Obstructive Esophageal Cancer Research Articles

I-125 seed-loaded versus normal stent insertion for obstructive esophageal cancer: a meta-analysis.

IntroductionMalignant esophageal obstruction is usually caused by esophageal and other chest cancers. More than 80% of cases of obstructive esophageal cancer (OEC) have lost the chance of curative resection. Stent insertion is a first-line palliative approach used to treat incurable OEC.AimTo gauge the relative clinical efficacy of I-125 seed-loaded stent (ISS) versus normal stent (NS) insertion as a treatment for OEC.Material and methodsQuerying of the PubMed, Embase, and Cochrane Library databases was conducted to find all relevant studies published up to November 2020. The meta-analysis was undertaken using RevMan v5.3.ResultsWe identified 158 studies initially, eight (4 randomized controlled trials and 4 retrospective studies) of which were used in this meta-analysis. We found that the two groups exhibited the comparable pooled Δdysphagia scores (MD = 0.02; p = 0.80), stent restenosis rates (OR = 0.97; p = 0.89), stent migration rates (OR = 0.81; p = 0.63), severe chest pain rates (OR = 1.05; p = 0.81), hemorrhage rates (OR = 1.53; p = 0.16), aspiration pneumonia rates (OR = 0.72; p = 0.38), and fistula formation rates (OR = 1.47; p = 0.44). The pooled time-to-restenosis and survival were both significantly longer in the ISS group (p = 0.04 and < 0.0001, respectively). Significant heterogeneity was detected in the endpoints of Δdysphagia scores and survival (I2 = 73% and 86%, respectively). Funnel plot analysis indicated an absence of publication bias related to the selected study endpoints.ConclusionsFor patients with OEC, our meta-analysis indicated that ISS insertion could provide longer stent patency and survival than NS insertion.

Photodynamic Therapy for Gastrointestinal Cancer.

The clinical application of photodynamic therapy (PDT) for gastrointestinal (GI) neoplastic lesions has been developed with appreciation for the great efforts and kind support of Dr. Tom Dougherty and his followers' contributions. There are several published studies on clinical PDT in the field of GI oncology. Esophageal cancer was one of the first clinical indications for PDT that was approved as an endoscopic procedure in both the United States and Japan. PDT was initially used as a palliative local treatment for patients with obstructive esophageal cancer. PDT is also indicated for eradicative therapy for dysplastic Barret's esophagus, which is the precursor state of esophageal adenocarcinoma, with the support of level one evidence. In Japan, PDT was approved as a curative treatment for superficial esophageal carcinoma lesions, which are difficult to treat with endoscopic resection. Further, PDT using second-generation photosensitizers is approved for early local failure after radiotherapy, for which treatment with other modalities is difficult. PDT has also been assessed in other GI cancers, including gastric cancer, biliary cancer and pancreatic cancer. In this review, we overview the history and state of PDT for GI cancer.

Clinical Efficacy of HiPorfin Photodynamic Therapy for Advanced Obstructive Esophageal Cancer.

Objective:To explore the clinical efficacy of HiPorfin photodynamic therapy for advanced esophageal cancer and evaluate its impact on survival.Methods:Retrospective analysis of 32 patients with advanced obstructive esophageal cancer at our institution from September 2013 to December 2016. HiPorfin was infused as the photosensitizer at a dose of 5 mg/kg, and after 48 hours, 630-nm laser irradiation was subsequently performed through an optical fiber that passed through the biopsy channel of a flexible endoscope.Results:The effectiveness rate was 78.1% (25/32), and the significant efficacy rate was 56.3% (18/32). The dysphagia score decreased from 3.43 ± 0.73 to 1.79 ± 0.53 (P < .05). There was no grade 3 or more toxicity. The median overall survival was estimated to be 16 months. Univariate analysis showed higher overall survival with a Karnofsky Performance Status score ≥80 compared with a Karnofsky Performance Status score <80 (hazard ratio: 2.626; 95% CI: 1.091-6.322; P = .024). Overall survival was higher in patients who had received radiation therapy than in patients who did not receive radiation therapy (hazard ratio: 3.574; 95% CI: 1.501-8.510; P = .002).Conclusion:Photodynamic therapy is an effective method for advanced esophageal cancer. The side effects are mild, and the short-term effect is good, especially in the relief of dysphagia. Photodynamic therapy can prolong the survival of patients with advanced esophageal cancer, and the Karnofsky Performance Status score and previous radiation therapy have a significant effect on the overall survival.

