How would you manage dysphagia and odynophagia in an otherwise healthy patient with newly diagnosed metastatic esophageal cancer with a large primary in the mid to distal esophagus?

Depending on patient goals of care, in an otherwise healthy patient starting with chemo to address both the esophageal cancer causing dysphagia as well as the systemic disease is also our preferred plan as well, with analgesics as needed for the odynophagia. Along with dietary modifications perhaps in consultation with a dietician, many patients seem to be able to avoid ever needing RT. An individualized, multidisciplinary approach is essential in these difficult situations.

I agree that planning for both RT & a stent should be avoided due to toxicity concerns. Working with the University of Utah team, we recently had publication accepted (Francis et al., IJROBP 2017) involving a series of 103 patients treated with definitive or neoadjuvant ...

This is a question that comes up frequently and has different answers depending on the context. In general, patients tend to tolerate stents in the distal esophagus poorly. That is because this typically requires the lower esophageal sphincter to be stented open, causing terrible acid reflux. In this situation, I usually advocate for palliative RT. If the lesion is higher up, then the question is really informed by two pieces of information: the severity of the dysphagia and the patient's prognosis. If the patient has some trouble swallowing, but has been able to maintain his or her weight with dietary modification, I think it is reasonable to even start chemotherapy in an untreated patient and observe for a clinical response in the esophag...

Here at our institution, we just completed a 10-patient pilot study of upfront cryotherapy before chemoradiotherapy. The publication is forthcoming. It was a safety study, and 0% had any complications. Almost all patients had significant symptom relief, but for many this was only transient. Nonetheless, it helped all of them avoid a stent - something which was previously being offered here, and an impetus to design this study in the first place. It may be instructive to share that we had previously witnessed several complications with esophageal stents, including one that led to a fatal aspiration.

Though it won't relate to mestastic patients, we are moving forward with a larger study to assess whether it can also improve esophagectomy-free...

We tend to place a J-tube and start the patient on FLOT chemotherapy. Often the tumor regresses adequately to take oral hydration and nutrition after the 2nd cycle. Here is the FLOT regimen from ASCO this year:

http://meetinglibrary.asco.org/record/147174/abstract