[Radiotherapy in the multimodal treatment of esophageal carcinoma. A review]

Retrospective evaluation of combined modality treatment and prognostic factors in patients with esophageal cancer

The influence of prognostic factors and combined modality treatment on survival was evaluated retrospectively for 156 patients with esophageal cancer receiving radiotherapy in different modalities between 1991 and 2001 at the University of Heidelberg and the Universitätsklinikum Mannheim. Forty-six patients (29.5%) were treated with radiotherapy alone, 74 patients (47.4%) had combined radiochemotherapy and 36 patients (23.1%) were operated on after receiving neoadjuvant radiochemotherapy. The median follow-up time was 10 months. Female patients showed a significantly better overall survival compared with male patients (p=0.031), younger patients (age </=60 years) a significantly better survival compared to older patients (age>60 years) (p=0.02). Patients with hemoglobin concentration>13.4 g/dl before therapy (median hemoglobin concentration) had a significantly better overall survival than patients with lower hemoglobin concentration (p=0.044). Patients who received combined radiochemotherapy (with or without operation) had a survival advantage compared with radiotherapy alone. Overall survival after neoadjuvant treatment followed by operation was significantly better than in the two other groups, median survival times were 20 vs. 9 (RCHT) vs. 8 months (RT) (p=0.003). The data presented show for the first time that hemoglobin concentration in addition to gender and age was a prognostic factor for patients with esophageal cancer. A low hemoglobin value was a negative predictor.

Clinical application of self-expandable medical memorial metallic stent with iodine-125 seeds in treatment of esophageal carcinoma

AIM: To analyze the curative effect of self-expan-dable medical memorial metallic stent with iodine-125 seeds in the treatment of esophageal carcinoma at advanced stage.

METHODS: Forty-five patients with esophageal carcinoma at advanced stage were divided into group A and B. The patients in group A were treated with normal self-expandable stents, while those in group B received the stents with iodine-125 seeds. After the operation, the patients were followed up and their complications and survival time were analyzed.

RESULTS: The stents were successfully implanted in all the 45 patients. The patients were obviously relieved from their difficulties in swallowing. The survival time of patients in group A were 90-300 d, with an average of 171 ± 56 d, and those in group B were 120-450 d, with an average of 316 ± 116 d. There was significant difference between them (t = -3.385, P < 0.05).

CONCLUSION: Self-expandable stent with iodine-125 seeds can obviously alleviate the symptoms of difficulty in swallowing, improve the patients' life quality and survival time.

Daytime pulsed dose rate brachytherapy as a new treatment option for previously irradiated patients with recurrent oesophageal cancer

The aim of this study was to evaluate the feasibility, effects, and toxicity of pulsed dose rate (PDR) brachytherapy for re-irradiation of oesophageal carcinoma. A total of 16 patients (median age 67 years) with inoperable recurrences from oesophageal cancer after primary radio-(chemo)-therapy (median 50 Gy) were re-irradiated using PDR brachytherapy ((192)Ir, 37 GBq). Treatment was carried out on an outpatient basis applying a weekly 5 Gy daytime schedule (0.5 Gy pulse(-1) h(-1), total dose 15-20 Gy). The dose was prescribed 10 mm from the mid-dwell position and encompassed the clipped tumour extension with 2 cm margins. The use of clips for delineation of tumour extent and catheter movement during irradiations was evaluated. All 61 PDR treatments were applied safely. The median catheter movement was 5 mm, range 2-12 mm. After a median follow-up of 8 months, three patients had a complete and five a partial remission. Body weight increased in 5 of 16 (31%) and was stable in 4 of 16 (25%) patients, respectively. The median grade 2 (RTOG/EORTC) dysphagia-free survival was 17 months. Seven patients experienced grade 1, five grade 2, and one grade 3 late toxicity. Three patients with uncontrolled locoregional disease showed grade 4 complications (oesophago-tracheal fistulae (n=2), fatal arterial bleeding (n=1). Daytime PDR brachytherapy proved to be feasible and provided effective palliation. Toxicity remains a major problem. Thus, total dose should be restricted to <15 Gy in this palliative situation.

Palliative treatment by high–dose-rate intraluminal brachytherapy in patients with advanced esophageal cancer

PURPOSE

The aim of this work was to analyze the results of palliative HDR brachytherapy in patients with advanced esophageal cancer.

METHODS AND MATERIALS

Ninety-one patients with unresectable, advanced esophageal cancer were treated palliatively by HDR brachytherapy. All patients received a total dose of 22.5 Gy in three fractions per week. Remissions of dysphagia and other clinical and radiological factors were assessed in the first month posttreatment, and then in the third, sixth, and twelfth months. The survival rate was compared with some chosen clinical factors using a log-rank test and the Kaplan-Meier method.

RESULTS

The median survival time among all patients was 8.2 months. The median survival time according to the obtained remission was 14.6, 7.2, and 3.8 months (log-rank p = 00001, F Cox p = 0.00001) for complete remission (CR), partial remission (PR), and lack of remission (NR), respectively. A longer median survival time was observed when tumor size was less then 5 cm (12.1 months), than between 5 and 10 cm (7.8 months), or longer than 10 cm (6.4 months) (log-rank p = 0.002). Longer median survival times were observed in clinical stage II (14.1 months), compared with clinical stage III (7.7 months) and IV (7.2 months) (log-rank p = 0.01). Significant correlations were found between survival and the Karnofsky Performance Status, grade of dysphagia, and age.

CONCLUSIONS

HDR brachytherapy for advanced esophageal cancer allowed for improvement of dysphagia in most patients. The complete or partial remission, the older age of patients, and the lower grade of dysphagia observed in first month posttreatment were the most important prognostic factors allowing for prolonged survival (confirmed by a multivariate analysis). In the univariate analysis, important prognostic factors for prolonged survival were: a higher Karnofsky Performance Status, a lower clinical stage and a small tumor size.

Perioperative radiotherapy for cancer of the esophagus

Carcinomas of the esophagus represent on average about 1% to 2% of all malignant tumors. The incidence shows extreme regional differences, reflecting the established environmental and acquired risk factors for cancer of the esophagus. There has been a major shift in tumor location and histology over the last decades, with the lower third/gastroesophageal junction becoming the most common location and adenocarcinoma the most common histology in white males. There has been a striking improvement in surgical resection rates and operative mortality; however, the curative potential of surgery is likely to be highest in early-stage disease. The poor prognosis for locally advanced tumors motivated the search for multimodal approaches to improve results. While neither perioperative radiotherapy nor perioperative chemotherapy alone have significantly improved survival rates, combined radiochemotherapy, used as neoadjuvant or definitive therapy, appears more promising. For patients with advanced tumors or extensive nodal involvement, first principles and extrapolation from other tumors of the gastrointestinal tract suggest that a combination of chemotherapy and radiation is likely to be of benefit, as compared to surgery alone. As this treatment is difficult to tolerate in the postoperative setting, neoadjuvant approaches have been emphasized. Although there are promising data, and preoperative chemoradiation is widely utilized, we do not consider the benefit of this approach to have been proven unequivocally. Future progress in the treatment of esophageal cancer may require that systemic therapy be improved to the point where occult metastatic disease can be controlled, enabling the local control provided by surgery and radiation to lead to improved survival.