Endoscopic Spray Cryotherapy for Esophageal Cancer: Safety and Efficacy

Abstract

Endoscopic spray cryotherapy is a novel technique for ablating dysplasia and malignancy in the esophagus. A previous small case series showed that cryotherapy is safe and can reduce or even eliminate localized esophageal cancer (EC). Aim: To assess the safety and efficacy of endoscopic spray cryotherapy in patients (pts) with localized EC. Methods: We performed a retrospective study of consecutive cases of spray cryotherapy performed for EC at 4 centers. Included were pts with localized (TxN0M0) EC treated with low pressure liquid nitrogen cryotherapy (CryoSpray Ablation, CSA Medical, Inc., Baltimore, MD). Pts refused, failed, or were ineligible for conventional therapies including esophagectomy, chemotherapy, or radiotherapy. Pts were generally treated with palliative intent. Treatment dosimetry was typically 20 second freeze for 3 cycles with at least 45 second thaws. All procedures were performed as an outpatient. Outcomes measured included complications (stricture, perforation, bleeding, death) and success (disease status, survival duration, ability to eliminate cancer). Results: Forty-four pts (73% male, 89% adenocarcinoma) were evaluated, median age 78.5 years (range 54-93). Tumor stage was T0 - 8 (18%), T1 - 22 (50%), T2 - 11 (25%), T3 - 1 (2%), unknown - 2. Mean tumor length was 3.6 cm. Previous treatments were EMR - 16 (36%), PDT - 10 (23%), radiation - 3 (7%), combined chemoradiation - 9 (20%), or chemoradiation/surgery - 1 (2%). 208 cryotherapy procedures were performed (mean 4.8/pt). Mean duration since initial treatment was 14.6 months (range 1-30). 20 pts completed treatment. Cryotherapy completely eliminated cancer in 16/20 (80%), with mean follow-up of 10 months after treatment. Final histology was normal - 8 (40%), intestinal metaplasia (IM) - 6 (30%), IM with LGD - 2, cancer - 3, unknown - 1. 17 pts continue cryotherapy for persistent disease. Mean treatment duration was 64 weeks (range 16-150). Of the 44 pts treated, 15 (34%) are alive and cancer-free, 1 (2%) died cancer-free from other causes, 7 (16%) died from EC, and 21 (48%) remain alive with cancer. No perforations occurred. Stricture was seen in 3 (7%), with mean of 4.3 treatments. No correlation was seen between number of cryotherapy treatments and development of stricture. 12 (27%) complained of pain requiring narcotic analgesia after treatment. Conclusion: Endoscopic cryotherapy ablation provides excellent palliation in locally advanced EC and is curative in a substantial proportion of subjects. Given its excellent side effect profile, spray cryotherapy provides an attractive option in EC pts with localized disease who are not eligible for or refuse traditional therapies.