Radiotherapy with high dose rate brachytherapy boost and concomitant chemotherapy for Stages IIB and III esophageal carcinoma: results of a pilot study

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.

A prospective study of radical external beam radiotherapy versus external beam radiotherapy combined with intraluminal brachytherapy for primary esophageal cancer

PURPOSE

This study compared the efficacy and side effects of external beam radiotherapy (EBRT) + intraluminal brachytherapy (IBT) with EBRT alone in patients with primary thoracic esophageal cancer.

MATERIALS AND METHODS

Between 2013 and 2020, 64 patients with primary thoracic esophageal cancer without surgery received radiotherapy. Thirty-two patients received EBRT + IBT. EBRT dose was 50 Gy, 2 Gy/f, 5 times a week, and IBT dose was 10 Gy, 5 Gy/f, once a week. Thirty-two patients received EBRT alone, and the total dose was 60 Gy. The median followup was 19 months.

RESULTS

The local control rates (LCR) of EBRT + IBT and EBRT alone group at 1, 2, and 3 years after treatment were 88% and 72%, 53% and 22%, 25%, and 9%, respectively. The overall survival (OS) of the EBRT + IBT and EBRT alone group at 3 years after treatment were 38% and 9%. The 3-year local recurrence-free survival (LRFS) rates of EBRT + IBT and EBRT alone group were 25% and 9%. Univariate analysis showed that EBRT + IBT could be the prognostic factor improving OS (p = 0.04), and tumor located in the mid-thoracic region exhibited a poorer prognosis on LRFS (p = 0.03). Grade 3 or higher acute side effects included two cases of dysphagia and three cases of bone marrow suppression. Severe late side effects included three cases of fistula, three cases of radiation pneumonia, and five cases of stenosis requiring treatment.

CONCLUSIONS

Compared with EBRT alone, EBRT + IBT is an effective treatment modality for T1∼3NanyM0 primary thoracic esophageal cancer with good local control. It can prolong the survival time of patients and has acceptable toxicity.

Review of brachytherapy complications - Upper gastrointestinal tract

While brachytherapy applications are not widely used for cancer diagnoses in the upper GI tract (including the esophagus, liver, stomach, and pancreas), they have a clear role in palliation and symptom management and occasionally definitive locoregional treatment. With the increasing use of image-guided techniques, the incidence of side effects and complications has shown to be lower than many other alternative treatment modalities, making brachytherapy approaches a preferred treatment option. This review examines procedural complications and acute and chronic adverse effects from radiation associated with esophageal, hepatobiliary, and pancreatic brachytherapy and their management.

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.

Comparative study of concomitant chemoradiation versus concomitant chemoradiation followed by high-dose-rate intraluminal brachytherapy in locally advanced esophageal carcinoma: a single institutional study

Purpose

The aim of this study is to compare efficacy and toxicity between concurrent chemoradiotherapy (CCRT) followed by high-dose-rate intraluminal brachytherapy (ILBT) and CCRT in inoperable, locally advanced esophageal carcinoma.

Material and methods

Thirty-four patients with inoperable, locally advanced esophageal carcinoma were randomized into two arms. In the CCRT + ILBT arm (arm A), eighteen patients received 50.4 Gy at 1.8 Gy per fraction over 5.6 weeks, along with concurrent cisplatin (75 mg/m²) intravenously on day 1, and 5-fluorouracil (1000 mg/m²) continuous intravenous infusion on days 1-5, starting on the first day of irradiation and repeated after 28 days. This was followed by ILBT boost with a dose of 10 Gy in 2 fractions, one week apart. In the CCRT arm (arm B), sixteen patients received two cycles of chemotherapy, using the same schedule, along with external beam radiotherapy fractionated in a similar manner without brachytherapy boost. The endpoints were tumor response, acute and late toxicities, disease and progression-free survival.

Results

With a median follow-up of 13 months, the complete response rate was 88.89% in arm A and 87.50% in arm B (p = 0.71). Acute esophageal toxicity was higher in CCRT followed by ILBT arm (p = 0.60). There was no significant difference between the Kaplan Meier survival plots of disease-free survival (p = 0.68) and progression-free survival (p = 0.55).

Conclusions

In our study, addition of brachytherapy as a boost following concurrent chemoradiation failed to improve treatment outcomes without additional toxicity in locally advanced esophageal cancer.

