Physician Newsletter published by the Allegheny Center for Lung and Thoracic Disease

Palliative management of esophageal obstruction

Background: A primary goal of treatment of patients with esophageal cancer is relief of esophageal luminal obstruction from the malignant process. Surgical resection is our preferred course of management for early-stage and regionally limited esophageal carcinoma in patients without significant medical infirmity. In addition to offering the possibility for cure of their disease, the surgical reconstruction of the alimentary tract following esophagectomy is quite effective in controlling the patient's difficulty swallowing.

Unfortunately, many patients with an obstructive esophageal carcinoma will present with disease that is already metastatic or regionally advanced so that surgical resection is not an option. Primary radiotherapy with or without concomitant systemic chemotherapy is a first line of management for these patients. Relief of the patient's difficulty swallowing may be only partially successful or not at all with these therapies.

A variety of palliative treatment options are available to the patient to aid in overcoming the esophageal obstruction and restoring oral alimentation for patients with unresectable esophageal carcinoma. These measures can be employed during their primary therapies (radiation and/or chemotherapy) to gain rapid relief of the dysphagia. The success with these measures depends upon the location and extent of the tumor and the patient's general state of well-being at the time of presentation. For the most part, these interventions are endoscopically based; however, an occasional patient with a good performance status may be a candidate for surgical bypass of the esophageal obstruction with the use of a substernal gastric interposition above the malignant lesion (see Figure 5A). Endoscopically based therapies used today include simple per oral dilation, Nd:YAG laser fulguration, endoesophageal radio-brachytherapy, endoscopic photodynamic therapy and esophageal stent placement across the obstruction. The use of these various modalities is not mutually exclusive and, indeed, we have simultaneously or sequentially employed a number of these approaches to aid our patients who have an obstructive esophageal carcinoma.

We will briefly describe the decision-making process behind the selection of these therapies and the relative palliative benefit one can expect to provide.

Esophageal dilation therapy Although simple bougienage (dilation) of the esophagus can be attempted, we prefer to use a wire-guided endoscopic approach to per oral dilation under fluoroscopic guidance. This allows for more precise control during the dilation process, which reduces the risk for perforation and im- proves the overall effectiveness of the intervention. Graduated dilation with wire-guided rubber dilators (bougies) is an effective approach if the dilation circumference of the esophageal lumen ultimately reached is greater than 40 Fr. An alternative method of wire-guided dilation therapy involves the use of a hydrostatic rigid balloon approach. This balloon dilation therapy can be accomplished by introducing the deflated wire-guided balloon through the biopsy channel of the fiber optic esophagoscope. A potential advantage of this endoscopic balloon dilation therapy is the direct visibility of the balloon expansion during the dilation process. The risk for iatrogenic esophageal perforation during the dilation procedure may also be less, as the forces of dilation are radial in nature as opposed to the axial shearing forces characteristic of the standard bougie technique. A possible disadvantage of the balloon dilation approach relates to the loss of tactile assessment of the tightness of the stricture, which is retained with the standard wire-guided bougienage approach.

Short strictures can be managed with reasonable short-term success using primary dilation therapy. Repeated dilations are the rule, and local progression of the malignant process tends to reduce the benefit over time. Long, angulated malignant strictures are poorly suited for primary dilation therapy, as the likelihood of complications is greater and the relief of dysphagia is less good. Additional palliative therapies described below should be combined with wire-guided dilation to achieve relief of dysphagia for long, complex strictures.

Nd:YAG laser fulguration therapy The Nd:YAG laser is a powerful coagulation and fulguration tool that allows for direct ablation of malignant tissues obstructing the esophageal lumen. This approach requires an endoscopist experienced in laser therapies. The possibility of laser perforation of the esophagus is always a concern. Relief of dysphagia associated with long, angulated strictures is often poorly controlled, and obstructive lesions of the proximal esophagus and gastroesophageal junction can be difficult to direct the laser fiber effectively without risk. The ideal location of an obstructing lesion chosen for Nd:YAG laser therapy is within the intra-thoracic body of the esophagus, where the laser can be applied parallel to the long axis of the esophageal lumen.

Treatment sessions are time-consuming, and the palliation of dysphagia achieved is often marginal. As with primary dilation therapy, other modalities such as endoluminal stenting or radio-brachytherapy are often combined with Nd:YAG laser therapy to achieve more meaningful and longer-term control of the patient's dysphagia.

Photodynamic therapy Photodynamic therapy combines the concept of selective absorption of a photosensitizing drug, porfimer sodium, by tumor cells and the activation of this agent within the cancer cells by a specific laser light wavelength (630 nm) to promote a chemical reaction within the cell that results in tumor cell death. Normal cells adjacent to the tumor and those elsewhere retain the chemical within them less strongly. This results in a relative sparing of normal cells next to the tumor and a more selective killing of tumor cells by the chemical reaction resulting from the laser light activation of the intracellular porfimer sodium. The porfimer sodium is administered intravenously 48 hours prior to the proposed endoscopic laser light therapy. After this period of time, the patient undergoes endoscopic delivery of the laser light through a fiber optic catheter advanced through the biopsy channel of the endoscope. Debridement of the dead tumor tissue is accomplished 48 hours after the light treatment at a subsequent endoscopic procedure. The laser light treatment can be repeated at this second endoscopic session, as some retention of porfimer sodium remains within the remaining tumor cells in the region. Successful relief of dysphagia from obstructing esophageal carcinomas appears to be equivalent to Nd:YAG laser therapy; however, the relative length of time that this palliation is sustained is less clearly defined.