Role of photodynamic therapy in the treatment of esophageal cancer.

Photodynamic therapy (PDT), a treatment of choice for cancer, induces a photochemical reaction, thereby eradicating tumor cells. This is achieved through the administration of a photosensitizer drug, which is activated with a laser after localization to the tumor mass, and is an approved curative endoscopic ablative treatment for superficial esophageal squamous cell carcinoma (ESCC) in Japan. PDT has been approved for dysplastic Barrett's esophagus and as a palliative treatment for patients with symptomatic obstructive esophageal cancer in US. However, its adverse events and complicated procedure and the development of alternative endoscopic procedures such as endoscopic submucosal dissection, radiofrequency ablation and cryotherapy, have largely limited the practice of PDT in esophageal cancer worldwide. Recently, owing to the invention of second-generation PDT using talaporfin sodium and diode laser, PDT can be performed with less phototoxicity and therefore has regained popularity in the treatment of ESCC. As a salvage treatment for patients with local failure after chemoradiotherapy (CRT), PDT has shown promising complete response with less phototoxicity and shorter sun shade period. In addition, the efficacy and safety of PDT in patients with local failure of ESCC after CRT were shown in several clinical trials. The direction of the study interest of the next-generation PDT is the safety and potential expansion of the indications for its application in the future. This review covers the PDT for the treatment of ESCC and dysplastic Barrett's esophagus, with special focus on the role of PDT in practice for esophageal cancer.

Palliative treatment of obstructive esophageal cancer by vascular targeted photodynamic therapy (VTP): Preclinical study in orthotopic rat model.

59 Background: Vascular targeted photodynamic therapy (VTP) based on local sensitization of circulating WST11 (Pd-bacteriochlorophyll), enables effective focal ablation of solid tumors. WST11 clears from the circulation with t1/2 ~40 min (in humans) and does not accumulate in tissues which assures high level of safety and minimal adverse effects. Here we evaluate WST11-VTP for the treatment of obstructive esophageal cancer aiming at developing clinically relevant protocol. Methods: Using endoscopy guided procedure rat esophageal cancer cells (JA) were implanted in the mid esophagus. Following intravenous infusion of WST11, established tumors were illuminated by cylindrical fiber using the same endoscope sleeve. Safety and efficacy were evaluated by monitoring animal weight shift and histology of treated esophageal tissues. Treated animals included control (light/no WST11 or WST11/no light), WST11-VTP and WST11-VTP following treatment with bevacizumab at day -3. Results: WST11-VTP on esophageal tissues resulted in coagulative necrosis of the tumor graft and prolonged survival as evident by Kaplan—Meyer curves. The impact was confined to the illuminated site without signs of perforation or death. Following Bevacizumab, WST11-VTP showed similar results while control groups showed no effect. All treated animals started to regain weight at day 7 after VTP. Esophageal tissue and function was completely restored. Conclusions: WST11-VTP could be safely applied for the treatment of esophageal tumors, with only transient and mild adverse effect that are not affected by previous, clinically relevant treatment such as Bevacizumab application. Importantly, VTP effectively eradicated established esophageal tumors and could be translated into a clinical treatment protocol.

