Brachytherapy in the Palliation of Oesophageal Cancer: Effective but Impractical?

Endoscopic Palliative Therapies for Esophageal Cancer

Endoscopic palliation of dysphagia for patients with inoperable esophageal cancer is complex, highly dependent on local expertise, and best done in a multidisciplinary fashion. Systemic therapy is the standard of care because it has been shown to improve survival. Esophageal stenting has traditionally been the most used endoscopic modality. Some modalities such as laser and photodynamic therapy are rarely used. There has been an increasing amount of data on cryotherapy, especially for patients with mild-to-moderate dysphagia on systemic chemotherapy. This article will discuss the latest evidence guiding the palliation of esophageal cancer.

Conformal 3D computed tomography planned endoluminal brachytherapy for the local control of esophageal cancer

PURPOSE

To outline the toxicity, tolerability, and efficacy of a 3D conformal computed tomography planned endoluminal brachytherapy (ELBT) treatment for esophageal adenocarcinoma (OAC) or squamous cell carcinoma (OSCC).

METHODS AND MATERIALS

A retrospective single-center analysis of toxicity, tolerability, and outcomes for 65 consecutive patients with OAC/OSCC who received 6-8Gy in one fraction or 12-16Gy in two fractions of high-dose-rate ELBT as salvage postchemoradiotherapy (n = 7 and n = 14 respectively), or as a boost to external beam radiotherapy (n = 14 and n = 30, respectively).

RESULTS

Median overall survival from the first brachytherapy application was 7.4 (IQR 5.0-14.7) months for the boost cohort and 9.2 (IQR 5.8-20.1) months for the salvage cohort. In a univariate analysis, use of a higher, fractionated dose of radiotherapy was associated with longer overall survival. At least one-third (33%; n = 7) of the salvage cohort and 28% (n = 12) of the boost cohort exhibited a local recurrence prior to death. Overall, 66.7% of the salvage and 56.8% of the boost cohort experienced odynophagia. Swallow function stabilized or improved early after treatment, with only 11.6% of the boost and 14.3% of the salvage cohort demonstrating a long-term decline in dysphagia score.

CONCLUSIONS

3D conformal planned ELBT is safe and tolerable. Most patients exhibit an early and sustained stabilization or improvement in their swallow function and greater survival is seen with higher brachytherapy doses. Further research is required to determine the place of brachytherapy in the management of esophageal cancer, particularly when planned using contemporary conformal approaches.

Organ and Function Preservation in Gastrointestinal Malignancies

Radiation plays an important role in organ preservation for gastrointestinal malignancies, with a watch and wait strategy enabling surgery to be avoided in patients who are not suitable or who are refusing surgery. Brachytherapy boost allows the radiation dose to be escalated, which plays a pivotal role in the successful outcome of achieving organ preservation. Here we describe the role of brachytherapy in two common gastrointestinal malignancies (oesophagus and rectum). Their indications and how the brachytherapy procedures are carried out, together with the dose and fractionation commonly used are discussed. The use of brachytherapy needs to be included in the training curriculum at all academic centres so that its use is developed by the newer generation of radiation oncologists. Its current non-use due to bias, lack of training and availability is no longer justified, given the overwhelming published evidence for the role of brachytherapy to improve organ preservation for both radical treatment and palliation in gastrointestinal malignancies.

Gastrointestinal Brachytherapy

Brachytherapy is a sophisticated and proven treatment technique of different GI localizations. Here the development of GI- brachytherapy of last 20 years, current position and the perspectives for next years are discussed. In summary: The GI-brachytherapy of different localizations is very effective, in experienced hands a safe technique and should be part of armamentarium of every radiation oncologist.

Best Supportive Care of the Patient with Oesophageal Cancer

BACKGROUND

Oesophageal cancer patients have poor survival, and most are unfit for curative or systemic palliative treatment. This article aims to review the best supportive care for oesophageal cancer, focusing on the management of its most frequent or distinctive symptoms and complications.

METHODS

Evidence-based review on palliative supportive care of oesophageal cancer, based on Pubmed search for relevant clinical practice guidelines, reviews and original articles, with additional records collected from related articles suggestions, references and societies recommendations.

RESULTS

We identified 1075 records, from which we screened 138 records that were related to oesophageal cancer supportive care, complemented with 48 additional records, finally including 60 records. This review summarizes the management of oesophageal cancer-related main problems, including dysphagia, malnutrition, pain, nausea and vomiting, fistula and bleeding. In recent years, several treatments have been developed, while optimal management is not yet standardized.

