Oesophageal self-dilation is an effective way of maintaining oesophageal patency in refractory benign oesophageal strictures, with safety comparable to current standard of care. Prospective studies are needed to further validate the role of self-dilation in treatment of refractory benign oesophageal strictures.

A 72-year-old healthy woman presented to the emergency department with acute-onset epigastric pain, diaphoresis, and nausea after eating almonds and bran flakes. Her vital signs showed a blood pressure of 101/63, a pulse rate of 110, and SpO2 95% in room air. On physical examination, the afebrile 72-year-old female patient seemed to be acutely ill, but she was otherwise normal. Laboratory abnormalities were a hemoglobin level of 10.8 and a hematocrit level of 32.2. Computed tomography (CT) of the chest demonstrated a tubular intraluminal mass in the esophagus extending from the thoracic inlet to the gastroesophageal junction (Figure 1). Upper endoscopy showed a pseudolumen with submucosal dissection and intraluminal clot (Figure 2). She was made nothing by mouth (NPO) and managed with intravenous hydration, pain control, and observation. Repeat CT of the chest revealed severe thickening of the esophagus with enhancement of the serosa. Because of inability to take oral feedings, a percutaneous gastrojejunostomy tube was inserted. The patient was discharged and sent to Mayo Clinic's esophageal clinic for consultation. A review of clinical information and CT and endoscopy images led to a diagnosis of esophageal apoplexy. Over the course of a month, the patient had resolution of her chest pain and felt well, with repeat endoscopy demonstrating mild scarring of the esophagus (Figure 2). She was started on oral feedings, and the gastrojejunostomy tube was removed.

Low-dose palliative radiation may offer symptomatic relief in patients with spinal metastases from primary renal cell cancer and is unlikely to result in radiation injury. Patients with advanced malignancy requiring palliative radiation are often also receiving chemotherapy. Synergistic adverse effects resulting from combined palliative radiation and novel antiprogrammed cell death-1 (anti-PD 1) and/or multityrosine kinase inhibitors are rare. We report about a 60-year-old woman with metastatic clear-cell renal cancer, status post-left nephrectomy, with debilitating mid-back pain from metastatic tumor burden and foraminal nerve compression. Her chemotherapeutic regimen was repeatedly altered because of progression of disease until she was maintained on the anti-PD 1 checkpoint inhibitor, nivolumab. She received palliative radiation to her thoracic spine over a 2-week period, and nivolumab was then switched to cabozantinib midway through a course of palliative radiation. The patient rapidly developed severe esophagitis, progressing to esophageal stricture, and required placement of a percutaneous endoscopic gastrostomy tube. She was successfully treated with serial esophageal dilation and hyperbaric oxygen treatments to diminish inflammation and improve tissue vascularity. Concurrent use of anti-PD 1 and/or multityrosine kinase drugs may accelerate development of radiation injury regardless of radiation dosage. Radiation-induced esophageal stricture was managed successfully in this patient with serial esophageal dilation and adjuvant hyperbaric oxygen.

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