Esophageal Cancer Guidelines

Recommendations for screening and surveillance of patients with gastroesophageal reflux disease (GERD) and/or Barrett esophagus have been issued by the following organizations:

• American Society for Gastrointestinal Endoscopy (ASGE)
• American Gastroenterological Association (AGA)
• American College of Gastroenterology (ACG)
• American College of Physicians (ACP)

None of the organizations recommend endoscopic screening of the general population with GERD. There is general agreement among the guidelines that patients with chronic GERD and multiple other risk factors associated with esophageal adenocarcinoma should undergo upper gastrointestinal endoscopy to screen for Barrett esophagus or esophageal adenocarcinoma. ^{[1, 2, 3, 4]} Those additional risk factors include the following:

• Male sex
• Age 50 years or older
• White race
• Hiatal hernia
• Obesity
• Tobacco smoking
• Family history of Barrett esophagus or esophageal adenocarcinoma in a first-degree relative

The 2019 ASGE guideline found insufficient evidence on the effectiveness of screening for Barrett esophagus, but suggested that if screening endoscopy is performed, it should be done in an at-risk population, defined as individuals with a family history of esophageal adenocarcinoma or Barrett esophagus (high risk) or patients with GERD plus at least 1 other risk factor (moderate risk). As a conditional recommendation, the ASGE suggests performing surveillance endoscopy in patients with nondysplastic Barrett esophagus. ^[1]

The ACP's best practice advice, issued in 2012, offers the following recommendations for upper endoscopy for GERD ^[4] :

• Screening endoscopy is not recommended for women of any age or men younger than 50, regardless of other risk factors, because of the low incidence of cancer in these populations.
• Screening is recommended in both men and women with GERD symptoms despite medical treatment, and especially in those with GERD and dysphagia, bleeding, anemia, weight loss, or recurrent vomiting.
• No further surveillance is recommended if endoscopy shows negative results for Barrett esophagus.
• In patients with Barrett esophagus and no dysplasia, surveillance examinations should occur at intervals of 3 to 5 years; shorter intervals are indicated in patients with Barrett esophagus and dysplasia.

The 2022 ACG guidelines suggest that use of a swallowable, nonendoscopic capsule sponge device combined with a biomarker obtained from the device (trefoil factor 3 [TFF3] or methylated DNA markers [MDMs]) is an acceptable alternative to endoscopy for screening for Barrett esophagus.

After initiation of maximal acid-suppressive therapy (twice-daily proton pump inibitor), the ACG recommends performing surveillance using both white-light endoscopy and chromoendoscopy, a structured biopsy protocol, and surveillance at intervals dictated by the degree of dysplasia noted on previous biopsies. ACG recommendations for the surveillance and therapy of confirmed Barrett esophagus are listed in the table below. ^[3]

Table. American College of Gastroenterology Recommendations on Surveillance of Barrett esophagus (Open Table in a new window)

Because of the known risk of recurrence despite CEIM, the ACG does not recommend discontinuation of surveillance after EET. Instead, ACG guidelines advise that "it is reasonable to cease endoscopic surveillance in patients with an estimated survival of less than 5 years and those who are no longer fit for repeated endoscopy or cannot tolerate endoscopic, surgical, or oncological intervention for esophageal neoplasia." In most cases, discussing cessation is reasonable when the patient reaches age 75 years. ^[3]

Recommendations for diagnosis and staging of esophageal cancer have been issued by the following organizations:

• Society of Thoracic Surgeons
• European Society for Medical Oncology (ESMO)
• National Comprehensive Cancer Network (NCCN)
• American Society for Gastrointestinal Endoscopy (ASGE)
• College of American Pathologists, American Society for Clinical Pathology, and American Society of Clinical Oncology

Society of Thoracic Surgeons

In 2013, the Society of Thoracic Surgeons released clinical practice guidelines to assist in the diagnosis and treatment of localized esophageal cancer. Their recommendations include the following ^[5] :

