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Mangesius J, Hörmandinger K, Jäger R, Skvortsov S, Plankensteiner M, Maffei M, Seppi T, Dejaco D, Santer M, Sarcletti M, Ganswindt U. Chemoradiotherapy Combined with Brachytherapy for the Definitive Treatment of Esophageal Carcinoma. Cancers (Basel) 2023; 15:3594. [PMID: 37509257 PMCID: PMC10377190 DOI: 10.3390/cancers15143594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/22/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
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.
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Affiliation(s)
- Julian Mangesius
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
- Comprehensive Cancer Center Innsbruck (CCCI), 6020 Innsbruck, Austria
| | - Katharina Hörmandinger
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
- Comprehensive Cancer Center Innsbruck (CCCI), 6020 Innsbruck, Austria
| | - Robert Jäger
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
- Comprehensive Cancer Center Innsbruck (CCCI), 6020 Innsbruck, Austria
| | - Sergej Skvortsov
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
- Comprehensive Cancer Center Innsbruck (CCCI), 6020 Innsbruck, Austria
| | | | - Martin Maffei
- Department of Radiotherapy, State Hospital of Bolzano, 39100 Bolzano, Italy
| | - Thomas Seppi
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Daniel Dejaco
- Comprehensive Cancer Center Innsbruck (CCCI), 6020 Innsbruck, Austria
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Matthias Santer
- Comprehensive Cancer Center Innsbruck (CCCI), 6020 Innsbruck, Austria
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Manuel Sarcletti
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
- Comprehensive Cancer Center Innsbruck (CCCI), 6020 Innsbruck, Austria
| | - Ute Ganswindt
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
- Comprehensive Cancer Center Innsbruck (CCCI), 6020 Innsbruck, Austria
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Pao TH, Chen YY, Chang WL, Chang JSM, Chiang NJ, Lin CY, Lai WW, Tseng YL, Yen YT, Chung TJ, Lin FC. Esophageal fistula after definitive concurrent chemotherapy and intensity modulated radiotherapy for esophageal squamous cell carcinoma. PLoS One 2021; 16:e0251811. [PMID: 33989365 PMCID: PMC8121322 DOI: 10.1371/journal.pone.0251811] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 05/04/2021] [Indexed: 12/24/2022] Open
Abstract
Background The literature regarding esophageal fistula after definitive concurrent chemotherapy and intensity modulated radiotherapy (IMRT) for esophageal squamous cell carcinoma (ESCC) remains lacking. We aimed to investigate the risk factors of esophageal fistula among ESCC patients undergoing definitive concurrent chemoradiotherapy (CCRT) via IMRT technique. Methods A total of 129 consecutive ESCC patients receiving definitive CCRT with IMRT between 2008 and 2018 were reviewed. The cumulative incidence of esophageal fistula and survival of patients were estimated by the Kaplan–Meier method and compared between groups by the log-rank test. The risk factors of esophageal fistula were determined with multivariate Cox proportional hazards regression analysis. Results Median follow-up was 14.9 months (IQR, 7.0–28.8). Esophageal perforation was identified in 20 (15.5%) patients, resulting in esophago-pleural fistula in nine, esophago-tracheal fistula in seven, broncho-esophageal fistula in two, and aorto-esophageal fistula in two patients. The median interval from IMRT to the occurrence of esophageal fistula was 4.4 months (IQR, 3.3–10.1). Patients with esophageal fistula had an inferior median overall survival (10.0 vs. 17.2 months, p = 0.0096). T4 (HR, 3.776; 95% CI, 1.383–10.308; p = 0.010) and esophageal stenosis (HR, 2.601; 95% CI, 1.053–6.428; p = 0.038) at baseline were the independent risk factors for esophageal fistula. The cumulative incidence of esophageal fistula was higher in patients with T4 (p = 0.018) and pre-treatment esophageal stenosis (p = 0.045). There was a trend toward better survival after esophageal fistula among patients receiving repair or stenting for the fistula than those only undergoing conservative treatments (median survival, 5.9 vs. 0.9 months, p = 0.058). Conclusions T4 and esophageal stenosis at baseline independently increased the risk of esophageal fistula in ESCC treated by definitive CCRT with IMRT. There existed a trend toward improved survival after the fistula among patients receiving repair or stenting for esophageal perforation.