Endoluminal brachytherapy: Bronchus and oesophagus

Endobronchial brachytherapy could be proposed in case of endoluminal tumours either as a palliative or a curative treatment. As a curative treatment, endobronchial brachytherapy could obtain a high local control rate in case of limited disease. In palliative setting, endobronchial brachytherapy improved thoracic symptoms in more than 80% of cases, but it is less efficient than external beam radiation therapy for palliation. It could be also proposed to maintain the airway open after laser therapy. Oesophageal brachytherapy is a valuable option as a palliative treatment, underused at this time. It causes less side effects and a better quality of life compared to self-expanded metallic stents. For a curative aim, there is today no demonstration that a combination of external beam radiotherapy and oesophageal brachytherapy give better results than external beam radiotherapy alone in locally advanced tumours. For superficial diseases, the combination of external beam radiotherapy and oesophageal brachytherapy seems, on the contrary, promising.

Intraluminal brachytherapy boost following external beam radiotherapy with concurrent chemotherapy of oesophagus carcinoma: Results of a prospective observational study

PURPOSE

The main objective of our study is to evaluate response and toxicity profile in patients receiving external beam radiotherapy with concurrent chemotherapy followed by intraluminal brachytherapy boost for a carcinoma of the oesophagus.

MATERIAL AND METHODS

Twenty patients with biopsy-proven carcinoma of the oesophagus received external beam radiotherapy (50Gy in 25 fractions) with concurrent chemotherapy (cisplatin: 40mg/m²). After a gap of two to three weeks, intraluminal brachytherapy (10Gy in two fractions each 1 week apart by a high dose rate ⁶⁰Co source) was given. Response was evaluated at 1 month and at 1 year of completion of treatment. In addition, acute and chronic toxicity was evaluated at 1 month and 6 months of treatment.

RESULTS

Complete response were seen in 80% of patients and partial response in 20% at 1 month. Moreover, there were 65% complete response, 10% local recurrences, 15% patients showed local control with distant metastasis and 10% patients died at 1 year. Grade 1, grade 2 and grade 3 oesophagitis were seen in 10%, 70% and 20% of patients respectively. Stricture was seen in 40% of patients and fistula in 10% of patients. There was no spinal cord, cardiac and nephrotoxicity found.

CONCLUSIONS

With the concept that high tumoricidal dose for adequate tumor control achieved by intraluminal brachytherapy as a mean of dose escalation, while sparing surrounding normal tissue and potentially improving therapeutic ratio, external beam radiotherapy followed by intraluminal brachytherapy could be a better choice for oesophagus carcinoma.

Radiation Therapy for Locally Advanced Esophageal Cancer

The treatment of locally advanced esophageal cancer is controversial. For patients who are candidates for surgical resection, multiple prospective clinical trials have demonstrated the advantages of neoadjuvant chemoradiation. For patients who are medically inoperable, definitive chemoradiation is an alternative approach with survival rates comparable to trimodality therapy. Although trials of dose escalation are ongoing, the standard radiation dose remains 50.4 Gy. Modern radiotherapy techniques such as image-guided radiation therapy with motion management and intensity-modulated radiation therapy are strongly encouraged with a planning objective to maximize conformity to the intended target volume while reducing dose delivered to uninvolved normal tissues.

[Brachytherapy for oesophageal cancer]

The main indication of oesophageal brachytherapy is palliative: it can improve dysphagia in patients with a tumor not suitable for surgery or chemoradiotherapy. A randomized clinical trial showed that survival without dysphagia and quality of life was improved by endoluminal brachytherapy in comparison to self-expansible metallic stents. It also increases the duration of palliation after laser deobstruction. Its role as a curative treatment of locally advanced tumors is still discussed: in combination with external beam radiotherapy, it seems that brachytherapy increased the rate of severe toxicity (haemorrhages, fistula, stenosis). In superficial lesions, brachytherapy with or without external beam radiotherapy seems logical but large prospective studies are missing in this setting.

Radiation Therapy and Esophageal Cancer

Background

Squamous cell carcinoma and adenocarcinoma account for more than 90% of all esophageal cancer cases. Although the incidence of squamous cell carcinoma has declined, the incidence of adenocarcinoma has risen due to increases in obesity and gastroesophageal reflux disease.

Methods

The authors examine the role of radiation therapy alone (external beam and brachytherapy) for the management of esophageal cancer or combined with other modalities. The impact on staging and appropriate stratification of patients referred for curative vs palliative intent with modalities is reviewed. The authors also explore the role of emerging radiation technologies.