Gradual tube dilation method before percutaneous endoscopic gastrostomy for obstructive esophageal cancer

In patients with obstructive esophageal cancer (OEC) with stenosis of the tract to the stomach, the percutaneous endoscopic gastrostomy (PEG) procedure cannot be performed if the endoscope is unable to pass through to the stomach. Our aim was to describe the safety and utility of the gradual tube dilation method (GTD) before PEG in cases of OEC. This study enrolled 38 consecutive patients. If an ultrathin transnasal endoscope (UTNE) could successfully reach the stomach through the esophageal stenosis, then PEG was performed without using the GTD. If even the UTNE could not be passed to the stomach, PEG was performed after the GTD. The GTD shows the method that gradually increases the size from an 8 Fr to 16 Fr nasogastric tube which passed through the obstruction before performing PEG. We conducted a retrospective review of all patients who received the GTD. The complications were examined from the first UTNE to the completion of PEG. Seventeen of 38 patients received the GTD. All 17 patients successfully underwent the PEG procedures. The intubation period was 9.8 ± 3.4 days. The mean number of replacements was 2.5. Regarding complications, only three of the 17 patients experienced a sore throat. No significant differences were found in the PEG procedure times between the patients with the GTD and those without the GTD (P = 0.360). If patients with progressive esophageal cancer, such as OEC, need to undergo PEG, then the GTD is considered to be a useful modality for dilating the stenosis simply and safely.

Self-Expanding Covered Metallic Stent as a Bridge to Surgery in Esophageal Cancer: Impact on Oncologic Outcomes

Self-expanding metallic stents (SEMSs) have been used as a bridge to surgery, relieving dysphagia and maintaining nutrition, in patients with operable but obstructive esophageal cancer (EC). However, the impact of SEMSs on oncologic outcomes is unknown. The aim of this study was to evaluate the impact of SEMS insertion before EC surgery on oncologic outcomes. From 2000 to 2010, two thousand nine hundred and forty-four patients who underwent an operation for EC with a curative intent were included in a multicenter European cohort. Through propensity score analysis, patients who underwent SEMS insertion (SEMS group, n= 38) were matched 1:4 to control patients who did not undergo SEMS insertion (control group, n= 152). The SEMS and control groups were comparable according to age, sex, tumor location, clinical stage, American Society of Anesthesiologists score, dysphagia, malnutrition, neoadjuvant treatment administration, histology, and surgical procedure. Self-expanding metallic stent insertion was complicated by tumoral perforation in 2 patients. The in-hospital postoperative mortality and morbidity rates for the SEMS vs control groups were 13.2% vs 8.6% (p= 0.370) and 63.2% vs 59.2% (p= 0.658), respectively. The R0 resection rate (71.0% vs 85.5%; p= 0.041), median time to recurrence (6.5 vs 9.0 months; p= 0.040), and 3-year overall survival (25% vs 44%; p= 0.023) were significantly reduced in the SEMS group, and the 3-year locoregional recurrence rate was increased (62% vs 34%; p= 0.049). The results remained significant after excluding SEMS-related esophageal perforations. After adjusting for confounding factors, SEMS insertion was a predictor of poor prognosis (hazard ratio= 1.6; p= 0.038). Self-expanding metallic stent insertion, as a bridge to surgery, has a negative impact on oncologic outcomes in EC. Clinicaltrials.gov ID: NCT 01927016.

Radiation treatment for newly diagnosed esophageal cancer with prior radiation to the thoracic cavity

The purpose of this report is to communicate the use of single-positron emission computed tomography scan in planning radiation treatments for patients with a history of radiation to the thoracic cavity. A patient presented with obstructive esophageal cancer, having previously received chemotherapy and radiation therapy to the mediastinum for non-Hodgkin lymphoma 11 years earlier. Owing to a number of comorbidities, the patient was not a surgical candidate and was referred to the University of Washington Medical Center for radiation therapy. Prior dose to the spinal cord and lung were taken into account before designing the radiation treatment plan.

Photodynamic Therapy: Establishing Its Role in Palliation of Advanced Esophageal Cancer