• For the diagnosis of esophageal cancer, flexible endoscopy with biopsy is the primary method
• For early-stage esophageal cancer, computed tomography (CT) of the chest and abdomen is an optional test for staging; for locoregionalized esophageal cancer, CT of the chest and abdomen is a recommended test for staging
• For early-stage esophageal cancer, positron emission tomography (PET) is an optional test for staging. For locoregionalized esophageal cancer, PET is a recommended test for staging
• In patients without metastatic disease, endoscopic ultrasonography is recommended to improve the accuracy of staging
• In patients with small, discrete nodules or areas of dysplasia in whom disease appears limited to the mucosa or submucosa as assessed by endoscopic ultrasonography, endoscopic mucosal resection should be considered as a diagnostic/staging tool
• In patients with locally advanced (T3/T4) adenocarcinoma of the esophagogastric junction infiltrating the anatomic cardia or Siewart type III esophagogastric tumors, laparoscopy is recommended to improve accuracy of staging.

European Society for Medical Oncology

The ESMO guidelines include the following key recommendations for diagnosis and staging ^[6] :

• All patients with new dysphagia, gastrointestinal bleeding, recurrent aspiration or emesis, weight loss, and/or loss of appetite should undergo upper gastrointestinal endoscopy
• Immunohistochemical stainings should be used to differentiate between squamous cell carcinoma (SCC) and adenocarcinoma 
• Staging should include a complete clinical examination and a CT scan of the neck, chest and abdomen
• In candidates for surgical resection, endoscopic ultrasound (EUS) is performed to evaluate the T and N staging
• In candidates for esophagectomy, ¹⁸F-fluoro-deoxyglucose positron emission tomography (FDG-PET) should be performed 

National Comprehensive Cancer Network

The NCCN guidelines include the following recommendations regarding diagnostic endoscopy ^[7] :

• Endoscopy should be used to determine the presence and location of esophageal cancer and to biopsy any suspicious lesions.
• Six to eight biopsies should be performed for histologic analysis; cytologic brushings and washings are not adequate for initial diagnosis. 
• Endoscopic resection (ER) of focal nodules is recommended for accurate staging of early-stage disease (T1a or b); ER may be fully therapeutic if the entire lesion can be removed.
• In patients who are unable to undergo biopsy, a 'liquid biopsy' using an next-generation sequencing (NGS)–based comprehensive genomic profiling assay may be considered.

The NCCN guidelines include the following recommendations regarding imaging ^[7] :

• Upper GI endoscopy and biopsy
• Chest/abdominal CT with oral and IV contrast
• Pelvic CT with contrast as clinically indicated
• FDG-PET/CT evaluation (skull base to mid-thigh) if no evidence of M1disease
• Endoscopic ultrasound (EUS), if no evidence of M1 unresectable disease

American Society for Gastrointestinal Endoscopy

The 2013 ASGE guidelines for use of endoscopy in the assessment and treatment of esophageal cancer make the following recommendations for accurate staging ^[8] :

• EUS and fine needle aspiration (FNA), when indicated, in conjunction with cross-sectional imaging is preferred over CT
• Endoscopic mucosal or submucosal dissection is indicated for the treatment and staging of nodular Barrett esophagus and suspected squamous cell carcinoma and adenocarcinoma

Pathological Testing

Guidelines from the College of American Pathologists, American Society for Clinical Pathology, and American Society of Clinical Oncology, issued in 2016, include the following recommendations for clinicians ^[9] :

• Request HER2 testing on tumor tissue in patients with advanced esophageal adenocarcinoma who are potential candidates for HER2-targeted therapy.
• Request HER2 testing on tumor tissue in the biopsy or resection specimens (primary or metastasis), preferably before starting trastuzumab therapy, if such specimens are available and adequate; an acceptable alternative is HER2 testing on fine-needle aspiration specimens.

NCCN guidelines for workup include the following recommendations ^[7] :

• HER2 testing is recommended for patients with inoperable adenocarcinoma esophageal or esophagogastric junction (EGJ) cancer considering treatment with trastuzumab.
• Testing for high microsatellite instability (MSI-H), deficient mismatch repair (dMMR), and programmed death ligand 1 (PD-L1)\ is recommended in all patients with esophageal or EGJ cancer who are candidates for treatment with PD-1 inhibitors.