Results

Current data show that neoadjuvant chemoradiotherapy followed by surgical resection is the accepted standard of care, with 3-year overall survival rates ranging from 30% to 60%. The benefit of adjuvant radiation therapy is limited to patients with node-positive cancer. The survival benefit of surgical resection after chemoradiotherapy remains controversial. External beam radiation therapy alone results in few long-term survivors and is considered palliative at best. Radiation dose-escalation has failed to improve local control or survival. Brachytherapy can provide better long-term palliation of dysphagia than metal stent placement. Although three-dimensional conformal treatment planning is the accepted standard, the roles of IMRT and proton therapy are evolving and potentially reduce adverse events due to better sparing of normal tissue.

Conclusions

Future directions will evaluate the benefit of induction chemotherapy followed by chemoradiotherapy, the role of surgery in locally advanced disease, and the identification of responders prior to treatment based on microarray analysis.

Effectiveness of Two High-dose-rate Intraluminal Brachytherapy Schedules for Symptom Palliation in Carcinoma Esophagus: A Tertiary Care Center Experience

Aim:

The aim was to analyze different radiation schedules with high-dose-rate (HDR) brachytherapy in patients with unresectable carcinoma esophagus in terms of dysphagia-free survival (DyFS), local control (LC), disease-free survival (DFS), and complications.

Materials and Methods:

Eighty-six patients were studied under three different radiation schedules: Schedule A – radiation 35 Gy/15# followed by HDR brachytherapy 6 Gy each in two sessions; schedule B – chemoradiation 35 Gy/15# with weekly injection cisplatin 30 mg/m² infusion and 5-fluorouracil 325 mg/m² bolus followed by HDR brachytherapy 6 Gy each in two sessions; and schedule C – same chemoradiation dose followed by HDR brachytherapy three sessions of 4.68 Gy each. The median follow-up was 12.1 months.

Results:

Treatment compliance was good. There were no significant differences in the incidence of acute toxicities across the three schedules. No grade III toxicities were noted. At 1 month, 27 patients had dysphagia improvement, which was not different across the three schedules. At 6 months, schedule C showed a trend toward better symptom control of dysphagia (dysphagia free=55%). The 2-year DyFS reached 49.5% in schedule C. Two-year LC rates were approximating 89% in both chemoradiation schedules versus 67.6% in schedule A. The 2-year DFS was also high in chemoradiation schedules. Major complications like ulceration and tracheoesophageal fistulas were more often seen with schedule B with a higher dose per fraction of the brachytherapy schedule.

Conclusion:

In unresectable carcinoma esophagus, radiation-only schedules are associated with lower LC and DFS rates. Concurrent chemoradiation followed by a brachytherapy boost is feasible in suitable patients with a good Karnofsky performance score and are associated with higher DyFS, LC, and DFS with acceptable toxicities. Still there is a need for the standardization of HDR brachytherapy schedules with chemoradiation protocols.

Palliative interventions and prognosis in patients with advanced esophageal cancer

In a retrospective review, in order to describe the palliative care and prognosis of patients with advanced cancer of the esophagus, the clinical characteristics and the treatment modalities applied were explored in relation to survival and symptom relief for 261 patients treated without curative potential. The data were obtained from a study of all patients with cancer of the esophagus treated at the Norwegian Radium Hospital in the 10-year period from 1990 to 1999. Medical data of the patients were reviewed and missing clinical information was retrieved from local hospitals and general practitioners. The patients were divided into three groups based upon the overall survival from start of treatment to death. Survival ≤3 months is in this paper, defined as 'short,' while survival > 6 months is defined as 'long.' Median survival for the total group of patients was 4 months. The 1-, 2-, and 3-year survival was 8%, 3%, and 1%, respectively. Patients with short survival (n= 107) had more advanced disease, lower performance status, and more dysphagia, weight loss, and pain and used more analgesics than patients with long survival (n= 91). Tumor characteristics such as localization, tumor length, and histology were not significantly associated with survival. This result was confirmed in a logistic regression analysis (with backward stepwise elimination) including sex, age, clinical stage, tumor length, tumor localization, histology, performance status, dysphagia, weight loss, and pain, where clinical stage, performance status, weight loss, and pain were included in the final model. A large variety of first-line palliative treatments were applied within the studied time period; external radiotherapy ± brachytherapy (n= 149), brachytherapy alone (n= 44), endoluminal stent (n= 28), laser evaporization (n= 8), chemotherapy (n= 5), and best supportive care only (n= 27). There were no clear differences in the effect on dysphagia between the modalities. Fourteen percent of the patients had treatment related complications. In conclusion, symptoms, performance status, and use of analgesics seemed to better prognosticate survival than tumor characteristics other than stage of disease. Our study reveals that knowledge about prognostic factors is crucial for the choice of palliative treatment. Even though all of the different treatment modalities seemed to provide relief of dysphagia, several other factors should be considered when deciding which treatment modality to offer. The time to onset of relief, duration of response, level of complications, and time spent in hospital should be a part of the decision-making process when selecting the appropriate treatment.

