Palliation of esophageal carcinoma. Laser and photodynamic therapy

Laser therapy is a well-established, relatively safe, rapid, and highly effective method of palliation for the dysphagia that usually accompanies esophageal and esophagogastric cancer. It is the treatment of choice in many patients, although there remains some disagreement regarding technique and predictors of outcome. The major limitation of laser therapy is the need for repeated treatments, although the interval between treatments may be lengthened by concomitant external beam or endoluminal radiotherapy. When laser therapy is available, use of an esophageal stent should be reserved for special circumstances, such as esophagopulmonary fistulas or extrinsic compression. In addition, stent placement usually is effective when laser photoablation fails or must be performed too frequently. It remains to be seen whether or not technical improvements in esophageal stents will reduce the frequency of complications associated with these devices. Other promising modalities that may be less expensive and more readily available, such as the BICAP tumor probe or injection therapy, deserve further study. It appears that most of these methods are complementary and different modalities may be suited to different types of lesions. The results of phase III clinical trials with PDT, now underway, should help to define the role of this promising modality in the overall scheme of treatment for esophageal cancer. The concept of PDT is attractive, although refinements in photosensitive compounds and methods of light delivery may be needed. Current information suggests a moderately high complication rate for PDT, although this may decrease with technical improvements and increasing experience. Issues surrounding the palliation of esophageal cancer are complex. Whereas the tendency is to focus on technical aspects of therapy and the relief of dysphagia, broader aspects of a patient's quality of life cannot be ignored. Ultimately, the choice of therapy may depend as much on a patient's psychosocial circumstances as on the appearance of the lesion. For instance, the patient who lives at a great distance from the center where laser therapy is performed may be better served by placement of an esophageal stent despite the higher complication rate for this procedure. PDT would be inappropriate for the patient who wishes to spend the remaining few months of life outdoors in the sun. Guiding the patient to the best choice requires the skills of a physician as much as the technical ability of an endoscopist.