For information on staging, see Esophageal Cancer Staging.

Recommendations for treatment of esophageal adenocarcinoma have been issued by the following organizations:

• National Comprehensive Cancer Network (NCCN)
• European Society for Medical Oncology (ESMO)
• American College of Gastroenterology (ACG)
• Society of Thoracic Surgeons (STS)
• American Society of Clinical Oncology (ASCO)

National Comprehensive Cancer Network

NCCN treatment recommendations for adenocarcinomas in medically fit patients include the following ^[7] :

• Stage Tis (in situ) or T1a:  The preferred treatments are endoscopic resection (ER), ablation, or ER followed by ablation.  Esophagectomy is an alternative treatment option.
• Superficial T1b tumors: Treated by ER followed by ablation or esophagectomy.
• Stage T1b, N0 and T2, N0 (low-risk): Treated by esophagectomy. 
• Stage T1b,N+, T2, N0 (high-risk), T2N+ or T3-T4a, any N:  Preoperative chemoradiation is a category 1–preferred recommendation. Other options include definitive chemoradiation (for patients who refuse surgery), and perioperative or preoperative chemotherapy with esophagectomy.
• Stage T4b (unresectable) tumors: Definitive chemoradiation is the preferred treatment modality. Chemotherapy alone may be considered in patients with involvement of the trachea, great vessels, or heart.

For patients with adenocarcinoma who have not received preoperative therapy, no further treatment is necessary (irrespective of their nodal status) if there is no residual disease at surgical margins (R0 resection). Patients with microscopic (R1 resection) or macroscopic (R2 resection) residual disease should be treated with fluoropyrimidine-based chemoradiation. Palliative therapy is an alternative option for patients with macroscopic residual disease. ^[7]

Postoperative treatment is based on the surgical margins, nodal status, and histology, as follows ^[7] :

• For patients with adenocarcinoma who have not received preoperative therapy, no further treatment is necessary for patients with Tis and T1, N0 tumors, if there is no residual disease at surgical margins (R0 resection)
• Postoperative fluoropyrimidine-based chemoradiation (following R0 resection) should be considered for patients with T2, N0 tumors.
• Chemoradiation is recommended for all patients with T3-T4 tumors  and node-positive T1-T2 tumors following R0 resection.
• Chemotherapy is an alternative postoperative treatment for all patients with R0 resction of node positive tumors.
• Patients with microscopic (R1 resection) or macroscopic residual disease with no distant metastatic disease (R2 resection) should be treated with fluoropyrimidine-based chemoradiation.
• Palliative therapy is an alternative option for patients with macroscopic residual disease.

NCCN guidelines for the management of adenocarcinomas in patients who are not surgical candidates includes the following ^[7] :

• Stage Tis (in situ):  The preferred treatments are ER, ablation, or ER followed by ablation
• Stage T1a and Stage T1b, N0:  ER or ER followed by ablation
• Stage T1b,N+, T2-T4a, any N and T4b (unresectable) tumors:  Definitive chemoradiation is the preferred treatment.  For patients unable to tolerate chemoradiation, palliative radiation therapy (RT) or best supportive palliative care is given.

NCCN recommendations for first-line systemic therapy of advanced or metastatic disease are as follows ^[7] :

• First-line systemic therapy regimens with 2 cytotoxic drugs are preferred for treatment of advanced disease because of their lower toxicity.
• Three-drug cytotoxic regimens should be reserved for medically fit patients with good performance status and access to frequent toxicity evaluation.
• The preferred regimens for first-line systemic therapy include a fluoropyrimidine (fluorouracil or capecitabine) combined with either oxaliplatin (preferred) or cisplatin.
• Patients with suspected stage IV metastatic adenocarcinoma should undergo assessment for tumor HER2 overexpression; in those with HER2-positive metastatic adenocarcinoma, trastuzumab should be added to first-line chemotherapy (category 1 for combination with cisplatin and fluoropyrimidine).