The best results with photodynamic therapy are achieved with relatively short lesions located within the esophageal body. Long lesions and those near the gastroesophageal junction are less successfully managed. Lesions associated with significant gastrointestinal bleeding can also be problematic, as bleeding can be made worse once necrosis of the tumor mass occurs from the phototherapy.

The primary shortcoming of this mode of therapy is the general photosensitivity that the patient experiences for four to six weeks following the intravenous injection of the porfimer sodium. A significant sunburnlike reaction can occur if the patient is exposed to ultraviolet light (sunlight) during this post-injection period. The patient is given specific instructions by our clinical nurse specialist regarding the use of protective clothing, hand and head wear, and sunglasses so that such adverse reactions are avoided during this period of photosensitivity.

The photodynamic therapy can be repeated at two- to three-month intervals without sequelae if necessary. At the present time, this therapy is approved for the management of obstructing esphageal cancers. We and others are investigating the potential role of this modality for non-obstructing esophageal carcinomas and for carci- noma in situ associated with gastroesophageal reflux-induced Barrett's esophagus. The relative utility of these measures compared to conventional therapy is yet to be determined; however, the risk of benign esophageal stricture resulting from esophageal injury from the phototherapy may be a significant problem, limiting photodynamic therapy's overall utility in this setting.

Endoscopic radio-brachytherapy At the present time, remote high-dose endoesophageal radio-brachytherapy can be applied as an adjunct to the palliative modalities described. This therapy can be applied endoluminally even after a patient has received full-dose external beam radiotherapy to the esophageal lesion. The treatment is accomplished by placing a trans-oral afterloading catheter within the esophagus endoscopically or under flouroscopic guidance. After confirmation of appropriate catheter positioning, the patient is transported to the Radiation Therapy department where the high-dose radiation (Iridium-192) is delivered into the endoesophageal catheter for delivery of the radiotherapy. Usually, three to four outpatient treatment sessions are applied at weekly intervals to deliver the desired dose of radiation. We have found this to be a useful addition to endoesophageal laser therapy or stenting procedures for eosphageal cancer obstruction.

Esophageal stenting of obstructing esophageal carcinomas Stenting of an obstructing esophageal carcinoma can be accomplished using a variety of methods. Older approaches required exploratory laparotomy and gastrotomy to aid in the advancement of a semi-rigid prosthesis across the area of esophageal obstruction. The subsequent development of endoscopic "push" insertion techniques allowed for the introduction of silastic endoprostheses without the need for an "open" surgical intervention. These approaches were associated with a significant risk for esophageal perforation. These endoscopic approaches did allow for the treatment of tracheo-esophageal fistulas that may be associated with the obstructive process, but possible compression of the left main stem bronchus was a concern with these rigid silastic prostheses. Today, a variety of expandable wire stents are available that obviate the need for the more dangerous "push" method of stenting an obstruction. The expandable stents can be introduced alongside the fiberoptic esophagoscope and deployed without difficulty under fluoroscopic guidance.

We tend to use the esophageal stents as an adjunct to most of the palliative therapies mentioned above. These prostheses are well-tolerated and provide a more sustained palliation of the obstructive process without the need for numerous follow-up endoscopic procedures.

When a communication exists between the esophageal obstruction and the bronchial passages (tracheobronchio-esophageal fistula), this stent therapy can be lifesaving. When this condition exists, the patient is very prone to aspiration of esophageal secretions and swallowed liquids and food. This can ultimately lead to a serious pneumonia. Other therapies for the obstructing esophageal carcinoma may be contraindicated (i.e. Nd:YAG laser, photodynamic therapy and radiation therapy) when these fistulas are present, as such treatments can make the communication between the esophagus and lungs larger as the tumor is debulked.

Summary Palliation of the esophageal cancer patient's primary symptoms of dysphagia can be achieved while systemic and regional radiation therapy is being applied for patients with unresectable cancers. These interventions can also be used as temporary measures to relieve esophageal obstruction and afford oral alimentation while the patient is being nutritionally repleted prior to surgical removal of the carcinoma. The physician caring for the esophageal cancer patient should keep these palliative opportunities in mind so that the patient's nutritional status can be maintained while other primary treatments are under way. These measures can also improve the patient's quality of life during his struggle with esophageal cancer.

References

1. Mehran RJ, Duranceau A. The use of endoprosthesis in the palliation of esophageal carcinoma. Chest Surgery Clinics of North America 1994;331-346.

2. Nesbitt JC, Carrasco H. Expandable stents. Chest Surgery Clinics of North America 1994;331-346.

3. Webb WA. Esophageal dilation: Personal experience with current instruments and techniques. American Journal of Gastroenterology 1988;83:471-475.

4. Reed CE. Cancer of the esophagus: Clinical presentation and stricture management. In: Roth JA, Ruckdeschel JC, Weisenburger TH. (eds) Thoracic Oncology 2nd ed. Philadelphia, WB Saunders, 1995, pp 356-367.

5. Goldberg SJ, King KH. Endoscopic Nd:YAG laser coagulation as palliative therapy for obstructing esophageal carcinoma. American Journal of Gastroenterology 1986;81:629-634.

6. McCaughan JS, Nims TA, Guy GT, et al. Photodynamic therapy for esophageal tumors. Archives of Surgery 1989;124:74-78.

7. Low DE, Pagliero KM. Prospective randomized clinical trial comparing brachytherapy and laser photoablation for palliation of esophageal carcinoma. Journal of Thoracic and Cardiovascular Surgery 1992;104:173-179.

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