Feasibility of chemoradiotherapy for oesophageal cancer in elderly patients aged >or=75 years: a prospective, single-arm phase II study

BACKGROUND

The number of elderly patients with oesophageal cancer is expected to increase with the aging of the population and the rapidly increasing incidence of adenocarcinoma. Surgical resection is standard treatment for patients with localized disease considered fit for operation. However, elderly patients with oesophageal cancer are rarely referred for surgery. The aim of this prospective, single-arm, phase II study was to evaluate the feasibility and efficacy (tumour response) of chemoradiotherapy in the treatment of elderly patients with localized oesophageal cancer. Secondary endpoints were progression-free survival (PFS) and quality of life (QOL).

METHODS

The main study inclusion criteria were: patients aged >or=75 years; oesophageal cancer disease stage II-III; Charlson co-morbidity index score <or=4; Eastern Cooperative Oncology Group (ECOG) performance status 0-2; and weight loss <15%. The radiotherapy regimen consisted of 50 Gy over 5 weeks. Cisplatin 75 mg/m2 was given on days 1 and 21 of radiotherapy. Complete response was defined as disappearance of the tumour at endoscopy and/or at oesophagography and CT scan. Written informed consent was obtained from all patients. A three-step Fleming design was used to calculate the sample size.

RESULTS

Twenty-two patients were included in the study between March 2000 and June 2004; this sample size was sufficient to allow conclusions to be drawn from the study. The mean age of the patients was 79.4 years (range 75-89 years), 18 were male (81.8%), 15 had squamous cell carcinoma (68%) and 11 had stage IIA disease (50%). The mean Charlson co-morbidity index score was 1. All patients were compliant with the planned treatment, including doses and timing. During treatment, ECOG performance status remained stable during the first 3 weeks and worsened slightly over the last 2 weeks. Dysphagia remained stable. Five patients (22%) had transient grade 2 vomiting after the second cisplatin injection. No patient experienced nephrotoxic adverse effects and there were no toxicity-related deaths. Six weeks after treatment, 14 patients were in complete response (63.6%) and 8 patients (36.4%) had no treatment effect. The overall survival was 81.6% at 6 months and 62.4% at 1 year. The PFS at 1 year was 50%. Four patients (18.2%) were alive without disease from 2.6 to 5.5 years after treatment. In 14 evaluable patients, QOL 6 weeks after treatment was slightly altered by treatment.

CONCLUSIONS

The results of this prospective phase II study support the feasibility of chemoradiotherapy for oesophageal cancer in carefully selected elderly patients, with the potential for a curative effect.

High dose rate brachytherapy (HDR-BT) in locally advanced oesophageal cancer. Clinic response and survival related to biological equivalent dose (BED)

INTRODUCTION

Ninety percent of oesophageal cancers are locally advanced at diagnosis, and treatment yields discouraging results. High dose rate brachytherapy (HDR-BT) permits an increment of local doses without a significant increment of toxicity. The goal of our study is to compare different HDR-BT fractions and assess global survival (GS) and cause-specific survival (CSS).

MATERIAL AND METHODS

Twenty-six patients were treated for locally advanced oesophageal cancer with chemotherapy concomitant with conformal three-dimensional radiotherapy (C3DR) from January 1994 to December 2000. Of this group, 96.2% were males, mean age 63.08 years; the most frequent location was medium third, for 50% of cases. Eighty-four percent of cases were G2-3 epidermoid carcinomas. The administration consisted of 44.2 Gy with C3DR and 5 applications of HDR-BT of 500 cGy each.

RESULTS

Actuarial GS and CSS at 5 years is 10.18% and 12.96%, a mean survival of 25.68 and 29.14 months respectively. The following factors (C3DR total dose, fraction dose and total dose of HDR-BT, number of applications, active length of application, total dose of C3DR plus HDR-BT, and BED of HDR-BT) are evaluated to find if they have an influence on treatment response, GS and actuarial CSS. The only result that yields statistical significance, in univariant analysis, is the active length in HDR-BT, thus for a greater active length of application, a minor response is obtained and GS diminishes (p=0.05). We grouped BT fractions on biological equivalent dose (BED) into: <28, 28-33 and >33 Gy; mean survival and GS at 5 years increases with BED>or=28 Gy (p=0.016).

