There are 10,000 cases of esophageal cancer per year in this country, and, unfortunately, most of those are un-resectable at time of presentation. The five-year survival was quite poor, and the life expectancy averages about six months in patients with un-resectable disease. Now as endoscopists, and physicians, our goal is to relive the most bothersome symptom for the patient, that is, the one that affects their quality of life most significantly, and that is dysphagia, and at the time providing nutritional access and also a means to prevent aspiration.
In the modern era it is important to at least consider now radiation therapy. There are special protocols designed to shrink tumors rapidly over a short period of time, such as over ten fractions, but importantly, the response rate is quite variable especially for the responses for adenocarcinomas. The time to see tumors shrink is also quite variable. It can take as long as six weeks, even in the responders, before you’ll get a significant effect – although the duration is usually around the time of five or six months where the benefit will be maintained. Importantly, stricture formation in patients who have radiation therapy can be a significant complication where endoscopic therapy is again called upon.
Since the advent of the fiberoptic endoscope, a number of interventional technologies have evolved, and listed here in the order in which they appeared. Dilation therapy, simply using a bougie or a balloon dilator is simple, quite easy to perform, but as you would imagine, the benefit is quite short-lived and typically, repeated dilatations are necessary. Aggressive dilatation can result in a dilatation in up to a quarter of the patients. Injection therapy is also quite simple, technically. You basically inject absolute alcohol or some other solutions into a kind of fleshy, soft, exophytic tumor where it works the best, and you may see some fluffage which occurs with that. But again, as you can imagine, with extensive fibrotic circumferential tumors this therapy doesn’t work very well.