Nd:YAG laser versus ethanol injection for palliation of esophageal malignancy

Among the different endoscopic approaches to unresectable esophageal malignancies, in the past few years, several experiences referred to Nd:YAG laser therapy and intratumoral drugs injection have been reported. Intratumoral injective therapy has turned out to be cheaper because no special equipment or special skills are required. In order to evaluate the feasibility and the effectiveness of intratumoral alchool injection in the management of unresectable fungating esophageal malignancies we set up a prospective randomized study comparing this new technique with Nd:YAG laser Between November 1992 and November 1996. 199 patients with unresectable cancer of the esophagus or gastric cardia underwent endoscopic palliation in our Department. Out of them, 84 had fungating lesions. The first 30 patients (21 males. 3 females, mean age 64, range 41-88) have been included in the study and randomly referred to endoscopie Nd:YAG laser treatment, performed with the retrograde technique after esophageal dilation (group A), or intratumoral injection of alcohol 98% always performed after dilation (group B). All the procedures have been performed under local pharyngeal anesthesia and conscious sedation. An improvement of at least 2 degrees of the dysphagia score has been reached in 87% of patients of group A and in 80% of group B and the dysphagia free interval between each treatment was an average 28 and 37 days respectively) Patients of both groups underwent a mean of 1.5 sessions of treatment. The patients' compliance to both treatments was good although 12 (80%) of group B experienced mild pain during the injection of alcohol Median survival was 6.1 and 5.3 months in group A and B respectively. No statistically differences (p = NS) have been observed m the mean dysphagia score of patients still alive. No morbidity and mortality were recorded in group A. In group B. an esophageal perforation occurred during the preliminary dilation before the second session of alcohol injection, and was successfully treated with intubation. No mortality was recorded in group B. In conclusion, although the morbidity related to the intratumoral alcohol injection was higher and included one esophageal perforation, the two techniques seem to be comparable in term of palliation of dysphagia and improvement of quality of life. Thus, intratumoral alcohol injection should reasonably be considered an effective and cheaper therapeutic option in the palliation of fungating esophageal lesions.