Optimal Management of Dysphagia in Patients with Inoperable Esophageal Cancer: Current Perspectives

Figures & data

Table 1 Advantages and Disadvantages of Various Treatment Modalities for Palliation of Dysphagia

Procedures	Advantages	Disadvantages
Endoscopic methods
Dilation	Simple Inexpensive Used as adjunct to facilitate stent placement Help completing other procedures such as staging EUS or PEG placement	Temporary symptom relief Not recommended as a primary treatment modality due to limited efficacy and adverse events
Laser therapy (Nd:YAG)^Citation9–11,Citation14	Used for short, non-angulated and exophytic tumors Can be used for proximal lesions	Requires multiple treatments Not for extrinsic or submucosal lesions Complication (4–20% cases): tracheoesophageal fistulas, bleeding and perforation Rarely used due to adverse events
Photodynamic therapy (PDT)^Citation15–17	Can be used for long tumors, narrow and angulated tumors, cervical tumors, flat and infiltrating tumor Longer lasting relief than laser treatment	Complex procedure High cost of the photosensitizers Skin photosensitivity as the most common complication Rarely used because of adverse events and cost
Argon plasma coagulation^Citation20–22,Citation24	Easy to use Widely available Relatively safe than other tumor ablation methods such as laser therapy or PDT	Limited efficacy because of superficial depth of tissue destruction Several sessions are often necessary for sustained luminal patency
Self-expandable metal stents (SEMS) – Fully covered SEMS and partially covered SEMS^Citation28,Citation39,Citation40	Widely available Effective as a single treatment modality for patients with poor functional status Treat associated tracheoesophageal fistula Provides immediate relief of dysphagia	Recurrent dysphagia common (30–40%) Causes reflux and regurgitation when placed across the gastroesophageal junction Other most common adverse events-hemorrhage, stent migration, chest pain, tissue ingrowth/overgrowth
Liquid nitrogen spray cryotherapy^Citation26–30	Relatively new ablative modality Good tolerability and safety profile	Need repeated treatments Limited data, large-scale studies are needed to further assess the treatment benefit
Non-endoscopic methods
External beam radiation therapy^Citation49–51,Citation59,Citation60	Widely available Effective with sustained dysphagia relief	Worsening before improvement limits its utility in severe symptoms Toxicity especially with high doses and in combination with chemotherapy limits its use
Brachytherapy^Citation44,Citation47,Citation48,Citation78	Improvement in quality of life in addition to dysphagia Advantage of more localized application of radiation energy	Limited availability Complexity of scheduling and procedures in addition to toxicity have limited it use
Chemotherapy^Citation61,Citation62,Citation66,Citation67	Standard of care in metastatic disease Prolonged survival More modalities are becoming available	Rarely effective alone for long-term relief Toxicities accumulate over time Requires a good functional status

Abbreviations: EUS, endoscopic ultrasound; PEG, percutaneous endoscopic gastrostomy; PDT, photodynamic therapy.

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