Comparison of efficacy and safety of low-dose-rate vs. high-dose-rate intraluminal brachytherapy boost in patients with superficial esophageal cancer

Chemoradiotherapy Combined with Brachytherapy for the Definitive Treatment of Esophageal Carcinoma

This study aims to investigate the effect of dose escalation with brachytherapy (BT) as an addition to definitive chemoradiotherapy (CRT) on local control and survival in esophageal cancer. From 2001 to 2020, 183 patients with locally limited or locally advanced esophageal cancer received definitive CRT with or without brachytherapy in a two-center study. External-beam radiotherapy was delivered at 50.4 Gy in 1.8 Gy daily fractions, followed by a sequential boost to the primary tumor of 9 Gy in 1.8 Gy daily fractions if indicated. Intraluminal high dose rate (HDR) Ir-192 brachytherapy was performed on 71 patients at 10 Gy in two fractions, with one fraction per week. The combined systemic therapy schedules used included 5-fluorouracil/cisplatin or 5-fluorouracil alone. Cisplatin was not administered in patients receiving brachytherapy. The median local progression-free survival was significantly extended in the BT group (18.7 vs. 6.0 months; p < 0.0001), and the median local control was also significantly prolonged (30.5 vs. 11.3 months, p = 0.008). Overall survival (OS) significantly increased in the BT group (median OS 22.7 vs. 9.1 months, p < 0.0001). No significant difference in the overall rate of acute toxicities was observed; however, the rate of acute esophagitis was significantly higher in the BT group (94.4% vs. 81.2%). Likewise, the overall rate of late toxicities (43.7% vs. 18.8%) was significantly higher in the BT group, including the rate of esophageal stenosis (22.5% vs. 9.8%). There was no difference in the occurrence of life-threatening or lethal late toxicities (grades 4 and 5). Brachytherapy, after chemoradiation with single-agent 5-FU, represents a safe and effective alternative for dose escalation in the definitive treatment of esophageal cancer.

The role of brachytherapy in treatment of stage I esophageal cancer: A systematic review

PURPOSE

Despite advancements in the early detection of esophageal cancer, optimal radiotherapy methods for treatment of early disease have not yet been determined. Moreover, the benefit of intraluminal brachytherapy on local control or survival remains controversial. We performed a systematic review to establish the role of brachytherapy as boost therapy in stage I esophageal squamous cell carcinoma, and to evaluate associated survival outcomes.

METHODS AND MATERIALS

A systematic search of three bibliographic databases from January 1950 to January 2019 was conducted. All studies investigating brachytherapy for curative intent were included and palliative treatment was excluded. Primary outcomes included overall survival and disease-free survival (DFS). Secondary outcomes included loco-regional control (LRC) and toxicity grades and/or complications. Two reviewers independently abstracted data and evaluated study quality using grading of recommendations assessment, development, and evaluation, pooled results were presented through risk ratios.

RESULTS

A total of 12 retrospective studies met inclusion criteria. The overall quality of evidence yielded a Grade 1C rating (strong recommendation, low quality evidence). Of 525 included patients, 325 patients received both external beam radiation (EBRT), and brachytherapy, 132 underwent EBRT only, and 68 received brachytherapy with and/or without chemoradiation. For patient group treated with EBRT and brachytherapy, 5-year mortality, DFS and LRC were: 43% (27-59%), 63% (49-76%) and 72% (63-80%) respectively. Rates of complications reported included 82.1% Grade 1 esophagitis for a combined external beam radiation and brachytherapy cohort, 12.3% ulcerations, and 3.3% fistulae.

CONCLUSIONS

Brachytherapy as a combined modality is encouraging, given its relative safety and effectiveness. Further prospective analysis using higher quality evidence is warranted to evaluate oncologic outcomes and survival advantage.

Pre-clinical dosimetry of a new six-channel applicator for high-dose-rate treatment of esophageal cancer

Purpose

To evaluate the dosimetry of a six-channel high-dose-rate (HDR) applicator for treatment of esophageal cancer with respect to lateral directionality and heterogeneous media.

Material and methods

A computed tomography (CT)- and magnetic resonance imaging (MRI)-compatible esophageal applicator consisting of 2 inflatable portions (anchor and therapeutic balloons) with 6 longitudinal treatment catheters equally spaced circumferentially was constructed. Treatment plans were prepared using Oncentra 4.5 for various catheter loadings and target locations and sizes. Calculated dose distributions were compared to measured distributions obtained using film and a water phantom. Balloon inflations with water and with air were tested.

Results

TG-43 dose calculations matched measurements well when inflation balloons were filled with water. When air was used to inflate, model-based dose calculations (TG-186) improved the comparison with measurement. Several cases with simulated ring targets demonstrated better dose conformity to non-uniform targets compared to a single central catheter. Additionally, the use of this applicator compared to a single catheter, gave rise to considerable improvement in sparing non-target tissue.