CONCLUSION

Tumour response increases (complete and partial) when BED on HDR-BT is increased, regardless of the fraction employed. A BED higher than 28 Gy yields a significant increase of mean survival and GS at 5 years (p=0.016).

The safety and usefulness of high-dose-rate endoluminal brachytherapy as a boost in the treatment of patients with esophageal cancer with external beam radiation with or without chemotherapy

PURPOSE

This study reports the results of a single-institution experience with high-dose-rate brachytherapy (HDRBT) used as a boost in the treatment of esophageal cancer with external beam radiation therapy (ERT) with or without chemotherapy.

METHODS AND MATERIALS

Patients without evidence of metastatic disease were identified. HDRBT was given before ERT with a dose of 20 Gy in 5 fractions. Patients with a Karnofsky performance of more than 70 received treatment with 50 Gy in 25 fractions and concurrent 5-fluorouracil and cis-platinum during Weeks 1 and 5, whereas patients with a Karnofsky performance of less than 70 were treated with radiation therapy alone with 35 Gy in 14 fractions.

RESULTS

Fifty-three patients received HDRBT treatment with combined ERT and chemotherapy and 17 patients with ERT alone. The incidence of acute bone marrow toxicity was 55% Grade 2 and 15% Grade 3, and 85% of patients had Grade 2 esophagitis. With a median follow-up time of 26 months, the median survival was 21 months; the 2-year local recurrence was 25%, and the 5-year survival rate was 28%.

CONCLUSION

HDRBT is safe and beneficial for local control in the radical treatment of patients with esophageal cancer.

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.

Multivariate analysis of treatment outcome in patients with esophageal carcinoma treated with definitive radiotherapy

To evaluate patient characteristics and treatment factors influencing outcome of patients treated with definitive radiotherapy, we performed retrospective analysis. From 1983 to 2000, 154 patients who were diagnosed as esophageal carcinoma without distant metastasis received definitive radiotherapy with (N = 90) or without (N = 64) systemic chemotherapy. One hundred forty-two males and 12 females were entered in the analysis. Thirty-four patients received an additional boost of intracavitary brachytherapy (ICBT). The median patient age was 68 years (range: 46-86). Disease stage was distributed as stage I, II, III, and IV for 33, 42, 33, and 45 patients, respectively. External beam radiotherapy was prescribed with a median 63 Gy (range: 38-77.8 Gy). The 2- and 5-year overall survival (OAS) and local control (LC) rates were 40.8/18.4% and 48.6/28.9%, respectively. In uni-/multivariate analyses, significant prognostic factors of OAS proved to be advanced T stage, absence of ICBT, and age less than 65 years. As for LC, adverse prognostic factors of uni/multivariate analysis were advanced T stage and poor performance status. The pretreatment T stage showed the most powerful influence on both survival and LC. Combination use of ICBT is proven to refine treatment outcome, although eligible criteria should be decided by a prospective study.

[Endo oesophageal brachytherapy]

Endo-oesophageal brachytherapy became more useful, since high dose rate brachytherapy is available. This technique allowed to treat in situ tumors and also to increase radiation dose to the tumor site for lesions treated by external radiotherapy associated with chemotherapy. Most series together with ours show a trend to increase the local control rate with brachytherapy, but few of them show an impact on survival. Endo-oesophageal brachytherapy requires a very accurate technique to limit the side effects.

Combined external and intraluminal radiotherapy in the treatment of advanced oesophageal cancer

BACKGROUND AND PURPOSE

Oesophageal cancer still has a dismal prognosis. Radical surgery is by far the most successful treatment but most patients are not operable at the time of diagnosis and for these patients external beam radiotherapy with or without concurrent chemotherapy offers the best choice for cure or palliation. In patients with advanced oesophageal cancer, intraluminal brachytherapy has been proposed as a complementary method to increase local control.

PATIENTS AND METHODS

Between 1989 and 1999, 40 patients with inoperable oesophageal cancer were treated with combined external and intraluminal radiation therapy in Turku University Central Hospital. The external radiation was performed with a median total dose of 40 Gy given in 20 fractions. On the average a week after the external radiation a median total dose of 10 Gy intraluminal radiation therapy was given in 4 fractions.

