Endoscopic spray cryotherapy for esophageal cancer: safety and efficacy

Abstract

Background: Few options exist for patients with localized esophageal cancer ineligible for conventional therapies. Endoscopic spray cryotherapy with low-pressure liquid nitrogen has demonstrated efficacy in this setting in early studies.

Objective: To assess the safety and efficacy of cryotherapy in esophageal carcinoma.

Design: Multicenter, retrospective cohort study.

Setting: Ten academic and community medical centers between 2006 and 2009.

Patients: Subjects with esophageal carcinoma in whom conventional therapy failed and those who refused or were ineligible for conventional therapy.

Interventions: Cryotherapy with follow-up biopsies. Treatment was complete when tumor eradication was confirmed by biopsy or when treatment was halted because of tumor progression, patient preference, or comorbid condition.

Main outcome measurements: Complete eradication of luminal cancer and adverse events.

Results: Seventy-nine subjects (median age 76 years, 81% male, 94% with adenocarcinoma) were treated. Tumor stage included T1-60, T2-16, and T3/4-3. Mean tumor length was 4.0 cm (range 1-15 cm). Previous treatment including endoscopic resection, photodynamic therapy, esophagectomy, chemotherapy, and radiation therapy failed in 53 subjects (67%). Forty-nine completed treatment. Complete response of intraluminal disease was seen in 31 of 49 subjects (61.2%), including 18 of 24 (75%) with mucosal cancer. Mean (standard deviation) length of follow-up after treatment was 10.6 (8.4) months overall and 11.5 (2.8) months for T1 disease. No serious adverse events were reported. Benign stricture developed in 10 (13%), with esophageal narrowing from previous endoscopic resection, radiotherapy, or photodynamic therapy noted in 9 of 10 subjects.

Limitations: Retrospective study design, short follow-up.

Conclusions: Spray cryotherapy is safe and well tolerated for esophageal cancer. Short-term results suggest that it is effective in those who could not receive conventional treatment, especially for those with mucosal cancer.

Figure 1

Endoscopic appearance of frozen esophageal mucosa by using spray cryotherapy with liquid nitrogen.

Figure 2

Endoscopic images of a patient with persistent luminal cancer after concurrent chemotherapy and external beam radiation therapy (chemoradiation) for T2N0 esophageal adenocarcinoma. A, Initial appearance of cancer before chemoradiation. B, One month after chemoradiation, esophagitis but no cancer is detectable. C, Appearance 5 months after chemoradiation, with adenocarcinoma and residual intestinal metaplasia present. D, After 3 cryotherapy sessions, residual cancer is no longer visible. Endoscopic biopsy specimens showed no evidence of cancer. An ink tattoo is visible marking the previous site of the tumor.