CONCLUSION

This review contributes toward improving supportive care and decision making for oesophageal cancer patients, presenting updated summary recommendations for each of their main symptoms. A robust body of evidence is still lacking, and the best supportive care decisions should be individualized and shared.

Relationship of expression of heat shock transcription factor 1 with sensitivity to radiotherapy and chemotherapy in esophageal squamous cell carcinoma

BACKGROUND

The morbidity and mortality of esophageal cancer are extremely high all over the world, and the treatment effect is not good. As the pathogenesis of esophageal cancer is not yet fully understood, this is not conducive to the study of specific therapeutic drugs for esophageal cancer. Heat shock transcription fact 1 (HSF1) is closely related to the occurrence and development of a variety of malignant tumors. Is HSF1 also closely related to the occurrence and development of esophageal squamous cell carcinoma (ESCC)? Will HSF1 become a biological target for the treatment of ESCC? Different patients with advanced ESCC have different sensitivity to radiotherapy and chemotherapy. Studies have shown that in hepatocellular carcinoma, HSF1 can weaken the toxic effect of radiotherapy and chemotherapy on tumors and reduce the curative effect. Does HSF1 affect the sensitivity of ESCC to radiotherapy and chemotherapy?

AIM

To investigate the expression of HSF1 in ESCC and its effect on the sensitivity of ESCC to radiotherapy and chemotherapy.

METHODS

Ninety-two patients were divided into four groups: 20 stage Ⅰ/Ⅱ ESCC patients undergoing surgical resection, 18 stage Ⅲ/Ⅱ ESCC patients undergoing surgical resection, and 44 stage Ⅲ/Ⅱ ESCC patients undergoing radiotherapy and chemotherapy. Among the 44 stage Ⅲ/Ⅱ ESCC patients undergoing radiotherapy and chemotherapy, 16 had low HSF1 expression and 28 had high expression. Ten cases of esophageal dysplasia. Ten esophagitis tissues were used as a control group. The expression of HSF1 in each group was detected by immunohistochemistry. The changes of non-tumorous lesion size, tumor diameter, and CEA value were compared between the HSF1 low expression group and high expression group before and after radiotherapy and chemotherapy to assess the sensitivity of patients to radiotherapy and chemotherapy. Factors that might affect the 3-year survival of ESCC patients were identified, and the 3-year overall survival rate of ESCC patients was calculated.

RESULTS

HSF1 was highly expressed in each ESCC group, but lowly expressed in esophagitis group and esophageal dysplasia group, and there was a significant difference in the expression of HSF1 between each ESCC group and esophagitis group and esophageal dysplasia group (P = 0.001). HSF1 expression was not significantly associated with age, gender, tumor location , tumor size, degree of differentiation, T stage, N stage, or M stage (P > 0.05). In the HSF1 low expression group, the non-tumor lesion was more significantly relieved, the tumor diameter was more significantly reduced, and the CEA value was more significantly decreased after radiotherapy and chemotherapy compared with those in the HSF1 high expression group (P < 0.05). In the ESCC surgical resection group, the 3-year survival period was significantly related to age (P = 0.019), HSF1 expression (P = 0.028), T stage (P = 0.007), and N stage (P = 0.016), but not related to gender, tumor location, tumor diameter, or degree of differentiation (P > 0.05). In stage Ⅲ/Ⅱ ESCC patients undergoing radiotherapy and chemotherapy, the HSF1 low expression group had a significantly higher 3-year overall survival rate than the HSF1 high expression group (P = 0.016). The 1-, 2-, and 3-year survival rates of the HSF1 low expression group were significantly higher than those of the HSF1 high expression group (P < 0.05). The HSF1 low expression group had a significantly higher 3-year overall survival rate than the HSF1 high expression group (P = 0.03).

CONCLUSION

HSF1 is highly expressed in ESCC and the higher the HSF1 expression, the worse the prognosis of patients. HSF1 expression is not related to patients' clinical characteristics. In stage Ⅲ/Ⅳ ESCC patients receiving radiotherapy and chemotherapy, the higher the expression of HSF1, the worse the sensitivity of patients to radiotherapy and chemotherapy. In ESCC patients undergoing surgical resection and stage Ⅲ/Ⅳ ESCC patients receiving radiotherapy and chemotherapy, the 3-year overall survival rate is higher in the HSF1 low expression group than in the HSF1 high expression group.