RESULTS

The intraluminal brachytherapy could be performed without technical difficulties and no major complications were seen. In many cases (16 out of 40 patients, 40%), the symptoms could be relieved immediately and in most cases the progression of the disease could be delayed as evidenced by post-treatment serial endoscopy. No major complications were encountered. The 1- and 2-year survival rates were 30 and 17.5%, respectively. All patients alive at 2 years can be considered as long-term survivors. Median follow-up was 86 months.

CONCLUSIONS

Intraluminal brachytherapy is a safe and efficient treatment modality which offers a potential means of cure for selected patients with oesophageal cancer.

Radical radiotherapy incorporating a brachytherapy boost for the treatment of carcinoma of the thoracic oesophagus: results from a cohort of patients and review of the literature

The optimal treatment for potentially curable carcinoma of the oesophagus unsuitable for surgical resection is unresolved. An intraluminal brachytherapy boost (ILBT) can be used following external beam radiotherapy (EBRT) with or without concurrent chemotherapy (CRT). ILBT increases the dose to the tumour volume substantially while reducing the lung dose but the corresponding high dose to the oesophageal wall may cause increased complications. We report the outcomes of 32 consecutive patients treated with radical radiotherapy. A dose of 45-55 Gy in 20-25 fractions with external beam radiotherapy (EBRT) followed by an ILBT boost. Earlier in the series a low dose rate (LDR) brachytherapy technique using 125Iodine seeds delivering a dose of 20-22 Gy at 25-40 cGy/h was used. This was later superseded by high dose rate (HDR) treatments delivering 8.5-10 Gy in one fraction at 1 cm from the catheter. Patients of age below 76 years, of good performance status and with no other medical contraindication were considered for concurrent chemotherapy (CRT) using a planned regime of cisplatin (80 mg/m2 day 1) and 5-flurouracil (1 g/m2 days 1 to 4) in the first and last weeks of radiotherapy (13 patients). The EBRT and ILBT were well tolerated but 8/13 (62%) patients had dose modifications of chemotherapy in one or both cycles due to advanced age, co-morbidity or toxicity. The median follow-up period of surviving patients was 37 months (range 35-39) and the median overall survival for the whole group was 9 months. The overall survival at 1 year was 34.4% (17.6-51.2%), 15.6% (2.8-28.4%) at 2 and 3 years. Local recurrence-free survival at 1 year was 35.3% (15.9-54.7%) and 24.5% (8.3-44.6%) at 2 and 3 years (Fig. 2). Though symptom relief was good there were six cases of ulceration, six of stricture and two fistulae. Biological equivalent for tumour response (BED Gy,10) and late radiation effects (BED Gy3) were calculated for the different radiotherapy regimens using equations derived from the linear quadratic model. In this series no advantage was found in terms of local control or survival for patients receiving radiotherapy doses resulting in a BED Gy10 greater than 75% of the maximum. Similarly, no significant increase in complications was noted in those patients receiving doses resulting in a BED Gy3 > 75% of the maximum. The merits and hazards of the ILBT boost used in radical radiotherapy are discussed and the relevant literature reviewed.

Evaluation of the histologic effect of chemoradiation therapy for squamous cell carcinomas of the esophagus by assessing morphologic features of surgical specimens

The histologic effects of chemoradiation therapy (CRT) for esophageal cancer, which determine the benefit obtained from a salvage operation, are difficult to evaluate preoperatively. We therefore investigated whether or not the morphologic features of esophageal cancer tissue after CRT can be correlated with the histologic features of the tissue. Seventy-six patients with advanced esophageal squamous cell carcinoma underwent CRT followed by esophagectomy. The effects of CRT were evaluated by histologic examination of the residual tumors in the surgical specimen and correlated with clinicopathologic factors, including postoperative prognosis. The histologic effects of CRT were used to classify tumors as grade 1 (CRT poorly effective; 23 cases, 30.3%); grade 2 (CRT moderately effective; 31 cases, 40.8%); or grade 3 (CRT completely effective with no residual tumors; 22 cases, 28.9%). Among the gross findings of the removed esophagus, significant correlation with the CRT effects was observed in the case of wall thickness and ulceration but not in the case of longitudinal tumor length. Tumors with no wall thickening or ulceration were never classified as grade 1, whereas tumors with both wall thickening and ulceration were frequently rated as grade 1 (18/30, 60%). Microscopic examination of grade 2 tumors (23/31, 74.1%) revealed residual tumor cells growing below the mucosal layer, whereas tumor cells were exposed to the esophageal surface in 22 out of 23 patients with grade 1 tumors. The morphologic features after CRT can be used to evaluate its histologic effect, especially in the case of grade 1 tumors. However, the detection and prediction of grade 2 tumors remains difficult because of the presence of small amounts of residual tumor underneath the mucosa.