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Affiliation(s)
- Tzu-Hui Pao
- Department of Radiation Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ying-Yuan Chen
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Lun Chang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jeffrey Shu-Ming Chang
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan
| | - Nai-Jung Chiang
- Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan
| | - Chia-Ying Lin
- Department of Diagnostic Radiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wu-Wei Lai
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yau-Lin Tseng
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Ting Yen
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ta-Jung Chung
- Department of Diagnostic Radiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Forn-Chia Lin
- Department of Radiation Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- * E-mail:
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Zhu C, Wang S, You Y, Nie K, Ji Y. Risk Factors for Esophageal Fistula in Esophageal Cancer Patients Treated with Radiotherapy: A Systematic Review and Meta-Analysis. Oncol Res Treat 2020; 43:34-41. [DOI: 10.1159/000503754] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
<b><i>Objective:</i></b> Esophageal fistula is a critical and fatal complication of esophageal cancer. The aim of this meta-analysis was to explore the risk factors for esophageal perforation in esophageal cancer patients treated with radiotherapy. <b><i>Methods:</i></b> Data from the PubMed and Embase databases were retrieved for clinical research published between 1990 and 2018. The Newcastle-Ottawa Scale was used to evaluate the quality of the articles. A meta-analysis was performed using the RevMan 5.3 software provided by the Cochrane Collaboration Network. <b><i>Results:</i></b> Seventeen articles were eligible for the meta-analysis. In these articles, over 35 risk factors for esophageal fistula formation were described and 17 risk factors were analyzed. Significant differences in the odds of developing an esophageal perforation were found with regard to age (OR 2.34, 95% CI 1.08–5.03, <i>p</i> = 0.001), ulcerative type (OR 2.72, 95% CI 1.43–5.16, <i>p</i> = 0.002), histology (OR 4.16, 95% CI 1.14–15.12, <i>p</i> = 0.03), T stage (OR 2.66, 95% CI 1.44–4.91, <i>p</i> = 0.002), short-term response (OR 2.21, 95% CI 1.06–4.62, <i>p</i> = 0.03), chemotherapy regimen (OR 2.80, 95% CI 1.38–5.68, <i>p</i> = 0.005), and stenosis (OR 2.00, 95% CI 1.03–3.89, <i>p</i> = 0.04). <b><i>Conclusions:</i></b> An age of <60–65 years, ulcerative type, squamous cell cancer, T4 stage, incomplete response, fluorouracil-based regimen, and stenosis were associated with an increased risk of esophageal fistula during or after radiotherapy. However, further, large-scale prospective studies are needed to establish the validity of this association.
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High-dose-rate intraluminal brachytherapy prior to external radiochemotherapy in locally advanced esophageal cancer: preliminary results. J Contemp Brachytherapy 2017; 9:30-35. [PMID: 28344601 PMCID: PMC5346601 DOI: 10.5114/jcb.2017.65147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 12/14/2016] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Dysphagia is a common initial presentation in locally advanced esophageal cancer and negatively impacts patient quality of life and treatment compliance. To induce fast relief of dysphagia in patients with potentially operable esophageal cancer high-dose-rate (HDR) brachytherapy was applied prior to definitive radiochemotherapy. MATERIAL AND METHODS In this single arm phase II clinical trial between 2013 to 2014 twenty patients with locally advanced esophageal cancer (17 squamous cell and 3 adenocarcinoma) were treated with upfront 10 Gy HDR brachytherapy, followed by 50.4 Gy external beam radiotherapy (EBRT) and concurrent chemotherapy with cisplatin/5-fluorouracil. RESULTS Tumor response, as measured by endoscopy and/or computed tomography scan, revealed complete remission in 16 and partial response in 4 patients (overall response rate 100%). Improvement of dysphagia was induced by brachytherapy within a few days and maintained up to the end of treatment in 80% of patients. No differences in either response rate or dysphagia resolution were found between squamous cell and adenocarcinoma histology. The grade 2 and 3 acute pancytopenia or bicytopenia reported in 4 patients, while sub-acute adverse effects with painful ulceration was seen in five patients, occurring after a median of 2 months. A perforation developed in one patient during the procedure of brachytherapy that resolved successfully with immediate surgery. CONCLUSIONS Brachytherapy before EBRT was a safe and effective procedure to induce rapid and durable relief from dysphagia, especially when combined with EBRT.