NCCN recommendations for second-line and subsequent systemic therapy of advanced or metastatic disease are as follows ^[7] :

• The selection of regimens for second-line or subsequent therapy depends on prior therapy and performance status.
• Category 1 preferred options for second-line or subsequent therapy include ramucirumab and paclitaxel and trifluridine and tipiracil for EGJ adenocarcinoma, single-agent docetaxel, paclitaxel, and irinotecan.
• Pembrolizumab is a third-line or subsequent therapy option for esophageal and EGJ adenocarcinomas with PD-L1 expression levels by combined positive score (CPS) of ≥1.
• Other recommended combined regimens for second-line therapy for esophageal adenocarcinoma include ramucirumab and paclitaxel,  irinotecan and cisplatin, and irinotecan and docetaxel (category 2B).

NCCN recommendations for targeted therapy include the following:

• Entrectinib or larotrectinib for NTRK gene fusion–positive tumors
• Pembrolizumab for MSI-H or dMMR tumors
• Pembrolizumab for high tumor mutation (≥10 mutations/megabase) tumors
• Dostarlimab-gxly for MSI-H or dMMR tumors

European Society for Medical Oncology 

ESMO guidelines for local and regional disease include the following ^[6] :

• Surgery is the treatment of choice for patients with stage T1-T2, N0 tumors. 
• Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are the preferred resection techniques for stage T1a and are considered an alternative to esophagectomy.  
• Radical and transthoracic esophagectomy is preferred for T1b-T2, N0 tumors.
• For non-surgical candidates, chemoradiation therapy is preferred over RT alone. ^[6]

For locally advanced disease (T3–T4), surgery alone is not standard of care and preoperative treatment is indicated. Perioperative chemotherapy with regimens containing a platinum and a fluoropyrimidine for a duration of 8–9 weeks in the preoperative phase (as well as 8–9 weeks in the postoperative phase, if feasible) or preoperative chemoradiotherapy (41.4–50.5 Gy) is the standard of care. ^[6]

Patients with metastatic disease should be offered palliative treatment specific to their clinical situation. ^[6]

American College of Gastroenterology 

ACG recommendations include the following ^[3] :

• In patients with intramucosal carcinoma (T1a): endoscopic eradication therapy (EET); resection of all visible lesions followed by ablation of remaining BE epithelium
• In patients with T1b esophageal adenocarcinoma, EET may be a viable alternative to esophagectomy for patients with superficial submucosal invasion (sm1—invasion into the upper third of the submucosa to a depth < 500 μm) and low-risk features such as negative deep margin, well-moderate differentiation, and no lymphovascular invasion. Patients with high-risk histology are best treated with esophagectomy.
• Endoscopic ultrasound (EUS) plays a role in appropriate staging of patients with T1b and more advanced esophageal adenocarcinoma, and in select cases of T1a disease.

Society of Thoracic Surgeons

In 2014, the STS released clinical practice guidelines for multimodal treatment of esophageal cancer with the following recommendations ^[10] :

• Locally advanced disease should be treated in a multidisciplinary setting
• Restaging should be performed after neoadjuvant therapy and before surgery
• Endoscopic ultrasound restaging for residual local disease is inaccurate and can be omitted
• A PET scan should be used for restaging after neoadjuvant therapy to detect interval development of distant metastatic disease
• Either neoadjuvant chemotherapy or chemoradiation therapy for locally advanced adenocarcinoma; multimodality therapy has advantages over surgical resection alone
• For patients with adenocarcinoma who have not received neoadjuvant therapy, adjuvant chemoradiotherapy is an option for regional lymph node disease.