Analysis of the role of adjuvant chemotherapy for invasive carcinoma of the esophagus

The purpose of this report is to analyze the role and optimum integration of chemotherapy for invasive carcinoma of the esophagus in the combined modality setting. The charts of 157 patients with primary invasive nonmetastatic carcinoma of the esophagus treated with curative intent between 1984 and 1998 were reviewed. Various combinations of chemotherapy (C), radiotherapy (R), and surgery (S) were used. Chemotherapy was multiagent (typically 5-fluorouracil [5-FU]/cisplatin/hydroxyurea, 5-FU/cisplatin/leucovorin, or docetaxel/cisplatin) for all but seven patients treated with single agents. The clinical endpoints examined were overall survival (OS) and cause-specific survival (CSS). Multivariate analyses and pairwise comparisons were made for determination of the benefit of chemotherapy. On the multivariate analyses, only American Joint Committee on Cancer stage and chemotherapy were statistically significant determinants of both OS and CSS. Following are the results of the pairwise analyses: 3-year OS: (no C) versus (any C): 16% versus 27% (p = 0.02); (S) versus (C+S): 19% versus 34% (p = 0.35); (R) versus (C+R): 0% versus 13% (p = 0.05); (R + S) versus (C + R + S): 18% versus 33% (p = 0.03). The administration of adjuvant chemotherapy can improve survival in patients with invasive nonmetastatic esophageal carcinoma. This benefit appears to be greater when chemotherapy is given with radiotherapy (with or without surgery) than in the absence of radiotherapy, perhaps because of a radiosensitizing effect not possible when using surgery is the only local control modality.

High dose rate brachytherapy for superficial cancer of the esophagus

PURPOSE

We analyzed our experience with external radiotherapy, combined modality treatment, or HDR brachytherapy alone to limited esophageal cancers.

METHODS AND MATERIALS

From 1991 to 1996, 25 patients with limited superficial esophagus carcinomas were treated by high dose rate brachytherapy. The mean age was 63 years (43-86 years). Five patients showed superficial local recurrence after external radiotherapy. Eleven patients without invasion of the basal membrane were staged as Tis. Fourteen patients with tumors involving the submucosa without spreading to the muscle were staged as T1. Treatment consisted of HDR brachytherapy alone in 13 patients, external radiotherapy and brachytherapy in 8 cases, and concomitant chemo- and radiotherapy in 4 cases. External beam radiation was administered to a total dose of 50 Gy using 2 Gy daily fractions in 5 weeks. In cases of HDR brachytherapy alone (13 patients), 6 applications were performed once a week.

RESULTS

The mean follow-up is 31 months (range 24-96 months). Twelve patients received 2 applications and 13 patients received 6 applications. Twelve patients experienced a failure (48%), 11/12 located in the esophagus, all of them in the treated volume. One patient presented an isolated distant metastasis. In the patients treated for superficial recurrence, 4/5 were locally controlled (80%) by brachytherapy alone. After brachytherapy alone, 8/13 patients were controlled (61%). The mean disease-free survival is 14 months (1-36 months). Overall survival is 76% at 1 year, 37% at 2 years, and 14% at 3 years. Overall survival for Tis patients is 24% vs. 20% for T1 (p = 0.83). Overall survival for patients treated by HDR brachytherapy alone is 43%. One patient presented with a fistula with local failure after external radiotherapy and brachytherapy. Four stenosis were registered, two were diagnosed on barium swallowing without symptoms, and two required dilatations.

CONCLUSION

High dose rate brachytherapy permits the treating of patients with superficial esophageal cancer with good tolerance. Early tumors, located in the mucosa, might be treated by HDR brachytherapy alone or by a combined modality treatment in which HDR brachytherapy can take place like a boost. This approach may cure localized recurrences.

Multi-institutional randomized trial of external radiotherapy with and without intraluminal brachytherapy for esophageal cancer in Japan. Japanese Society of Therapeutic Radiology and Oncology (JASTRO) Study Group

PURPOSE

With the aim of improving the results of treatment of esophageal cancer, we designed this multi-institutional, randomized trial to establish the optimal irradiation method in radical radiation therapy for esophageal cancer by clinically evaluating external irradiation alone and in combination with intraluminal brachytherapy.