See Article on Page 278-284 Photodynamic therapy (PDT) is a unique treatment modality that uses photosensitizers activated by light. Photosensitizers accumulate in malignant tissue, and light energy is used to destroy cancer cells by production of activated oxygen [1]. There are three main steps in PDT: injection of photosensitizers, activation of photosensitizers by endoscopy-guided red light application, and cell death by production of active oxygen [2]. PDT is comprised of three separate components: the photosensitizer, light source, and light delivery system [3]. PDT was first used in the treatment of esophageal cancer in the 1980s [4]. Since then, its indications have been broadened to include treatment of gastric biliary colon and other non-gastrointestinal malignancies such as skin cancer and lung cancer. Of course, the treatment of choice in esophageal cancer is surgical or endoscopic resection of the malignant tissue. In reality, 40% to 50% of patients diagnosed with esophageal cancer have a cancer lesion that is not completely resectable [5]. Therefore, when disease cure is not expected, palliation with improvement in the patient's quality of life becomes the next priority. In advanced esophageal the biggest problem arising from esophageal lumen obstruction by the ingrowing tumor mass is and difficulty maintaining sufficient nutritional support. For palliation of esophageal many treatment modalities have been used, such as dilation of the lumen with self-expanding metallic stents (SEMS), radiation therapy, chemotherapy, brachytherapy, and argon plasma coagulation. Of all of these treatment methods, insertion of a SEMS into the esophagus has been the primary treatment and is a widespread practice [6]. Nevertheless, restenosis of the esophageal lumen due to tumor ingrowth and overgrowth warrants an additional procedure or another treatment modality. In the current article entitled Role of photodynamic therapy in the palliation of obstructing esophageal cancer, the authors describe the effect of PDT as part of a multimodal treatment strategy for palliation of esophageal lumen obstruction in advanced esophageal cancer [7]. They enrolled 20 patients with obstructive esophageal cancer who all had dysphagia. After primary treatment with PDT, the patients were given additional treatment with external beam radiation therapy or SEMS for palliation of dysphagia, which was the main goal of the treatment. The results of the study showed significant improvement of dysphagia, numerically described as the dysphagia score. Only two of the total enrolled patients showed major complications (i.e., esophageal stricture), and these patients were treated by placing a stent across the stricture. The authors achieved a mean dysphagia-free interval of 81 days. Although the study was a non-randomized, single-arm study, the results are very promising. Improvement of the score in 90% of patients indicates that a better quality of life was achieved by most of the patients who received PDT as part of the multimodal treatment. Other recent studies have stated that PDT can be used as an effective treatment modality in combination with other techniques, such as stents and radiation therapy for palliation of obstructive esophageal alleviating [8-10]. These results, including those in the current article, show that PDT is becoming established as a treatment of lumen-obstructing advanced esophageal cancer. In terms of treating difficult lesions, PDT has a significant advantage, compared with stents, in treating advanced esophageal cancer. When the lesion is located at the cervical esophagus, which can cause a foreign body sensation and pain, or at the gastroesophageal junction, when stent migration and symptoms due to reflux can frequently occur, PDT can be an appropriate solution. Indeed, PDT is more expensive than other treatment modalities. In the future, studies comparing the cost-effectiveness of PDT with other techniques such as stents are warranted. To achieve a better effect and gain more ground in terms of treatment indications, new photosensitizers with fewer side effects and light delivery systems allowing for deeper penetration are needed. With improvement in procedure equipment and further larger, randomized trials, the status of PDT, as an established therapeutic choice in the treatment of will be confirmed.

Cryotherapy with Uncovered Metal Stent for Palliation of Obstructive Esophageal Cancer

Purpose: This is a case report of palliation of dysphagia from obstructive esophagus cancer using an uncovered metal stent to avoid migration and to allow access for cryotherapy to the tumor. An 85 year old male presented 2 years ago with dysphagia due to obstructing lower esophageal adenocarcinoma. He was not a candidate for surgery and refused chemoradiation therapy. His dysphagia was treated with multiple courses of cryotherapy and dilation. However his esophagus stricture progressed. Additionally, the distal portion of the tumor could not be reached with cryotherapy due to the esophageal obstruction. Furthermore, two attempts of fully covered metal stents placement were complicated with migration to the stomach. After obtaining informed consent, we placed an uncovered metal stent across the tumor (Figure 1). One week after expansion of the stent, cryotherapy was performed using C02 system with 0.005 inch forward-firing flexible catheter, gas flow (6-8 liters/minute), 10-15 seconds of ice effect x 4 applications with thaw (Figure 2). Cryotherapy was able to be delivered to tumor through the uncovered stent. Subsequently, cryotherapy was repeated every 6 to 8 weeks The stent provided rapid relief of dysphagia. The ingrowth of tumor was controlled with cryotherapy. Patient gained 10 pounds and has been symptom free for six months since placement of the uncovered metal stent. For patients with inoperable obstructing esophageal cancer, who are not candidates for standard therapy, combined approach of using uncovered metal stent and cryotherapy provides immediate dysphagia relief and access for continued cryotherapy. A clinical trial using this technique is warranted (we are initiating a cryo/stent trial).Figure: No Caption available.Figure: No Caption available.