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Sigounas DE, Krystallis C, Couper G, Paterson-Brown S, Tatsioni A, Plevris JN. Argon plasma coagulation compared with stent placement in the palliative treatment of inoperable oesophageal cancer. United European Gastroenterol J 2017; 5:21-31. [PMID: 28405318 PMCID: PMC5384556 DOI: 10.1177/2050640616650786] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 04/27/2016] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Self-expandable metal stents (SEMSs) are the main palliative modality used in inoperable oesophageal cancer. Other palliative modalities, including argon plasma coagulation (APC), have also been used. OBJECTIVE The purpose of this study was to assess the relative efficacy of SEMS and APC regarding the survival of patients with inoperable oesophageal cancer, not receiving chemo/radiotherapy. METHODS Single centre, retrospective analysis of all patients (n = 228) with inoperable oesophageal cancer between January 2000 and July 2014, not receiving chemo-radiotherapy, treated with SEMS (n = 160) or APC (n = 68) as primary palliation modalities. Cox regression analysis was performed to identify individual factors affecting survival and Kaplan-Meier curves were created for patients treated with APC and SEMS for stage III and IV disease. Survival intervals were compared by the log-rank test. RESULTS Type of treatment was the only statistically significant factor affecting survival, after disease stage stratification (hazard ratio (HR): 1.36, 95% confidence interval (CI): 1.13-1.65 of SEMS over APC, p: 0.002). Median survival for patients treated with APC and SEMS was 257 (interquartile range (IQR): 414, 124) and 151 (IQR: 241, 61) days respectively in stage III disease. It was 135 (IQR: 238, 43) and 70 (IQR: 148, 32) days respectively in stage IV disease. Both differences were statistically significant (p = 0.02 and 0.05 respectively). CONCLUSIONS APC is a promising palliation modality in inoperable oesophageal cancer, when patients are not candidates for chemo-radiotherapy. A randomized controlled trial will be needed to confirm those results.
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Affiliation(s)
- Dimitrios E Sigounas
- Centre for Liver and Digestive Disorders, University of Edinburgh, Edinburgh, UK
| | | | - Graeme Couper
- University Department of Surgery, The Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Simon Paterson-Brown
- University Department of Surgery, The Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - John N Plevris
- Centre for Liver and Digestive Disorders, University of Edinburgh, Edinburgh, UK
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Rovirosa Á, Anchuelo J, Crispin V, Gutiérrez C, Herreros A, Herruzo I, Menéndez JC, Pino P, Polo A, Rodríguez S. Recommendations of the Spanish Brachytherapy Group of SEOR for HDR endoluminal treatments. Part 1: Oesophagus. Clin Transl Oncol 2015; 17:581-9. [DOI: 10.1007/s12094-015-1284-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 03/20/2015] [Indexed: 11/25/2022]
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Aggarwal A, Harrison M, Glynne-Jones R, Sinha-ray R, Cooper D, Hoskin P. Combination External Beam Radiotherapy and Intraluminal Brachytherapy for Non-radical Treatment of Oesophageal Carcinoma in Patients not Suitable for Surgery or Chemoradiation. Clin Oncol (R Coll Radiol) 2015; 27:56-64. [DOI: 10.1016/j.clon.2014.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 08/10/2014] [Accepted: 09/02/2014] [Indexed: 10/24/2022]
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Keshavkumar B. Computed organ doses to an Indian reference adult during brachytherapy treatment of esophagus, breast, and neck cancers. J Med Phys 2012; 37:151-4. [PMID: 22973082 PMCID: PMC3437172 DOI: 10.4103/0971-6203.99238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Revised: 04/02/2012] [Accepted: 04/02/2012] [Indexed: 11/13/2022] Open
Abstract
This study aims to generate the normalized mean organ dose factors (mGy min(-1) GBq(-1)) to healthy organs during brachytherapy treatment of esophagus, breast, and neck cancers specific to the patient population in India. This study is in continuation to the earlier published studies on the estimation of organ doses during uterus brachytherapy treatments. The results are obtained by Monte Carlo simulation of radiation transport through MIRD type anthropomorphic mathematical phantom representing reference Indian adult with (192)Ir and (60)Co high dose rate sources in the esophagus, breast, and neck of the phantom. The result of this study is compared with a published computational study using voxel-based phantom model. The variation in the organ dose of this study to the published values is within 50%.
