116-5107/90/3601-0043$02.00 ASTROINTESTINAL ENDOSCOPY opyright © 1990 by the American Society for Gastrointestinal Endoscopy Jse of ethanol-induced tumor necrosis to Jalliate dysphagia in patients with 3sophagogastric cancer J. J. Payne-James, FRCS, FRCSEd, R. C. Spiller, MD, MRCP J. J. Misiewicz, FRCP, D. B. A. Silk, MD, FRCP London, United Kingdom :Ieven patients with dysphagia caused by inoperable, unresectable, or recurrent cancer were treated by endoscopic injection of ethanol (with or without per-oral dilation) to induce tumor necrosis. Prior to treatment, patients had a mean dysphagia grade of 3. After one treatment, dysphagia grade had improved to a mean of 1.5. An optimum dysphagia grade (mean, 0.9) was achieved after a mean of 1.6 injection treatments. Treatments were repeated as symptoms recurred, with a mean period between repeat treatments of 32 days (median, 26). There were no complications associated with ethanol-induced tumor necrosis (ETN). Mean patient survival was 140 days (median, 109). These results suggest that ETN has considerable potential for palliation of malignant dysphagia in selected patients. (Gastrointest Endosc 1990;36:43-46) Prognosis for patients with carcinomas of the esophagus and stomach is poor, and most patients are beyond cure by the time the diagnosis has been made. Palliation of symptoms, predominantly dysphagia, is therefore often the main aim of treatment. Surgery offers the possibility of complete relief of dysphagia with an acceptably low mortality rate,1 even within the elderly population. 2 There are, however, three groups of patients, those with inoperable tumors, those with unresectable tu- mors, and those with recurrent tumors, in whom sur- gery is not possible and for whom an effective method of palliation is needed. It has been stated that the ideal palliative technique should be "quick, safe, pain- less, needing only a short inpatient stay, and a low complication rate.,,3 To this list could be added, "easily repeatable, but only needing repetition infrequently," as regrowth of tumor and recurrence of symptoms is common. Four main methods of palliation of malig- nant dysphagia are available, each with differing ad- vantages and disadvantages. Intubation of the malig- Received December 1, 1988. For revision April 3, 1989. Accepted July 19, 1990. From the Department of Gastroenterology and Nutrition, Central Middlesex Hospital, London, United Kingdom. Reprint requests: J. J. Payne-James, FRCS, Department of GaBtro- enterology and Nutrition, Central Middlesex Hospital, Acton Lane, London NWlO 7NS, United Kingdom. VOLUME 36, NO.1, 1990 nant obstruction, by either a surgical or an endoscopic technique, has been shown to be effective in improving quality of life, albeit with an associated morbidity and mortality.4,5 Per-oral endoscopic dilation by itself ful- fills most of the criteria for an ideal palliative tech- nique, but may require repeating on many occasions, sometimes on a weekly basis. G ,7 Radiation therapy is predominantly suitable for squamous cell carcinomas, and despite increasingly sophisticated techniques (some requiring general anesthesia 8 ) the degree of palliation may not be markedly different from other methods. 9 Recent studies have demonstrated the use- fulness of laser,1O-12 but this equipment is not readily available in a majority of hospitals at present. Despite the variety of palliative techniques, it is apparent that the optimal therapy has not yet been found for this difficult group of patients. Clearly it is desirable to keep hospital attendances and length of inpatient stay to a minimum. Encouraging results using dehydrated alcohol to cause necrosis and destruction of gastric cancer have been reported. 13 Injection of sclerosant solutions into the esophagus for the treatment of esophageal varices has become an established proce- dure that has been performed on an outpatient ba- SiS. 14 ,15 The possibility was considered that malignant dysphagia related to esophageal or gastric cardia neo- plasms could be palliated by direct injection of tumor with alcohol via an endoscope, thereby inducing tumor 43