cancer is often diagnosed at an advanced 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 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 [1]. 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 [2]. 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 "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 [4]. However, repeat dilatation is usually required every two 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].

LASER THERAPY — Laser therapy with neodymium-yttrium-aluminum-garnet (Nd:YAG) had been the traditional form of palliative treatment for esophageal cancer [9], but subsequent studies suggest that photodynamic therapy offers advantages over laser therapy [10,11]. (See 'Photodynamic therapy' below.)

ABSOLUTE ALCOHOL INJECTION — Injection of absolute alcohol into a tumor is a chemical method of ablating esophageal cancer [12-14]. The advantages of this technique are that it is the least expensive method, it uses equipment that is readily available, and the method of injecting alcohol is similar to that used during free-hand injection of esophageal varices.

The disadvantages are that there is relatively little experience with this method and there are potential complications, including chest pain, mediastinitis, tracheoesophageal fistulas, and perforation, which is possibly due to the uncontrolled tracking of the sclerosant along tissue planes. Overall duration of palliation tends to be short, and additional endoscopic sessions are often needed [14].

INTRATUMORAL INJECTION OF CISPLATIN/EPINEPHRINE GEL — An approach to minimally invasive palliation of tumors of the upper aerodigestive tract is local injection of a chemotherapy-containing gel directly into the tumor. In pilot studies, an objective tumor response and improvement in dysphagia following multiple injections was observed in some patients [15-17]. The utility of this approach might be enhanced if used in conjunction with other therapeutic options, a strategy that requires further study.

PHOTODYNAMIC THERAPY — 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, Lederle Parenterals, Carolina, PR), 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 [18].

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.

Palliation of dysphagia in advanced disease — Initial trials in esophageal cancer have demonstrated that PDT provides significant palliation from dysphagia in patients with advanced disease or locoregional failure after chemoradiotherapy [19,20]. In a preliminary report of 10 patients with residual or locally recurrent disease following definitive chemoradiotherapy, seven had a complete clinical response from PDT, three of whom remained progression-free at six months [20].

PDT is technically easier than neodymium-yttrium-aluminum-garnet (Nd:YAG) laser therapy and is better tolerated by patients. The expense of PDT is similar to traditional laser therapy due to the expense of the Photofrin and because it requires sophisticated equipment.

●In a comparative trial of PDT and laser therapy, PDT was more effective for palliation and associated with fewer complications [18]. PDT was particularly superior to laser therapy for proximal esophageal cancers and was twice as effective at providing longer luminal patency in long malignant strictures (larger than 8 cm).

●In a prospective, randomized trial involving 236 patients, PDT and laser therapy had similar overall efficacy in terms of dysphagia relief, although there was a trend toward a better response with PDT for tumors located in the upper and middle third of the esophagus and for long tumors [21]. PDT was associated with fewer perforations than with the Nd:YAG laser (1 versus 7 percent), although treatment with PDT was limited by photosensitivity (sunburn in 19 percent.) Termination of sessions due to adverse events occurred in 3 percent with PDT versus 19 percent with laser therapy.

The most common side effects with PDT in these studies were chest pain and worsening dysphagia. These complications gradually resolved over several weeks, except for a small percentage of patients with stricture development. 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 are being developed and may be the future of PDT therapy [22].

PDT is less commonly utilized for the palliation of malignant dysphagia with the widespread availability of newer self-expanding metal stents for esophageal cancer. PDT can be used to treat tissue ingrowth or overgrowth in patients who have already undergone esophageal stenting. PDT has also been studied in combination with argon plasma coagulation (APC). (See 'Argon plasma coagulation' below.)

Inoperable patients with early stage disease — Another potential use of PDT is for patients with early stage disease who pose a high surgical risk, or those who refuse surgery [23,24]. 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 [23].

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 [25]. The most common complication was bleeding. (See "Argon plasma coagulation in the management of gastrointestinal hemorrhage".)

Outcome data for APC compared with stent placement are limited [26]. 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 [27]. 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 to cause cryonecrosis and has been used to palliate esophageal cancer [28-30]. In a series of 49 patients with inoperable esophageal cancer, endoscopic cryotherapy was associated with improvement in dysphagia [30]. Major adverse events included benign stricture requiring dilation (one patient) and dilation-related perforation that occurred prior to a cryotherapy session (one patient). In another series of 79 patients with esophageal cancer, a complete intraluminal response was seen in 31 of 49 patients (63 percent) who completed therapy (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 [29].

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 [31]. This topic is discussed in detail elsewhere. (See "Endoscopic stenting for palliation of malignant esophageal obstruction".)

BRACHYTHERAPY — Brachytherapy refers to the placement of a radioactive source within or in close proximity to a malignancy in order to provide local radiation therapy. This approach delivers the highest doses of radiation in close proximity to the tumor and thus offers a theoretical advantage over external beam radiation therapy. It can provide long-term palliation of dysphagia, although its role is not yet well defined. (See "Management of locally advanced, unresectable and inoperable esophageal cancer".)

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 5^th to 6^th 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 10^th to 12^th 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 — 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

There are several endoscopic approaches to providing palliation from malignant dysphagia:

●Dilation

●Endoscopic injection therapies

●Photodynamic therapy

●Argon plasma coagulation (APC)

●Cryospray ablation

●Placement of prosthetic tubes (stenting)

●Brachytherapy

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.