American Society of Clinical Oncology

ASCO guidelines include the following recommendations ^{[11, 12]} :

• For patients with clinical earlier-stage esophageal cancer (T2, N0), surgery alone may be considered after discussion with a multidisciplinary team, provided the lesions are low-risk cT2N0 (ie, well-differentiated, < 2 cm) and there is a sufficient degree of confidence in the results of pretreatment staging.
• Preoperative chemoradiotherapy (CRT) or perioperative chemotherapy (CT) should be offered to patients with locally advanced esophageal adenocarcinoma.
• Following neoadjuvant CRT and surgery, nivolumab should be offered to patients with locally advanced esophageal carcinoma with Eastern Cooperative Oncology Group status 0-1 who did not experience a pathological complete response (ie, with residual disease of at least ypT1 or ypN1 in resected specimens).

Recommendations for treatment of esophageal adenocarcinoma have been issued by the following organizations:

• National Comprehensive Cancer Network (NCCN)
• European Society for Medical Oncology (ESMO)
• American Society of Clinical Oncology (ASCO)

National Comprehensive Cancer Network

The NCCN recommends consideration of enteric feeding tube placement for preoperative nutritional support of patients with squamous cell carcinoma (SCC). For treatment of medically fit patients, NCCN recommendations include the following ^[7] :

• Stage Tis (in situ):  The preferred treatments are endoscopic resection (ER), ablation, or ER followed by ablation.  Esophagectomy is an alternative treatment option.
• Stage T1a: The preferred treatments are endoscopic resection (ER), ablation or ER followed by ablation. Esophagectomy is an alternative treatment option.
• Stage T1b, N0 and T2, N0 (low-risk): Esophagectomy. 
• Stage T1b,N+, T2, N0 (high-risk), T2N+ or T3-T4a, any N:  Preoperative chemoradiation for SCC of the non-cervical esophagus or definitive chemoradiation for SCC of the cervical esophagus
• Stage T4b tumors: Definitive chemoradiation is the preferred treatment modality. Chemotherapy alone may be considered in patients with involvement of the trachea, great vessels, or heart.

Postoperative treatment of SCC is based on the surgical margins, nodal status, and histology, as follows ^[7] :

• For patients who have not received preoperative therapy, no further treatment is necessary (irrespective of their nodal status) if there is no residual disease at surgical margins (R0 resection).
• Patients with microscopic (R1 resection) or macroscopic (R2 resection) residual disease should be treated with fluoropyrimidine-based chemoradiation.
• Palliative therapy is an alternative option for patients with macroscopic residual disease.

NCCN guidelines for the management of SCC in patients who are not surgical candidates includes the following ^[7] :

• Stage Tis (in situ):  The primary treatments are ER, ablation or ER followed by ablation
• Stage T1a and Stage T1b, N0:  Treated by ER or ER followed by ablation
• Stage T1b,N+, T2-T4a, any N and T4b (unresectable) tumors:  Definitive chemoradiation is the preferred treatment.  For patients unable to tolerate chemoradiation, palliative radiation therapy (RT) or best supportive palliative care is given.

NCCN recommendations for first-line systemic therapy of advanced or metastatic disease are as follows ^[7] :

• First-line systemic therapy regimens with 2 cytotoxic drugs are preferred for treatment of advanced disease because of their lower toxicity.
• Three-drug cytotoxic regimens should be reserved for medically fit patients with good performance status and access to frequent evaluation of toxicity.
• The preferred regimens for first-line systemic therapy include a fluoropyrimidine (fluorouracil or capecitabine) combined with either oxaliplatin (preferred) or cisplatin.

NCCN recommendations for second-line and subsequent systemic therapy of advanced or metastatic disease are as follows ^[7] :

• The selection of regimens for second-line or subsequent therapy depends on prior therapy and performance status.
• Nivolumab is a category 1 option
• Pembrolizumab is a category 1 option for SCC with PD-L1 expression levels (by combined positive score [CPS]) of ≥10  
• Other category 1 options for single-agent second-line or subsequent therapy include docetaxel, paclitaxel, and irinotecan.
• Other recommended combined regimens for second-line therapy include irinotecan and cisplatin, and irinotecan and docetaxel (category 2B).