A Phase II Study of Biodegradable Stents Plus Palliative Radiotherapy in Oesophageal Cancer

AIMS

Self-expanding metal stents provide rapid improvement of dysphagia in oesophageal cancer but are associated with complications. The aim of the present study was to test the effectiveness of an alternative treatment of combining biodegradable stents with radiotherapy.

MATERIALS AND METHODS

A Simon two-stage single-arm prospective phase II trial design was used to determine the efficacy of biodegradable stents plus radiotherapy in patients with dysphagia caused by oesophagus cancer who were unsuitable for radical treatment. Fourteen patients were recruited and data from 12 were included in the final analyses.

RESULTS

Five of 12 patients met the primary end point: one stent-related patient death; four further interventions for dysphagia within 16 weeks of stenting (41.7%, 95% confidence interval 15.2-72.3%). The median time to a 10-point deterioration of quality of life was 2.7 weeks. Nine patients died within 52 weeks of registration. The median time to death from any cause was 15.0 weeks (95% confidence interval 9.6-not reached).

CONCLUSION

The high re-intervention observed, which met the pre-defined early stopping criteria, meant that the suggested alternative treatment was not sufficiently effective to be considered for a larger scale trial design. Further work is needed to define the place of biodegradable stents in the management of malignant oesophageal strictures.

Stage III Esophageal Squamous Cell Carcinoma Patients With Three-Dimensional Conformal or Intensity-Modulated Radiotherapy: A Multicenter Retrospective Study

Aim: To evaluate long-term outcome and prognostic factors of stage III esophageal cancer after definitive radiotherapy using three dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT) techniques.

Methods: Patients with T3N1M0/T4N0-1M0 esophageal squamous cell carcinoma (ESCC) treated with definitive radiotherapy from 2002 to 2016 in 10 Chinese medical centers were retrospectively analyzed. Overall survival (OS) and progression-free survival (PFS) rates were calculated. Prognostic factors were analyzed by Log-rank test and multivariable Cox model.

Results: Survival data of 1,450 patients were retrospectively collected. With a median follow-up time of 65.9 months, 1-, 3-, and 5-year OS rates were 69.3, 36.7, and 27.7%, respectively, and PFS rates were 58.6, 32.7, and 27.4%, respectively. Univariable analyses showed that gender, age, lesion location, lesion length, largest tumor diameter, lymph node metastasis, gross tumor volume, EQD2, short-term response, and concurrent chemotherapy were prognostic factors for OS. Multivariable analyses showed that lesion location, T-classification, GTV size, EQD2, and short-term response to RT were independent prognostic factors for OS, and tumor diameter, GTV size, and short-term response were independent prognostic factors for PFS.

Conclusions: This study demonstrated that definitive radiotherapy using 3DCRT and IMRT provides promising outcomes for locally advanced ESCC.

Radioactive feeding tube in the palliation of esophageal malignant obstruction

PURPOSE

A radioactive feeding tube was used to achieve both nutrition and brachytherapy for the treatment for malignant esophageal obstruction. We report the safety and effectiveness of this technique.

METHODS

We conducted a retrospective analysis of 16 consecutive patients who employed this technique from January 2015 to March 2018. The radioactive feeding tube was made by binding the ¹²⁵I seed chain on the feeding tube. Under fluoroscopic guidance, the tube was inserted into the obstructed esophagus, with the seed chain crossing over the segment of malignant esophageal obstruction. Technical success rate, dysphagia score, procedure time and complications were analyzed. Kaplan-Meier analysis was used to analyze the survival time.

RESULTS

The radioactive feeding tube was easy to prepare. The technical success rate was 100%, without serious complications such as bleeding or infection. The median procedure time of tube insertion was 44.0 min. The Kamofsky score and Neuhaus dysphagia grading were significantly improved after tube insertion (p < 0.01). On esophageal radiography, the contrast agent passed through the narrow area smoothly. Complete remission (n = 1) and partial remission (n = 13) of local tumor were obtained in 14 patients, and the local tumor control rate was 87.5% (14/16). During follow-up, four patients survived with no obvious clinical symptom and 10 patients died of cancer. The median survival was 12.0 months.

CONCLUSION

Preparation of the radioactive feeding tube is simple and easy. The insertion of this kind of tube achieves parenteral nutrition and brachytherapy simultaneously and is safe and effective in dysphagia palliation of malignant esophageal stricture. The radiological-radiotherapeutic procedure could be an alternative tool in the case of refusing other treatments by the patients.