Conclusions

Lateral dose modulation is achievable with the applicator described in this work. The use of TG-186 dose calculation made a small improvement in heterogeneous media.

Brachytherapy for Oesophageal Carcinoma: A Comprehensive Review of Literature and Techniques

Introduction:

Oesophageal carcinoma is one of the fatal cancers mainly because of its rapid spread and poor prognosis. Treatment modalities involves a multimodality approach, including surgery, radiation therapy and chemotherapy. Radiation therapy includes brachytherapy in the form of intraluminal radiation therapy. Brachytherapy permits delivery of high tumouricidal doses to superficial cancerous growth of the oesophagus while delivering much lower doses to the surrounding tissue. It is mostly given in combination with external beam radiation in patients with poor performance scores not likely to tolerate an aggressive chemoradiation regimen or as a boost to concurrent chemoradiotherapy. It is very effective in terms of local tumour control as well as in relieving symptoms in advanced/recurrent disease. Intraoperative brachytherapy and seed brachytherapy have also been tried to address the nodal disease.

Methods:

We undertook a review of the available literature and techniques developed in the past three decades to emphasise the role of brachytherapy in curative or palliative settings in the treatment of oesophageal carcinoma.

Conclusion:

Oesophageal brachytherapy will remain a tangible treatment of oesophageal cancer, although it is less commonly used due to high expertise requirement, lack of established evidence, risk of life-threatening complications and lack of interest in brachytherapy. It offers quick and useful palliation for a prolonged period, along with good quality of life and superior dosimetry. Use of novel applicators may allow dose escalation and lower toxicity. Seed brachytherapy is also emerging as a promising option in nodal recurrences.

Esophageal brachytherapy: Institut Gustave Roussy's experience

PURPOSE

Esophageal cancer is characterized by its propension to local evolution, which conditions prognosis and quality of life. Brachytherapy may be a therapeutic option for all stages of esophageal cancer.

METHODS AND MATERIALS

This retrospective unicentric study included all consecutive patients treated for an esophageal high-dose-rate brachytherapy in our institution from 1992 to 2018.

RESULTS

Ninety patients were included. They were treated in four distinct indications: exclusive (7 patients), boost after external beam radiotherapy (41), reirradiation (36), or palliative aim (6). Most frequently prescribed schemes were 3 × 5 Gy (boost) or 6 × 5 Gy (exclusive treatment and reirradiation) at applicator's surface or at 5 mm. At the end of follow-up, 50% of patients had presented with local recurrence. Seventeen percent of patients had a metastatic relapse. Median overall survival was 15 months in the whole cohort: 22 months in the boost setting, 25 months for exclusive brachytherapy, 15 months for reirradiation, and only 2 months for palliative treatment. Tumor length at brachytherapy, brachytherapy dose, and interfraction response were significantly associated to overall survival. 40% of patients presented with grade 2+ toxicity, mostly esophagitis, including three toxic deaths.

CONCLUSIONS

Although local control outcomes are still poor, one must remember that patients are unfit for any curative therapeutic option and that palliative chemotherapy offers mediocre results. The most promising setting probably is reirradiation because brachytherapy offers a remarkable dose gradient allowing best organ at risk sparing, with an encouraging rate of long survivors (19% at 2 years). Esophageal brachytherapy deserves to be further investigated because some patients, even unfit, may benefit from it, with acceptable toxicity.

Oesophageal perforation during neo-adjuvant brachytherapy for oesophageal squamous cell carcinoma

Neo-adjuvant brachytherapy (NBT) for oesophageal cancer is under rapid development in recent years and more reports are required to elucidate its complications and drawbacks. Here, we report a case treated for NBT whose oesophagus was perforated during the procedure and mention necessary precautions to avoid it. A 73 year old male whose upper gastrointestinal endoscopy showed a lesion extending from 29 cm to 33 cm of the incisors with a histology of poorly differentiated squamous cell carcinoma, without metastases. Endoscopic ultrasonography diagnosed a T3 N0 grade tumour. He was selected for NBT and neo-adjuvant chemotherapy. The patient received 5 Gy in the first session of NBT, but in the second session before receiving the same dosage his control chest X-ray showed the tip of the catheter to be out of the oesophageal tract. After confirmation of the perforation by Gastrografin, we performed total oesophagectomy combined with a gastric pull-up procedure. To our best knowledge, our case is the first reported complication related to the direct effect of the catheter and tissue manipulation rather than the radiation beam. Weakness in the oesophageal wall due to tumour involvement makes it prone to perforation by any rigid catheter.

Intraluminal brachytherapy in oesophageal cancer: defining its role and introducing the technique

Intraluminal brachytherapy plays an important role in the treatment of oesophageal tumours. This article aims to define this role in the curative as well as in the palliative treatment settings drawing on data from the literature, and also emphasizing its potential for harm when used inexpertly. It also provides a short introduction to practical aspects of the treatment procedure and treatment planning.