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Affiliation(s)
- Biju Keshavkumar
- Health Physics Division, Bhabha Atomic Research Centre, Trombay, Mumbai, India
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Homs MYV, Steyerberg EW, Eijkenboom WMH, Siersema PD. Predictors of outcome of single-dose brachytherapy for the palliation of dysphagia from esophageal cancer. Brachytherapy 2006; 5:41-8. [PMID: 16563996 DOI: 10.1016/j.brachy.2005.12.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2005] [Revised: 12/08/2005] [Accepted: 12/12/2005] [Indexed: 11/20/2022]
Abstract
BACKGROUND Single-dose brachytherapy is a commonly used palliative treatment modality for esophageal carcinoma, however, a considerable number of patients need additional treatment for persistent or recurrent dysphagia. Our aim was to establish predictors of an unfavorable outcome after single-dose brachytherapy. METHODS AND MATERIALS Between December 1999 and July 2002, 95 patients with dysphagia from inoperable esophageal carcinoma were treated with single-dose (12 Gy) brachytherapy. Patients were followed-up prospectively by monthly home visits by a specialized research nurse. We investigated the patient and tumor characteristics that influence the risk of persistent dysphagia (continuing dysphagia within 4 weeks after treatment necessitating a second treatment) or recurrent dysphagia (occurring more than 4 weeks after treatment) after single-dose brachytherapy, using logistic and Cox regressions. RESULTS At 4 weeks after brachytherapy, the dysphagia score was improved in 62/84 (74%) patients. Major complications occurred in 11/95 (12%) patients. In total, 42/95 (44%) patients were treated for persistent (n = 18) and/or recurrent dysphagia (n = 28). Persistent dysphagia (n = 18) was caused by persisting obstructing tumor confirmed at endoscopy, and these patients were treated with stent placement. Patients needing dilation before treatment had a higher risk of persistent dysphagia (odds ratio = 4.1; 95% CI 1.3-12). There was a trend toward a higher risk of persistent dysphagia for patients previously treated with chemotherapy (odds ratio = 3.2; 95% CI 0.81-12). In total, 34 events of recurrent dysphagia occurred in 28 patients, caused by obstructing tumor regrowth (n = 26), food bolus obstruction (n = 5), or other reasons (n = 3). None of the investigated patient and tumor characteristics had a significant association with the risk of developing recurrent dysphagia. Of all patients needing additional treatment (42/95), those who needed dilation before treatment had a higher risk of persistent and/or recurrent dysphagia (hazard ratio = 2.1; 95% CI 1.1-4.1). CONCLUSIONS Patients with stenotic esophageal tumors that cannot be bypassed or who previously underwent chemotherapy are poor candidates for single-dose brachytherapy. For these patients, a higher and/or fractionated dose of brachytherapy or alternative palliative treatment modalities should be considered.
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Affiliation(s)
- Marjolein Y V Homs
- Department of Gastroenterology and Hepatology, Erasmus Medical Center/University Medical Center Rotterdam, The Netherlands
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Vuong T, Szego P, David M, Evans M, Parent J, Mayrand S, Corns R, Burtin P, Faria S, Devic S. 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. Int J Radiat Oncol Biol Phys 2005; 63:758-64. [PMID: 16199311 DOI: 10.1016/j.ijrobp.2005.02.042] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2004] [Revised: 02/08/2005] [Accepted: 02/21/2005] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Té Vuong
- Department of Radiation Oncology, McGill University Health Center, Montréal, Québec, Canada.
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Eickhoff A, Knoll M, Jakobs R, Weickert U, Hartmann D, Schilling D, Eickhoff JC, Riemann JF. Self-expanding metal stents versus plastic prostheses in the palliation of malignant dysphagia: long-term outcome of 153 consecutive patients. J Clin Gastroenterol 2005; 39:877-85. [PMID: 16208111 DOI: 10.1097/01.mcg.0000180631.61819.4a] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Malignant dysphagia due to esophagogastric cancer is associated with poor overall prognosis. Placements of self-expandable metal stents or plastic tubes are established methods as palliative treatment options. As an alternative and/or complementary therapy, radiologic techniques (external beam radiation/brachytherapy) and locally endoscopic techniques (laser, APC-beamer, PDT) are often used. STUDY AND GOALS: Retrospective trial of 153 patients treated in our department between 1993 and 2001. Forty-five patients received a plastic tube (Group A) and 108 patients were treated with metal stents (Group B). Both groups were compared for improvement of dysphagia score, survival, recurrent dysphagia and complications. RESULTS Stent placement was successful in 41 of 45 (93%) patients of Group A and 107 of 108 (99%) of Group B. The median dysphagia score improved significantly in Group A (from 3.03 to 1.55, P = 0.010) and Group B (from 2.77 to 1.44, P = 0.009). Recurrent dysphagia was noted in 12 of 45 (27%) patients of Group A and 27 of 108 (25%) patients of Group B. Median survival time after stent insertion was 78 days (Group A) and 113 days (Group B). Overall complications occurred in 15 of 45 (33%) patients of Group A and 28 of 108 (26%) patients of Group B. However, significantly (P = 0.05) more major complications were seen in Group A than in Group B (22% vs. 9%). CONCLUSIONS Our results indicate a marginal clinical benefit for metal stents versus plastic tubes in malignant dysphagia in the long run. However, metal stents seem to be safer and associated with a prolonged improvement of dysphagia score.