Complete obstructive esophageal cancer with esophagopleural fistula successfully treated by combined antegrade and retrograde rendezvous technique

Complete obstructive esophageal cancer with esophagopleural fistula successfully treated by combined antegrade and retrograde rendezvous technique

Self‐expandable metal stents and trans‐stent light delivery: Are metal stents and photodynamic therapy compatible?

Obstructive non-small cell lung cancer and obstructive esophageal cancer are US FDA approved indications of photodynamic therapy (PDT). The usefulness of PDT for the treatment of cholangiocarcinoma is currently under clinical investigation. Endoscopic stenting for lumen restoration is a common palliative intervention for those indications. It is important to assess whether self-expandable metal stents are compatible with trans-stent PDT light delivery. Direct effects of various components of metal biliary (n = 2), esophageal (n = 2), and bronchial (n = 1) stents on PDT light transmittance and distribution were examined using a point or linear light source (630 or 652 nm diode laser). Resected pig biliary duct and esophageal wall tissues were used to examine the feasibility of PDT light delivery through the fully expanded metal stents. While using a point light source, the metal components (thread and joint) of the stent could cause a significant shadow effect. The liner material (polytetrafluoroethylene or polyurethane) could cause various degrees of light absorption. When the stent was covered with a thin layer of biliary duct and esophageal tissues containing all wall layers, the shadow effect could be mitigated due to tissue scattering. This study clearly demonstrates that it is feasible to combine stenting and PDT for the treatment of luminal lesions. PDT light dose should be adjusted to counteract the reduction of light transmittance caused by the metal and liner materials of stent.

Endosonographic Staging of Obstructive Esophageal Cancer: How Far Should We Go?

Objective: Endoscopic ultrasonography (EUS) is a valuable tool in staging esophageal cancer. TNM-staging accuracy decreases in stenotic esophageal cancer when visualization of the tumor is incomplete. Little is known about the best strategy in pre-treatment staging in stenotic esophageal cancer. In the USA patients are often carefully dilated to facilitate passage of a standard EUS instrument. In Europe patients are either staged using a slim ultrasonic probe, a miniprobe, or surgery is performed without complete endosonographic evaluation. To determine the optimal strategy we studied the outcome of patients with non-traversable esophageal cancer. Methods: Esophageal staging EUS examinations between 1999 and 2003 with a minimal follow-up of 6 months were analysed. Data were collected regarding location of stenosis, histology, operative results and outcome. The Olympus GF-UM20 radial echoendoscope (diameter 13.2 mm) was used. Results: 718 patients were analysed (70 % adeno; 30 % squamous). In 157 patients (22 %) the tumour could not be passed (65 % adeno; 35 % squamous; p=0.29). EUS staging in these patients was incomplete. Of these 157, 56 underwent primary surgery. Of these 56 patients, 23 (41 %) were irresectable due to local invasion (T4) or metastatic disease; 8 had liver or peritoneal metastases (M1b disease); 15 had T4 and/or M1a disease and could therefore have been detected by standard EUS with dilation or slim ultrasonic probe (65 %), or by miniprobe EUS (43 %). Of the remaining 33 patients, 24 underwent a microscopically radical resection (R0), 9 were microscopically irradical (R1). Disease-free survival after R0 resection was 46 % and after R1 resection 27 %. Overall 6 months disease-free survival was 27 % (15/56). Conclusions: The prognosis in severely stenotic esophageal cancer is poor. Maximal effort should be put in complete endosonographic staging since potentially 65% of primarily irresectable tumours could have been detected by EUS and surgery could have been avoided.

Intratumoral therapy of cisplatin/epinephrine injectable gel for palliation in patients with obstructive esophageal cancer.

