In advanced stages, the tumor may grow so large that the lumen of the esophagus is blocked, causing an obstruction to eating. The tumor also causes the peristalsis of the esophagus to slow down, causing food to become trapped in the lumen. At this time, difficulty in swallowing is the most likely situation you will encounter, and in severe cases, you may not even be able to drink water. What to do at this point?
Difficulty swallowing can be graded from mild to severe as follows:
- Grade 0: intermittent choking on food, able to eat regular solid food without cutting it into small pieces and without chewing very well;
- Level 1: Able to swallow solid foods less than 18 mm in diameter and requires full chewing;
- Level 1: Able to swallow solid foods less than 18 mm in diameter and requires full chewing;
- Grade 2: able to eat only semi-liquid food;
- Grade 2: able to eat only semi-liquid food;
- Grade 3: able to swallow only full liquids;
- Grade 4: unable to swallow liquids or saliva.
The main treatment for dysphagia is either recanalization of the obstruction site or establishment of a tube feeding channel and enteral nutritional support.
Radiotherapy alone or radiotherapy combined with chemotherapy can relieve dysphagia, but alternative treatments are recommended for patients who cannot tolerate radiotherapy or have a short estimated life expectancy (less than 6 months).
Whichever approach is used will depend on your specific situation.
Treatment options depending on the grade of dysphagia are:
- Placement of an artificial self-expanding metal stent
It can be placed with the assistance of endoscopic guidance fluoroscopy, requiring an initial esophageal stricture that can be dilated to 6-10 mm to allow passage of the stent before deployment.
After treatment, 95% of dysphagia can be relieved to the point of being able to eat at least a full liquid diet, and also allows for successful closure of 70% to 100% of esophagotracheal fistulas.
After stent placement, it is recommended that you avoid thick and high-fiber foods, such as thicker porridge and celery; you should eat liquids or thin, soft foods to avoid food impaction.
While this approach provides relatively quick relief, as the disease progresses, the tumor often grows into the stent, at which point other means are needed to manage recurrent dysphagia. In addition, there are risks associated with this approach, such as bleeding.
- Esophageal dilation
Esophageal dilation using a transendoscopic balloon or guidewire-guided probe can temporarily relieve dysphagia. The probes are often made of polyethylene, which is nontoxic and harmless.
After the first dilation, re-dilation is usually required every 3 to 4 weeks. With several dilations, most esophageal strictures can be safely dilated to 16 to 17 mm. However, there is a higher risk of perforation with this approach.
- Establishment of tube feeding access
In some patients with complete feeding obstruction, a nasogastric, or nasojejunal nutrition tube, or an endoscopic gastrostomy or jejunostomy can be placed endoscopically. If the endoscopic evacuation operation fails, a conventional gastrostomy or jejunostomy may be considered.
- Short-cuts
Local radiation therapy is performed by placing a radiation source within or very close to the tumor. This approach produces the highest dose of radiation in very close proximity to the tumor, achieving long-term relief of dysphagia.
- Chemical ablation
Injection of anhydrous ethanol into the tumor tissue. This method is simple and easy to perform, but the overall time to remission is short and can lead to complications such as chest pain, mediastinitis, esophagotracheal fistula, and perforation.
- Laser therapy
Laser cauterization of esophageal cancer tissue results in lumen patency in more than 90% of patients and functional recovery in 70% to 80% of patients, with remission lasting from 1 month to several months. However, this approach has a high frequency and cost of treatment, a high recurrence rate of esophageal strictures, and a risk of serious complications such as esophageal perforation.
- Photodynamic therapy
After intravenous injection of photo-sensitizing drugs, the lesion is destroyed by endoscopic irradiation with a low-power laser.
Sodium porphonium is the only light-sensitizing agent approved for palliative treatment of esophageal cancer. After intravenous injection, it selectively finds the lesion and accumulates around it. Approximately 24-48 hours later, the physician irradiates the cancerous tissue through an endoscopically placed laser diffuser, causing necrosis of the tumor. Repeated irradiation allows for optimal treatment.
To some extent, photodynamic therapy is superior to laser therapy alone. However, with the widespread use of self-expanding metal stents, laser therapy and photodynamic therapy have been used less frequently for the treatment of dysphagia in esophageal cancer.