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Affiliation(s)
- Axel Eickhoff
- Medical Department C, Klinikum Ludwigshafen, Bremserstrasse 79, D-67063 Ludwigshafen, Germany.
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Homs MYV, Steyerberg EW, Eijkenboom WMH, Tilanus HW, Stalpers LJA, Bartelsman JFWM, van Lanschot JJB, Wijrdeman HK, Mulder CJJ, Reinders JG, Boot H, Aleman BMP, Kuipers EJ, Siersema PD. Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial. Lancet 2004; 364:1497-504. [PMID: 15500894 DOI: 10.1016/s0140-6736(04)17272-3] [Citation(s) in RCA: 387] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Both single-dose brachytherapy and self-expanding metal stent placement are commonly used for palliation of oesophageal obstruction due to inoperable cancer, but their relative merits are unknown. We undertook a randomised trial to compare the outcomes of brachytherapy and stent placement in patients with oesophageal cancer. METHODS Nine hospitals in the Netherlands participated in our study. Between December, 1999, and June, 2002, 209 patients with dysphagia from inoperable carcinoma of the oesophagus or oesophagogastric junction were randomly assigned to stent placement (n=108) or single-dose (12 Gy) brachytherapy (n=101), and were followed up after treatment. Primary outcome was relief of dysphagia during follow-up, and secondary outcomes were complications, treatment for persistent or recurrent dysphagia, health-related quality of life, and costs. Analysis was by intention to treat. FINDINGS Nine patients (six [brachytherapy] vs three [stent placement]) did not receive their allocated treatments. None was lost to follow-up. Dysphagia improved more rapidly after stent placement than after brachytherapy, but long-term relief of dysphagia was better after brachytherapy. Stent placement had more complications than brachytherapy (36 [33%] of 108 vs 21 [21%] of 101; p=0.02), which was mainly due to an increased incidence of late haemorrhage (14 [13%] of 108 vs five [5%] of 101; p=0.05). Groups did not differ for persistent or recurrent dysphagia (p=0.81), or for median survival (p=0.23). Quality-of-life scores were in favour of brachytherapy compared with stent placement. Total medical costs were also much the same for stent placement (8215) and brachytherapy (8135). INTERPRETATION Despite slow improvement, single-dose brachytherapy gave better long-term relief of dysphagia than metal stent placement. Since brachytherapy was also associated with fewer complications than stent placement, we recommend it as the primary treatment for palliation of dysphagia from oesophageal cancer.
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Affiliation(s)
- Marjolein Y V Homs
- Department of Gastroenterology and Hepatology, Erasmus MC/University Medical Centre Rotterdam, Rotterdam, Netherlands
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Polinder S, Homs MYV, Siersema PD, Steyerberg EW. Cost study of metal stent placement vs single-dose brachytherapy in the palliative treatment of oesophageal cancer. Br J Cancer 2004; 90:2067-72. [PMID: 15150566 PMCID: PMC2409487 DOI: 10.1038/sj.bjc.6601815] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Self-expanding metal stent placement and single-dose brachytherapy are commonly used for the palliation of oesophageal obstruction due to inoperable oesophagogastric cancer. We randomised 209 patients to the placement of an Ultraflex stent (n=108) or single-dose brachytherapy (12 Gy, n=101). Cost comparisons included comprehensive data of hospital costs, diagnostic interventions and extramural care. We acquired detailed information on health care consumption from a case record form and from monthly home visits by a specialised nurse. The initial costs of stent placement were higher than the costs of brachytherapy (€1500 vs €570; P<0.001). Total medical costs were, however, similar (stent €11 195 vs brachytherapy €10 078, P>0.20). Total hospital stay during follow-up was 11.5 days after stent placement vs 12.4 days after brachytherapy, which was responsible for the high intramural costs in both treatment groups (stent €6512 vs brachytherapy €7982, P>0.20). Costs for medical procedures during follow-up were higher after stent placement (stent €249 vs brachytherapy €168, P=0.002), while the costs of extramural care were similar (€1278 vs €1046, P>0.20). In conclusion, there are only small differences between the total medical costs of both palliative treatment modalities, despite the fact that the initial costs of stent placement are much higher than those of brachytherapy. Therefore, cost considerations should not play an important role in decision making on the appropriate palliative treatment strategy for patients with malignant dysphagia.
