Non-cancerous ulcer in the esophagus after radiotherapy for esophageal carcinoma--a report of 27 patients

A Case of Refractory Esophageal Ulcer Caused by Radiotherapy for Hepatocellular Carcinoma

A 77-year-old man who underwent radiotherapy for hepatocellular carcinoma 6 months prior consulted for esophageal obstruction. Esophagogastroduodenoscopy revealed an esophageal ulcer caused by radiotherapy for hepatocellular carcinoma. He was treated with dietary counseling and vonoprazan. After 9 months, the ulcer improved but a moderate stenosis remained. Several factors such as high fraction size, history of chemotherapy, and stress associated with food intake might involve in the development of a radiation-associated ulcer. Opportunities to choose radiotherapy for hepatocellular carcinoma may increase, so we hypothesize that esophageal ulcers might be a complication that should be noted associated with this therapy.

Oesophagus side effects related to the treatment of oesophageal cancer or radiotherapy of other thoracic malignancies

The oesophagus as a serial organ located in the central chest is frequent subject to "incidental" dose application in radiotherapy for several thoracic malignancies including oesophageal cancer itself. Especially due to the radiosensitive mucosa severe radiotherapy induced sequelae can occur, acute oesophagitis and strictures as late toxicity being the most frequent side-effects. In this review we focus on oesophageal side effects derived from treatment of gastrointestinal cancer and secondly provide an overview on oesophageal toxicity from conventional and stereotactic fractionated radiotherapy to the thoracic area in general. Available data on pathogenesis, frequency, onset, and severity of oesophageal side effects are summarized. Whereas for conventional radiotherapy the associations of applied doses to certain volumes of the oesophagus are well described, the tolerance dose to the mediastinal structures for hypofractionated therapy is unknown. The review provides available attempts to predict the risk of oesophageal side effects from dosimetric parameters of SBRT.

Chemoradiation in conservation therapy for esophageal cancer

Irradiation alone can be highly beneficial for patients with advanced or metastatic esophageal cancer, but external beam irradiation alone is now usually reserved for patients only requiring palliation. Higher cure rates are achieved with irradiation delivered with radiosensitizing chemotherapy based on clinical trials performed over the last decade. Chemoradiation programs based on the modest success with infusional 5-FU, cisplatin, and 50 Gy are justified for either palliative or curative treatment as long as the toxicity is acceptable. One challenge is to increase the incidence of pathologic complete response rates without incurring unacceptable acute toxicity, which is the major dose-limiting factor in current trials. Newer methods that may ameliorate acute injury are different dose schedules for chemoradiation and different methods of dose delivery. Infusional administration of chemotherapy and new dose planning and delivery systems for irradiation (conformal irradiation) are currently under study. Organ preservation for larger numbers of patients may be possible if any of these methods hold up to the early indications of success.

High dose rate brachytherapy before external beam irradiation in inoperable oesophageal cancer

To induce fast relief of dysphagia in patients with oesophageal cancer high dose rate (HDR) brachytherapy was applied before external radiotherapy in a prospective study. Seventy-four patients with inoperable oesophageal cancer (36 squamous cell, 38 adenocarcinoma) were treated with a combination of 10 Gy HDR brachytherapy, followed by 40 Gy in 4 weeks external beam radiotherapy (EBRT), starting 2 weeks later. Tumour response, as measured by endoscopy and/or barium swallow, revealed complete remission in 21 and partial response in 38 patients (overall response rate 80%). Improvement of dysphagia was induced by brachytherapy within a few days in 39%, and achieved at the end of treatment in 70% of patients. Further weight loss was prevented in 39 of the 59 patients who presented with weight loss. Pain at presentation improved in 12 out of 25 patients. Median survival was 9 months. No differences in either response rate or survival were found in squamous cell or adenocarcinoma. Side-effects were either acute with minimal discomfort in 32 (42%) or late with painful ulceration in five patients (7%), occurring after a median of 4 months. A fistula developed in six patients, all with concurrent tumour. In conclusion, brachytherapy before EBRT was a safe and effective procedure to induce rapid relief of dysphagia, especially when combined with EBRT.

Modulation of toxicity following external beam irradiation preceded by high-dose rate brachytherapy in inoperable oesophageal cancer

To induce fast relief of dysphagia in inoperable oesophageal cancer, we applied high-dose rate (HDR) intraluminal irradiation followed by external irradiation (EBRT) in a phase II study. 15 patients (group A: n = 15; 10 men, 5 women; median age 66 years) were treated with 10 Gy HDR brachytherapy plus 40 Gy EBRT (15 fractions of 2.67 Gy). Severe side-effects were encountered in 60% of patients: 3 late ulceration, 2 pending fistula, 2 fistula and 2 patients with fatal haemorrhage after an interval of 6 months. Overall response was excellent: 9 complete remissions (60%) and 6 partial responses (40%). Because of the high toxicity rate, in a subsequent study (group B: n = 30; 23 men, 7 women; median age 66 years) the EBRT scheme was changed using smaller fractions (2.0 Gy) to reach the same total dose of 40 Gy. The complication rate (17%) was significantly reduced, while the overall response remained excellent (83%): 17 complete and 8 partial responses. The impressive change in complication rate of HDR brachytherapy and EBRT stresses the impact of the fraction per dose and illustrates the small therapeutic margins.

Esophageal ulceration following high-dose-rate intraluminal brachytherapy for esophageal cancer

Prophylaxis of esophageal ulceration was studied in 78 esophageal carcinoma patients after high-dose-rate intraluminal brachytherapy. Before the standard treatment regimen of radiotherapy was established, 15/17 patients developed ulcers. This decreased to 19/38 with the standard treatment regimen, and to 9/23 when antiulcer therapy was added (p < 0.01).

Combined external beam and low dose rate intraluminal radiotherapy in oesophageal cancer

Thirty-five patients with oesophageal cancer were treated with external beam irradiation (50-60 Gy) followed by a boost-dose of 15-20 Gy by means of low dose rate intraluminal brachytherapy. Of the 35 patients treated 17 (48%) were pretreated with laser therapy or dilation alone. Although the intraluminal application time was long (up to 36 h) the treatment was feasible with minor acute toxicity. The palliative effect of the combined treatment was excellent; a 6 weeks post-treatment 32 of the 35 patients were able to eat solid food. Late complications were seen in six patients (17%), of which only one was severe and probably treatment-related. The median survival was 11 months; the 1- and 2-year survival were 42% and 10% respectively. The survival was strongly dependent on local control. Distant metastases became evident in 23% of patients. The interval between external radiotherapy and brachytherapy seemed to be critical. The results were compared with 68 historical controls. A significantly better survival was observed at 6 months. It is concluded that low dose rate intraluminal brachytherapy is a useful and feasible technique to increase the total dose for obtaining a better local control. The shortcomings are discussed and ideas for further improvement are mentioned.