Obstructing esophageal cancer produces severe dysphagia with ensuing death within 90 days. Palliation is possible with modalities like stent placement, laser, and photodynamic therapy. However, these treatments have a high rate of complications, and the overall mortality is not altered. A new alternative treatment evaluated in this study is endoscopic intratumoral injection with cisplatin/epinephrine (CDDP/epi) gel. CDDP/epi gel injections were administered weekly for 3 to 8 weeks in nine patients, median age, 72 years; mean tumor volume (+/-SEM), 41.44 (+/-22.4) cm3. Eight patients had stage IV, and one had stage III esophageal carcinoma. The mean dysphagia score (+/-SEM) was 3.5 (+/-0.17). All patients were followed up until death. Dysphagia resolved in eight patients with reduction in mean dysphagia score (+/-SEM) from 3.5 (+/-0.17) to 0.75 (+/-0.28; p = 0.005). Tumor volume was reduced by 75% in one patient and by 50% in two patients. The median survival was 4 months. The longest follow-up has been 15 months (458 days). In this pilot study, intratumoral injection of CDDP/epi gel restored swallowing in eight of nine patients and was an effective and safe outpatient treatment in patients with obstructive esophageal cancer.

7043 A new endoscopic strategy for the treatment of completely obstructing unresectable esophageal cancer.

OBJECTIVE:To determine the efficacy of photodynamic therapy as a treatment strategy in patients with unresectable esophageal cancer and completely obstructed esophagus.METHODS:The medical records of all patients treated with photodynamic therapy for unresectalble esophageal cancer at our institution were reviewed. Five patients with newly diagnosed, completely obstructive esophageal cancer were treated. None were candidates for surgical resection because of extensive or metastatic disease. Three patients had adenocarcinoma of the distal esophagus, and 2 had squamous carcinoma of the proximal esophagus. One of the latter patients also had an esophago-cutaneous fistula arising in the esophagus proximal to the tumor and exiting in the neck. In all cases the tumor was completely obstructing the esophagus and could not be transversed utilizing endoscopic or fluoroscopic methods. All patients were treated with two sessions of photodynamic therapy commencing 48 hours after the injecion of 2 mg/Kg of Photofrin. In all cases the photodynamic therapy light probe was pushed into the tumor mass for the treatments. Within several weeks of the treatments, all 5 patients underwent a successful endoscopic placement of an expandable covered metallic esophageal stent (Ultraflex) with no difficulty in order to insure long-term patency. RESULTS:In all 5 patients treated the esophageal tumor responded to the photodynamic therapy and allowed for a safe dilatation of the previously obstructing strictures. There were no treatment related complications and no long-term serious stent related complications. The 2 patients who had proximal stents did have respiratory complications due to the extent of their disease. The esophago-cutaneous fistula healed after treatment, and then the patient tolerated external beam radiation therapy to the site. CONCLUSIONS:We have successfully applied photodynamic therapy to completely obstructive esophageal carcinoma, and then insured future patency with the placement of an expandable covered metallic stent. In all patients the esophagus remained patent after the stent placement. There were no perforations or stent migrations noted.We report this treatment strategy as a safe palliative endoscopic alternative for patients with obstructing, unresectable esophageal carcinoma who cannot be stented because of a complete obstruction. In this group placing a stent within a few weeks of photodynamic therapy appears to be safe.

