Spray cryotherapy for dysphagia palliation in esophageal cancer prior to systemic therapy: is it ready for prime time?

Endoscopic spray cryotherapy for dysphagia palliation in esophageal cancer: Systematic review and meta-analysis

Background and study aims Endoscopically delivered liquid nitrogen spray cryotherapy is reported to be a safe and possibly more effective strategy for dysphagia palliation in patients with advanced esophageal cancer. This systematic review and meta-analysis aimed to pool all available data to evaluate the impact of this treatment modality. Methods Electronic databases (PubMed, Embase, and Cochrane Library) from January 2005 through June 2023 were searched for studies evaluating endoscopically delivered liquid nitrogen spray cryotherapy for dysphagia palliation in patients with advanced esophageal cancer. Pooled proportions were calculated using random-effects (DerSimonian-Laird) model. Results From an initial 895 studies, data were extracted and analyzed from five studies comprising a total of 230 patients that met inclusion criteria. In this pooled analysis, dysphagia improved or did not deteriorate in 81.40% of patients (95% confidence interval [CI] 73.75-87.99). Significant improvement in dysphagia was reported by 55.19% of patients (95% CI 29.62-79.37). An alternate method of dysphagia palliation despite spray cryotherapy was required in 18.78% of patients (95% CI 8.09-32.63) with 10.56% (95% CI 2.53-23.18) requiring esophageal stents. The weighted mean number of spray cryotherapy sessions per patient was 3.37 (95% CI 2.55-4.18). The pooled major adverse event rate was 3.26% (95% CI 0.15-10.14). Conclusions Endoscopic liquid nitrogen spray cryotherapy can effectively and safely treat dysphagia in esophageal cancer. It can be considered an option for dysphagia palliation in centers with expertise and equipment.

Spray cryotherapy prevents need for palliative stenting in patients with esophageal cancer-associated dysphagia

BACKGROUND

Dysphagia is the most common symptom in advanced esophageal cancer patients. Esophageal stent placement (SP) is a common palliation method but can be associated with significant morbidity. Limited data exist regarding the ability of spray cryotherapy (SC) prolong time to SP.

METHODS

A Mayo Clinic (Rochester, MN) patient database was reviewed for cases with a SC indication of esophageal cancer palliation from 2007-2019. Procedures were performed using a liquid nitrogen SC system to apply 2-5 separate 20 second freeze and 60 second thaw cycles based on tumor characteristics. Primary outcome was time to subsequent palliative SP.

RESULTS

Of 56 patients (71.4% male, mean age 77.8 ± 10.2 years) who underwent a total of 199 SC sessions (mean 3.6 ± 2.7, range 1-12 per patient), 41 had adenocarcinoma and 15 squamous cell carcinoma (SCC). Overall, 13 patients underwent subsequent SP within a mean duration of 15.7 ± 11.0 months over a mean follow-up duration of 25.6 ± 29.4 months. Treatment did produce stenosis in 16 patients, who required dilation within a mean period of 193.1 ± 294.1 days; notably, 10 patients had a history of preceding malignant strictures requiring dilation. Two patients experienced bleeding requiring transfusion, whereas 1 experienced perforation at the start of SC. Prior chemotherapy and/or radiation was not associated with developing an SC-related complication (risk ratio (RR) 1.5; 95% CI 0.6-3.7, P > 0.4).

CONCLUSIONS

SC appears to be an effective and safe modality to palliate esophageal cancer in appropriate candidates. Majority of patients who undergo SC avoid the need for future SP. If patients eventually require SP, they are able to, on average, defer stenting for >1 year from SC initiation.