Surgical radical resection is the first choice of treatment for resectable esophageal carcinoma. Unfortunately, the vast majority of patients with esophageal cancer do not go to the hospital until the onset of significant dysphagia, often being diagnosed late stage and losing the chance of radical surgical resection. The prognosis of surgical radical resection is still poor and the survival rate ranges from 15 to 20% due to the recurrence of residual carcinoma and tumor metastasis. Nowadays, neoadjuvant chemotherapy and/or radiotherapy has been attempted to improve the survival time and local control rate [13]. For the systematic chemotherapy, fluorouracil plus cisplatin is the first-line chemotherapy regimen, and oxaliplatin based regimen (epirubicin + oxaliplatin + 5-Fu) is also effective for advanced esophageal carcinoma [14]. However, the incidence of postoperative complications may increase, such as esophageal fistula and esophageal tracheal fistula, which is a main concern for both doctors and patients.

DEB-TACE is an effective local interventional treatment with low adverse reaction due to slow release of chemotherapeutic drugs and embolization of tumor-feeding arteries, and has been used clinically for many kinds of cancer, such as hepatocellular carcinoma [8, 15] and refractory lung cancer [5, 6, 16,17,18]. DEB-TACE could theoretically improve antitumor efficacy and reduce the toxicity of chemotherapeutic drugs if compared with conventional TACE and intravenous chemotherapy. Currently, few studies have been reported except for one case report [19] and one study with doxorubicin-eluting CB for advanced esophageal carcinoma [20]. To our knowledge, DEB-TACE with oxaliplatin-loaded CB has not been reported for the treatment of unresectable or recurrent esophageal carcinoma.

In the present study, 22 patients with unresectable or recurrent esophageal carcinoma were treated with DEB-TACE; there were 2 (14.3%) cases of complete response, 6 (42.9%) cases of partial response, and 3 (21.4%) cases of stable disease 6 months after treatment. The objective response rates were 62.5%, 42.9% and 57.1% respectively at 1-, 3-, and 6-months after DEB-TACE. Our result seem better than previous report with doxorubicin-eluting CB for advanced esophageal carcinoma [20], in which, the objective response rates were 42.9%, 28.6% and 20.0% respectively at 1-, 3-, and 6-months after DEB-TACE. In the previous study [20], the median overall survival was 9.4 months, and the 3-, 6- and 12-month overall survival rates were 75.5%, 55.0 and 13.8%, respectively. In this current study, the median overall survival was 13.9 months and the 3-, 6- and 12-month overall survival rates were 90.0%, 85.0 and 65.0%, respectively. It’s indicating that oxaliplatin-loaded CB shows a better survival outcome than doxorubicin-eluting CB for advanced esophageal carcinoma.

Unlike TACE or DEB-TACE treatment for advanced hepatocellular carcinoma, the key to TACE or DEB-TACE treatment for advanced esophageal carcinoma is to find all accurate tumor-feeding arteries, considering that the tumor-supplying arteries are more variable and complex. The feeding artery of esophageal carcinoma is closely related to the tumor location, which is conducive to the operator to find the correct tumor-feeding artery. For patients with carotid esophageal carcinoma, inferior thyroid artery is often the supply artery of tumor mass; the proper esophageal artery and bronchial artery should be found out for patients with thoracic esophageal carcinoma. Besides, the left gastric artery and right gastroepiploic artery is the main tumor-feeding artery supply vessel for tumor located in esophageal cardiac junction. In our study, 50 tumor-feeding arteries were embolized, including the bronchial arteries (n = 6), the internal mammary arteries (n = 5), the proper esophageal arteries (n = 4), the right gastroepiploic arteries (n = 5), the left gastric arteries (n = 21) and other tumor-feeding arteries (n = 9). A microcatheter was used for superselective catheterization in 31 procedures to prevent drug reflux and ectopic embolization.

Regarding safety, no serious complications were observed in this study, which is similar to previous reports [6, 20, 21]. Unlike solid malignancies (e.g., hepatocellular carcinoma, lung cancer), if malignant tumors of cavity organs (e.g., esophageal, gastric, and colorectal cancer), are treated with TACE or DEB-TACE, researchers often worry about the risk of perforation and rupture of cavity organs. Based on our clinical experience, the choice of an appropriate embolization endpoint is crucial. The disappearance of tumor staining was considered the embolization endpoint and additional embolization of the main tumor-feeding artery to complete stasis of blood flow is not recommended.

Previous studies have shown that DEB-TACE with doxorubicin-loaded beads seems safe for gastric cancer and colorectal cancer [6, 21]. It’s reported that DEB-TACE with doxorubicin-loaded beads was conducted in 21 patients with with unresectable or recurrent esophageal carcinoma, and no serious complications were observed, including procedure-related deaths, massive bleeding, and esophageal perforation [20]. No serious complications were observed in this preliminary study, which seems to confirm that DEB-TACE with oxaliplatin-loaded beads is also safe in the treatment of esophageal carcinoma.

Subsequent interventional treatments are other factors that may be able to influence patient survival and prognosis, such as esophagus stenting, airway stenting and radioactive 125I seeds implantation. Patients with advanced esophageal cancer often have severe dysphagia due to esophageal stricture, and the placement of esophageal stent to improve the nutritional status of patients is beneficial to patient survival. It’s also important to treat life-threatening complications caused by esophageal cancer, such as severe airway stricture, and airway stenting can avoid death as much as possible. In this study, airway stent implantation was performed in 5 patients with severe airway stricture. Additionally, TACE and 125I seeds implantation of esophageal cancer metastases (such as hepatic metastasis) may also prolong patient survival.

There were some limitations. This is a single-center retrospective study, and selection bias may be present. As a cavity organ that is not easy to measure, there is no standard for the efficacy evaluation of esophageal cancer, and our response evaluation by RECIST 1.1 may not be accurate enough. The sample size was small and only 22 patients were enrolled in this study. There was no control group and lack of comparison with chemotherapy, TACE or radiotherapy is a major shortcoming, it is unknown whether this treatment has advantages in terms of cost and efficacy. Thus, further multicentre, prospective studies with large sample size and comparison are required to validate the true efficacy and safety of DEB-TACE for esophageal carcinoma.