METHODS AND MATERIALS

The study population consisted of patients with squamous cell carcinoma who were expected to be successfully treated with radical radiation therapy. The patients who could be given intraluminal brachytherapy at the end of external irradiation of 60 Gy were stratified into 2 groups. Patients assigned to receive external irradiation alone received boost irradiation of 10 Gy/week on a schedule similar to the previous one, and with the same or smaller irradiation field. Intraluminal brachytherapy was performed, as a rule, with the reference dose point set at a depth of 5 mm of the esophageal submucosa, and a total of 10 Gy was irradiated at a daily dose of 5 Gy, on a once-weekly schedule with low-dose-rate or high-dose-rate brachytherapy equipment.

RESULTS

A total of 103 patients were registered, 94 of whom were analyzable, with 8 ineligible, and 1 for whom complete information was unavailable. The overall cumulative survival rate was 20.3% at 5 years. The cause-specific survival rate was 31.8% at 5 years. The cause-specific survival rate at 5 years was 27% in the external irradiation alone group and 38% in intraluminal brachytherapy combined group. There was no significant difference between the 2 groups (p = 0.385). However, in the patients with 5 cm or less tumor length, the cause-specific survival rate was 64% at 5 years in the intraluminal brachytherapy combined group, which showed a significant improvement over 31.5% in the external irradiation alone group (p = 0.025). In the patients with Stage T1 and T2 disease, cause-specific survival rates tended to be better in the intraluminal brachytherapy combined group than in the external irradiation alone group (p = 0.088). In the patients with more than 5 cm tumor length or Stage T3-4 disease, there were no significant differences between the two groups by treatment methods (p = 0.290). The incidence of early and late complications did not differ according to whether intraluminal brachytherapy was used.

CONCLUSION

For the purpose of establishing the usefulness of intraluminal brachytherapy, further prospective randomized studies are necessary to evaluate the efficacy in tumors with short length and those with shallow invasion, or to assess the usefulness of intraluminal brachytherapy, as additional irradiation in large advanced tumors have been shown to have disappeared by diagnostic imaging after chemoradiotherapy with 60 Gy/6w external irradiation.

High-dose-rate brachytherapy boost following concurrent chemoradiotherapy for esophageal carcinoma

PURPOSE

To assess the efficacy, toxicity, and the optimum dose of high-dose-rate brachytherapy following chemoradiotherapy (CRT) compared with a historical group of patients treated with a combination of external beam and brachytherapy (RT alone).

METHODS AND MATERIALS

Fifty-three patients with localized esophageal cancer received concurrent chemoradiotherapy followed by brachytherapy. The chemotherapy regimen was a combination of cisplatin 60 mg/m2 on day 1 and fluorouracil 600 mg/m2 continuous infusion from days 1-4 during the first and last week of external irradiation. Radiotherapy consisted of external irradiation to a total dose of 40-61 Gy (median 50 Gy) and brachytherapy to 8-24 Gy (median 16 Gy) in 2-4 fractions.

RESULTS

Acute toxicity was well tolerated. A fistula occurred in one patient 1 week after completion of external irradiation. Local control was achieved in 32/53 (60%) compared with 42% of the RT group (p = 0.029). Local control rates of the CRT group were significantly better than those of the RT group in Stages II and III. Late toxicity (esophageal ulceration and strictures) occurred in 18 (34%) of the CRT group compared with 12% in the RT group (p = 0.013). Severe late toxicity (RTOG/EORTC criteria Grade 3-4) occurred in six patients (15%) whose chemotherapy was followed by 16-24 Gy via brachytherapy compared with 2.5% in the RT group (p = 0.010).

CONCLUSION

Combined chemoradiotherapy and brachytherapy boost achieved better local control than radiotherapy alone. However, a high level of severe late toxicity was observed especially with 16-24 Gy via brachytherapy.

[Concomitant chemoradiotherapy of cancer of the esophagus]

Radiation therapy with concomitant chemotherapy is the standard treatment for non resectable esophageal carcinoma. For patients with operable tumors, surgery is the traditional treatment. However several data have suggested that preoperative chemo- and radiotherapy could improve therapeutic results. At the present time, no randomized trial has demonstrated, except for adenocarcinoma of the cardia, the benefit of preoperative treatment. Other randomized trials are needed to determine the role and the optimal modalities of these treatments. This is a review of the literature data in concomitant chemotherapy and radiation in the management of esophagus.