advanced disease and severe obstructive symptoms to handle secretions and swallow liquids such as

dietary supplements. Like with palliative chemotherapy, radiotherapy does not offer immediate relief

and will require time in order to reach maximal palliative effect. Patients with life expectancies greater

than 3 months can be offered a combination of chemotherapy and radiation to achieve palliation. Side

effects of radiation therapy include skin irritation and erythema. Patients may also experience

esophagitis with painful swallow, stricture formation, radiation pneumonitis, and fistulization to the

airway.

Stenting

Stenting technology has advanced significantly since its initial introduction in the 1970s as a palliative

option for inoperable malignant esophageal strictures.23 Currently, many stents are available on the

market included self-expanding coated and uncoated nitinol types. Patients have the option of either

inserting them endoscopically or radiologically. Stenting can be done in conjunction with other

palliative treatment options including balloon dilation, neodymium; yttrium-aluminum-garnet (Nd:YAG)

laser fulguration, and photodynamic therapy (PDT), which we will discuss next.

Neodymium:Yttrium-Aluminum-Garnet Laser Fulguration

In patients with unresectable obstructive tumors, endoscopic Nd:YAG laser fulguration is a surgical

option that can provide temporary relief of esophageal obstruction. First, an esophagoscope is used to

identify the lesion. The YAG laser energy is delivered through a flexible quartz fiber that is passed

through the working channel of the scope. Multiple YAG laser sessions will be required to debulk the

lumen of the esophagus to the point where patients may function relatively normally. As with many

palliative treatments, laser fulguration is often performed in conjuncture with endoluminal stenting and

radiation therapy to achieve better functional success. It can be particularly useful in patients who have

undergone prior stenting and are experiencing an ingrowth of tumor through the stent. Tumor ingrowth

is less of a problem with many of the current stents because we prefer to use the fully covered stents.

Photodynamic Therapy

Another form of palliative therapy is intraluminal PDT. It is a nonthermal ablative technique that

requires the systemic administration of a photosensitizing substance such as hematoporphyrin. Over the

course of 48 hours, this photosensitizing substance becomes highly concentrated in malignant cells.

Patients will then undergo endoscopic evaluation with application of an argon-pump dye-laser

introduced endoluminally in the esophagus to deliver light at a wavelength of 630 nm. This endoluminal

light source will cause a chain reaction that generates an overwhelming concentration of oxygen

radicals, quickly leading to tumor necrosis and patent luminal area. Perforation is of little concern with

PDT because the risk of full-thickness necrosis of the esophagus is rare due to the limited depth of

penetration of the light. Unfortunately, photosensitizing agents such as hematoporphyrin are frequently

retained by the reticuloendothelial system of the skin. This retention will cause patients to be sensitive

to infrared wavelength light, including sunlight, radiant heat, fluorescent light, and strong incandescent

light. Patients should be informed of these side effects as they may persist for up to 3 months depending

on what agent was used as well as the individual. Because of these long-lasting postoperative effects,

endoluminal PDT may not be a favored option for patients with shorter life expectancies.

In a recent series of 215 patients who underwent endoluminal PDT for palliation, investigators

reported a procedure-related mortality rate of 1.8%. With a median survival of 4.8 months, this series

found this technique to be an effective palliative treatment in 85% of patients with obstructive

esophageal tumors.78 Of note, some of these patients also required stenting for palliation, suggesting

that PDT may have a role in a multimodal palliative treatment plan for patients with obstructing

esophageal cancers.

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