Endoscopic Nd:YAG laser with aggressive multimodality therapy for locally advanced esophageal cancer

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

The majority of patients with esophageal cancer are diagnosed at an advanced, incurable stage. Palliation of symptoms, specifically dysphagia, is a crucial component to improve quality of life and optimize nutritional status. Despite multiple available treatment modalities, there is not one accepted or recommended to be the preferred treatment option. Palliative management is often decided by a multidisciplinary team considering factors including local availability, preference, patient life expectancy, and symptom severity. Systemic therapies such as chemotherapy are the most commonly used palliative modalities. Oncologists are most familiar with radiation for dysphagia palliation, especially for advanced metastatic cancer patients with good performance status. One common approach used by endoscopist is self-expandable metal stents. This is preferred for patients with short-term survival and poor functional status as it provides rapid relief of dysphagia. Cryotherapy is a relatively new endoscopic ablative modality and appears to be a promising option for dysphagia palliation, but more data is needed for wider adoption. This review summarizes the current literature on endoscopic and non-endoscopic treatment options for malignant dysphagia.

Recurrence after surgery in esophago-gastric junction adenocarcinoma: Current management and future perspectives

Recurrent esophago-gastric junction adenocarcinoma is not a rare event and its correct management is still debated. Many approaches for the treatment of these patients exist, but only few studies compare the different techniques. Most of the studies are retrospectives series and describe the experiences of single institutions in the treatment of recurrent esophageal and esophago-gastric junction cancers. Nowadays surgery is still the main and only curative treatment. Other alternative palliative therapies could be endoscopic stent placement and balloon dilation, photodynamic therapy, thermal tumor ablation (laser photoablation and Argon plasma coagulation), radiation therapy and brachytherapy, and chemotherapy. The aim of this review is to investigate the different rates, patterns and timings of recurrence of this tumor, and to explain the various approaches used for the treatment of recurrent esophago-gastric junction cancer.

Therapeutic endoscopy and endoscopic ultrasound for gastrointestinal malignancies

Gastrointestinal endoscopy and endoscopic ultrasound not only provide strategies to diagnose and stage malignancy, but also to administer palliative and definitive care. Options for anticancer therapy include endoscopic mucosal resection, photodynamic therapy, thermal therapy, self-expanding metal stents and recently, endoscopic ultrasound-guided therapy, such as intratumoral injection. This review summarizes the available endoscopic techniques with a discussion of indications and recent clinical data pertaining to gastrointestinal malignancy. This review will inform the reader of emerging treatment options and stress the importance of incorporating gastroenterologists into the multidisciplinary approach in the management of gastrointestinal cancers.

Endoscopic therapeutic esophageal interventions: old, new, borrowed and . . . methylene blue?

PURPOSE OF REVIEW

Endoscopic interventions in the esophagus continue to evolve. This article reviews some of the notable advances over the past year in endoscopic therapy for the esophagus.

RECENT FINDINGS

In 2002 several endoscopic therapies were reintroduced or modified. Ablative treatments, including Nd:YAG laser, photodynamic therapy, and thermal contact treatments have been shown to be effective for Barrett esophagus and some early esophageal cancers. The addition of endoscopic mucosal resection may improve these therapies. Endoscopic stenting remains the dominant endoscopic palliative modality for unresectable esophageal cancers, and modifications of this therapy have focused on reducing side effects and complications. Innovations in endoscopic treatments for strictures and bleeding esophageal varices have been proposed and may improve outcomes, although probably only marginally. Additional endoscopic antireflux procedures have been introduced, although the results of long-term studies still need to be published before their place in the treatment of gastroesophageal reflux disease can be determined.

SUMMARY

Rather than heralding novel endoscopic therapeutics, 2002 was a year of retooling and refining existing techniques.

Diagnosis and therapy for advanced esophageal cancer

PURPOSE OF REVIEW

The majority of esophageal cancers are advanced at presentation, rendering cure unlikely, especially by surgery alone. Consequently, much research effort has been directed towards studies of adjuvant chemotherapy and chemoradiation, particularly in defining the best regimens from the standpoint of efficacy and minimal toxicity and in an attempt to predict response.

RECENT FINDINGS

Overall results of adjuvant therapy have been conflicting, although a survival advantage has been documented in those demonstrating objective response to chemoradiation. In such circumstances, comparable survival has been demonstrated using chemoradiation alone, leading to the hypothesis that surgery may be best reserved for nonresponders. For those with stage IV disease or unfit for radical treatment, a variety of palliative modalities exist including stenting, laser photocoagulation, brachytherapy, and chemotherapy used singly or in combination, the latter providing encouraging improvement in survival over single-modality treatment.

SUMMARY

Current research is directed towards securing better results using newer chemotherapeutic agents such as taxanes and irinotecan and deploying molecular markers both to predict response to chemotherapy and to target its delivery to tumor sites.

Nonsurgical approaches to esophageal malignancy

Esophageal cancer remains one of the leading causes of cancer death worldwide. Patients generally present with progressive dysphagia, malnutrition, and weight loss. The diagnosis commonly involves radiologic studies and conventional esophagogastroduodenoscopy. Advances in endoscopic evaluation have allowed early detection of premalignant and malignant lesions. These techniques include chromoscopy, which can be performed in conjunction with high-resolution/magnification endoscopy, and fluorescent endoscopy. Such techniques as endoscopic ultrasound with dedicated echoendoscopes or high-frequency probes, positron emission tomography, optical coherence tomography, endoscopic magnetic resonance imaging, and tactile sensing may complement conventional imaging by CT to enhance staging accuracy. Because the majority of patients present with incurable disease at the time of diagnosis, nonsurgical approaches to their management have evolved. These include endoscopic mucosal resection, stenting, tumor ablation, and palliative chemoradiotherapy. The ablative techniques include argon plasma coagulator therapy, laser, and photodynamic therapy. For patients with early malignancies of the esophagus who are not surgical candidates, such techniques may be used with curative intent.