European Society for Medical Oncology 

ESMO guidelines recommend surgery as the treatment of choice for patients with stage T1-T2, N0 tumors. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are the preferred resection techniques for stage T1a and are considered as an alternative to esophagectomy.  Radical and transthoracic esophagectomy is preferred for T1b-T2, N0 tumors. For non-surgical candidates, chemoradiation therapy is preferred over RT alone. ^[6]

For locally advanced disease (T3–T4), surgery alone is not standard of care and preoperative treatment is indicated. The guidelines note that while SCC patients benefit from preoperative chemotherapy, preoperative chemoradiation therapy results in higher rates of complete tumor resection and better local tumor control and survival. Weekly administration of carboplatin (area under the curve of 2 mg/ml/min) and paclitaxel (50 mg/m²) for 5 weeks and concurrent RT (41.4 Gy in 23 fractions, 5 days/week), followed by surgery is considered standard of care. ^[6]

American Society of Clinical Oncology

ASCO recommendations include the following ^{[11, 12]} :

• For patients with clinical earlier-stage esophageal cancer (T2, N0), surgery alone may be considered after discussion with a multidisciplinary team, provided the lesions are low-risk cT2N0 (ie, well-differentiated, < 2 cm) and there is a sufficient degree of confidence in the results of pretreatment staging.
• Preoperative CRT or CRT without surgery (definitive CRT) should be offered to patients with locally advanced esophageal squamous cell carcinoma.
• Following neoadjuvant CRT and surgery, nivolumab should be offered to patients with locally advanced esophageal carcinoma with Eastern Cooperative Oncology Group status 0-1 who did not experience a pathological complete response (ie, with residual disease of at least ypT1 or ypN1 in resected specimens.

European Society for Medical Oncology (ESMO) guidelines note that there is no evidence that regular follow-up after initial therapy has an impact on survival outcomes. Therefore, follow-up visits should concentrate on symptoms, nutrition and psychosocial support. However, in patients with a complete response to chemoradiotherapy and no operation, a 3-month follow-up based on endoscopy, biopsies, and CT scan may detect early recurrence. ^[6]

According to NCCN guidelines, surveillance strategies after successful local therapy of esophageal cancers remain controversial since very limited prospective data are available. Recommendations for surveillance are based on the available evidence from retrospective studies and the expertise of the panel members. ^[7]

For asymptomatic patients, NCCN recommends that follow-up include a complete history and physical examination every 3 to 6 months for 1 to 2 years, then every 6 to 12 months for 3 to 5 years, and annually thereafter. Complete blood cell count, comprehensive serum chemistry evaluation, upper GI endoscopy with biopsy, and imaging studies should be obtained as clinically indicated. In addition, some patients may require dilatation of an anastomotic or a chemoradiation-induced stricture. Nutritional assessment and counseling should be performed. ^[7]

NCCN surveillance reommendations by disease stage are listed below. ^[7]

Stage Tis or T1a without Barrett esophagus (BE): Following endoscopic resection (ER)/ablation, upper GI endoscopy (EGD) every 3 months for the first year, then every 6 months for the second year, and annually thereafter. Imaging studies for surveillance are not recommended.

Stage Tis or T1a: Following esophagectomy, incompletely resected BE should undergo ablation. EGD every 3 months for the first year, then every 6 months for the second year, and annually thereafter. Imaging studies for surveillance are not recommended.

Stage pT1b (N0 on endoscopic ultrasound [EUS]): Following endoscopic resection (ER)/ablation, esophagogastroduodenoscopy (EGD) every 3 months for the first year, then every 4-6 months for the second year, and annually thereafter.  EUS may be considered.  CT with contrast may be considered every 12 months for 3 years and then as clinically indicated.

Stage T1b, Any N: Following esophagectomy, CT with contrast should be considered every 12 months for 3 years if additional curative-intent therapy for recurrence is likely.

Following chemoradiation, EGD every 3-6 months for 2 years, then annually for 3 more years thereafter. CT with contrast should be considered every 6-9 months for 2 years and annually for up to 5 years thereafter. Patients who are candidates for salvage esophagectomy, EUS/fine needle aspiration (FNA) as indicated based on imaging results.