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Affiliation(s)
- S Polinder
- Department of Public Health, Erasmus MC/University Medical Center Rotterdam, PO Box 1738, 3000 CA Rotterdam, The Netherlands.
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Skowronek J, Piotrowski T, Zwierzchowski G. Palliative treatment by high–dose-rate intraluminal brachytherapy in patients with advanced esophageal cancer. Brachytherapy 2004; 3:87-94. [PMID: 15374540 DOI: 10.1016/j.brachy.2004.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2004] [Revised: 05/25/2004] [Accepted: 05/28/2004] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Janusz Skowronek
- Department of Brachytherapy, Great Poland Cancer Centre, Ulica Garbary 15 61-866, Poznań, Poland.
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15
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Homs MYV, Eijkenboom WMH, Coen VLMA, Haringsma J, van Blankenstein M, Kuipers EJ, Siersema PD. High dose rate brachytherapy for the palliation of malignant dysphagia. Radiother Oncol 2003; 66:327-32. [PMID: 12742273 DOI: 10.1016/s0167-8140(02)00410-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND PURPOSE High dose rate (HDR) brachytherapy is a commonly used palliative treatment for esophageal carcinoma. We evaluated the outcome of HDR brachytherapy in patients with malignant dysphagia. MATERIAL AND METHODS A retrospective analysis over a 10-year period was performed of 149 patients treated with HDR brachytherapy, administered in one or two sessions, at a median dose of 15Gy. Patients were evaluated for functional outcome, complications, recurrent dysphagia, and survival. RESULTS At 6 weeks after HDR brachytherapy, dysphagia scores had improved from a median of 3 to 2 (n=104; P<0.001), however, dysphagia had not improved in 51 (49%) patients. Procedure-related complications occurred in seven (5%) patients. Late complications, including fistula formation or bleeding, occurred in 11 (7%) patients. Twelve (8%) patients experienced minor retrosternal pain. Median survival of the patients was 160 days with a 1-year survival rate of 15%. Procedure-related mortality was 2%. At follow-up, 55 (37%) patients experienced recurrent dysphagia. In 34 (23%) patients a metal stent was placed to relieve persistent or recurrent dysphagia. CONCLUSION HDR brachytherapy is a moderately effective treatment for the palliation of malignant dysphagia. The incidence of early major complications is low, however, persistent and recurrent dysphagia occur frequently, and require often additional treatment.
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Affiliation(s)
- Marjolein Y V Homs
- Department of Gastroenterology and Hepatology, Erasmus MC/University Medical Center, P.O. Box 2040, Rotterdam 3000 CA, Rotterdam, The Netherlands
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16
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Sharma V, Agarwal J, Dinshaw K, Nehru RM, Mohandas M, Deshpande R, Rayabhattnavar S. Late esophageal toxicity using a combination of external beam radiation, intraluminal brachytherapy and 5-fluorouracil infusion in carcinoma of the esophagus. Dis Esophagus 2001; 13:219-25. [PMID: 11206636 DOI: 10.1046/j.1442-2050.2000.00115.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
One hundred patients with potentially curable squamous cell carcinoma of the esophagus were treated using a combination of external beam radiation, medium-dose intraluminal brachytherapy (ILBT), and 5-fluorouracil infusion (as a radiosensitizer) from January 1990 to December 1993. The main objective was to determine late toxicity and optimization of the dose of intraluminal radiation. All patients had external radiation of 50 Gy over 5 1/2 weeks, followed by ILBT of 20 Gy for 50 patients (group 1) and 15 Gy for a subsequent 50 patients (group 2), using a dose rate of 315-330 cGy/h with the prescription at 1 cm off axis. The 5-fluorouracil infusion was 500 mg/m2 administered 12 h prior to ILBT. The treatment-related complications among groups 1 and 2 were strictures 24% vs. 8% (p = 0.029), ulceration 30% vs. 28% (p = 0.8), and tracheoesophageal fistulae 12% for both groups. The overall survival for groups 1 and 2 was 8% and 23% at 5 years. The development of life-threatening complications is a major concern and extreme caution is urged before selecting patients for a combination of ILBT and 5-fluorouracil treatment.