Photodynamic Therapy for Obstructive Esophageal Malignancies

Objectives Determine factors affecting survival rates, benefits and complications of patients with obstructive esophageal cancer treated with photodynamic therapy (PDT). Methods From 1982 to January 1998, we used PDT to treat 140 patients with obstructive adeno or squamous carcinoma and evaluated survival up to November 1998. All patients had failed, refused, or were ineligible for surgery, ionizing radiation or chemotherapy. The effect of different variables on survival was estimated using multivariate analysis. The Karnofsky Performance Status (KPS), weight, diet and complications were recorded and biopsies and brushings were taken at each endoscopy. At the beginning and end of each endoscopy the minimal diameter open of the esophagus, and the length, thickness and color of the tumor were recorded. Edema, exudate, bleeding, and mucositis were evaluated and recorded on an ordinal scale. Results The only significant variable affecting survival was the clinical stage. The median survival after PDT for all patients was 6.5 months (mean = 13.9). Kaplan–Meier survival after PDT curves were statistically significantly different when stratified by the clinical Stage at the time of PDT (p < 0.0001). Median survival (months) were for: Stage I = 56; Stage II = 12; Stage III = 6.5; Stage IV = 3.5. Analysis of each individual stage showed the KPS was the only confounding variable with a statistically significant effect on survival after PDT and this was only for Stages III and IV. The most significant effect occurred when the KPS was ≥ 70. For Stage III the median survival when the KPS was ≥ 70 was 7.7 months and for a KPS < 70 it was 5.0 months (p = 0.0001). For Stage IV the median survival when the KPS was ≥ 70 was 5.5 months and for a KPS < 70 it was 2.5 months (p = 0.0002). The mean minimum diameter open before PDT was 6.2 mm (median 6.0mm) and at the end of the PDT treatment endoscopy 11.1 mm (median 12.0 mm) for a mean increase in the minimum diameter open of 4.9 mm (median 5.0 mm) This was statistically significant using paired t-tests (p < 0.0001). Conclusions Photodynamic therapy for esophageal carcinoma caused minimal complications and procedure related mortality. Complete obstruction can be relieved by the end of the PDT endoscopy. The length of palliation for “non-curative” patients was equal to or better than that reported historically for most other treatment regimens.

Palliative Treatment of Esophageal Carcinoma Using Laser and Tumor Probe Therapy

Laser therapy and BICAP tumor probe therapy offer effective and safe means of palliating obstructive esophageal cancer. Future developments may allow more precise application of these techniques, based on more sensitive means of identifying abnormal tumor tissue. The development of endoscopic ultrasonography and the use of tissue sensitizing agents (such as hematoporphyrin derivatives) may allow more accurate means of differentiating normal from abnormal tissue. This may lead to more precise and extensive tumor destruction, less injury to normal tissue, and less potential for complication. As the use of both of these modalities becomes more widespread, their role in the treatment of esophageal cancer will continue to grow.

Gastrointestinal Laser Endoscopy—Future Horizons

The laser, especially the neodymium:yttrium-aluminum-garnet device, has been a dominant influence on the development of gastrointestinal therapeutic endoscopy. More than 2,000 such procedures were performed in the first 5 years of experience with laser endoscopy at the Mayo Clinic. The major areas for future development are (1) the control of acute and chronic gastrointestinal bleeding, (2) the palliation of malignant gastrointestinal neoplasms, and (3) the management of benign and malignant obstructive lesions of the biliary tract. Refinements in laser devices, delivery systems, and techniques such as photodynamic therapy will be needed to achieve more selective tissue destruction. Improvements in the new adjunctive endoscopic methods of electronic (video) endoscopy and ultrasonography may enhance evolving laser applications by more accurately identifying diseased tissues and guiding their destruction.

Endoscopic Ablation of Esophageal Malignancies With the Neodymium-YAG Laser and Electrofulguration

The case reports of 40 patients with obstructive esophageal cancer treated with electrofulguration (EF) or neodymium (Nd)-YAG laser were reviewed. Surgery was contraindicated because of advanced carcinoma (17 patients), recurrence after resection (13 patients), recurrence after irradiation (four patients), and poor medical condition (four). Two patients refused surgery. There were 31 men and four women; mean age was 62 years. There were 31 adenocarcinomas, eight squamous cell carcinomas, and one metastatic breast carcinoma. Tumor locations were lower esophagus in 35 patients, middle esophagus in three, and cervical esophagus in two. Thirty-five patients had obstructions; two, bleeding, and three, both. None of the patients could swallow solids. A total of 255 treatments were given (mean, 6.6 per patient). The mean number of Nd-YAG treatments was 1.9; for EF, 1.3. All 40 patients tolerated solid food after treatment and the esophagus remained open from three to 14 weeks. Mean survival from first treatment was 11 months; from diagnosis, 17 months. Both techniques were safe and effective.