Stage II-III (T2-T4, N0-N+, T4b): Following chemoradiation, CT with contrast should be considered every 6 months for up to 2 years if additional curative-intent therapy for recurrence is likely.  EGD every 3-6 months for 2 years, then every 6 months for 1 more year, then as clinically indicated.  Unscheduled evaluation should be performed in symptomatic patients. 

Following trimodal therapy, CT with contrast should be considered every 6 months for up to 2 years if additional curative-intent therapy for recurrence is likely. Unscheduled evaluation should be performed in symptomatic patients. EGD should be performed as clinically indicated.

The value of carcinoembryonic antigen (CEA) and other tumor markers is unknown.

National Comprehensive Cancer Network guidelines recommend that patients with dysphagia who are not candidates for curative surgery should be considered for palliation based on symptom severity. Esophageal stent placement is most commonly used, but is generally not advised in patients who may undergo curative surgery in the future due to concerns that stent-related adverse events may preclude such surgery. ^[7]

For obstruction, recommendations vary according to the severity. For complete esophageal obstruction, options are as follows ^[7] :

• Endoscopic lumen restoration, generally performed via simultaneous retrograde (via a gastrostomy tract) and antegrade endoscopy
• If endoscopic lumen restoration is not undertaken or is unsuccessful, establish enteral access with surgical or radiologic placement of a J-tube or gastrostomy tube
• External beam radiation therapy (EBRT)
• Brachytherapy may be considered in place of EBRT if a lumen can be restored that allows for the use of appropriate applicators, and experienced practitioners are available to perform the procedure.
• Photodynamic therapy (PDT) can be effective, but has the disadvantages of associated photosensitivity and costs.
• Chemotherapy
• Surgery may be useful in carefully selected patients.

For severe esophageal obstruction (ability to swallow liquids only), options are as follows ^[7] :

• Wire-guided dilation or balloon dilation (exercise caution with malignant strictures, due to possible increased risk of perforation)
• Endoscopy- or fluoroscopy-guided placement of partially or fully covered expandable metal stents. Data suggest that larger-diameter covered expandable metal stents may have lower migration and stent occlusion rates, but they pose an increased risk for  bleeding and esophago-respiratory fistula.
• EBRT and brachytherapy both effectively treat malignant dysphagia. Onset of symptom relief is slower than with endoscopic palliation but is  likely to be more durable

European Society for Medical Oncology guidelines note that options for palliative treatment depend on the clinical situation, and offer the following recommendations ^[6] :

• For dysphagia, single-dose brachytherapy may be preferred, even after external RT, since it provides better long-term relief with fewer complications than metal stent placement.
• Chemotherapy is indicated for palliative treatment in selected patients, particularly for patients with adenocarcinoma who have a good performance status. Newer regimens based on oxaliplatin/fluoropyrimidine combinations are an alternative to the ‘classical’ cisplatin/5-fluorouracil (5-FU) schedule. Infusional 5-FU may be replaced by capecitabine if the swallowing of tablets is not compromised. Taxanes are recommended in first-line combinations or as monotherapy in second-line therapy.
• In squamous cell carcinoma, the value of palliative chemotherapy is less proved. Cisplatin-based combinations showed increased response rates but no gain in survival compared with monotherapy. Therefore, best supportive care or palliative monotherapy should also be considered

Pallative therapy for chronic blood loss from esophageal cancer is with EBRT. Acute bleeding from esophageal cancer may be a pre-terminal event resulting from tumor-related aorto-esophageal fistualization, so endoscopic assessment and intervention should be undertaken cautiously, as it may lead to precipitous exsanguination. If bleeding appears to be primarily from the tumor surface, endoscopic electrocoagulation may be useful, but the rate of recurrent bleeding is very high.

The 2013 American Society for Gastrointestinal Endoscopy (ASGE) guidelines have the following recommendations for palliative care ^[6] :

• Esophageal stent placement is the preferred method for palliation of dysphagia and fistulae.
• Patient preferences, quality of life, and prognosis should be addressed with the patient and family before initiating endoscopic palliation.