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Affiliation(s)
- V Sharma
- Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, India
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17
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Abstract
The goal of palliative radiation is to alleviate symptoms in a short amount of time and maintain an optimal functional and quality-of-life level while minimizing toxicity and patient inconvenience. Despite advances in multimodality antineoplastic therapies, failure to control the tumor at its primary site frustratingly remains the predominant source of morbidity and mortality in many patients with cancer. Escalation of doses of radiation using external beam irradiation has been shown to improve local tumor control, but limits are imposed by the tolerance of normal surrounding structures. The highly conformal nature of brachytherapy enables the radiation oncologist to accomplish safe escalation of radiation doses to the tumor while minimizing doses to normal surrounding structures. Thus, by enhancing the potential for local control, brachytherapy used alone or as a supplement to external beam radiation therapy retains a significant and important role in achieving the goals of palliation. Proper patient selection, excellent technique, and adherence to implant rules will minimize the risk of complications. The advantages realized with the use of brachytherapy include good patient tolerance, short treatment time, and high rates of sustained palliation. This article reviews various aspects of palliative brachytherapy, including patient selection criteria, implant techniques, treatment planning, dose and fractionation schedules, results, and complications of treatment. Tumors of the head and neck, trachea and bronchi, esophagus, biliary tract, and brain, all in which local failure represents the predominant cause of morbidity and mortality, are highlighted.
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Affiliation(s)
- D Shasha
- Department of Radiation Oncology, Beth Israel Medical Center, New York, NY 10003, USA
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Isacsson U, Lennernäs B, Grusell E, Jung B, Montelius A, Glimelius B. Comparative treatment planning between proton and x-ray therapy in esophageal cancer. Int J Radiat Oncol Biol Phys 1998; 41:441-50. [PMID: 9607363 DOI: 10.1016/s0360-3016(98)00047-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Conformal treatment planning with megavoltage x-rays and protons for five patients with esophageal cancer has been studied in an attempt to determine if there are advantages of using protons instead of x-rays. METHODS AND MATERIALS For each of the five patients, two different proton plans, one x-ray plan, and one mixed plan with x-rays and protons were made. A three-dimensional treatment planning system, TMS, was used. The evaluation of the different plans was made by applying the tumor control probability (TCP) model proposed by Nahum and Webb and the normal tissue complication (NTCP) model proposed by Lyman on the dose distributions in terms of dose-volume histograms (DVHs). RESULTS The comparison shows advantages of using protons instead of x-rays for all five patients. The dose-limiting organs at risk are the spinal cord, the lungs, and the heart, but the proton plans also spare the kidneys better than the x-ray plan does. At 5% NTCP in any risk organ, the calculated mean TCP value for the five patients is increased by an average of 20%-units (from 2 to 23%-units) with the best proton plan compared with x-rays only. However, if we assume maximally a 1% risk in the spinal cord and a total NTCP for the two lungs of 100%, the mean TCP value for the five patients is increased from 6 to 49% with the best proton plan compared with x-rays only. The corresponding figure for the mixed plan is 27%. These gains are relatively insensitive to variations within reasonable limits in the biological parameters. CONCLUSIONS Protons appear to have clear therapeutic advantages over conventional external radiotherapy when treating esophageal carcinoma.
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Affiliation(s)
- U Isacsson
- Department of Oncology, University of Uppsala, Akademiska sjukhuset, Sweden
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Siersema PD, Dees J, van Blankenstein M. Palliation of malignant dysphagia from oesophageal cancer. Rotterdam Oesophageal Tumor Study Group. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1998; 225:75-84. [PMID: 9515757 DOI: 10.1080/003655298750027272] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Palliative therapies for advanced oesophageal cancer include surgery, radiation therapy, chemotherapy, endoscopic procedures and combinations of these. Of the non-endoscopic modalities is external beam radiation therapy (EBRT) effective and non-invasive. A disadvantage is that relief of dysphagia only occurs over a period of 4-6 weeks. Brachytherapy is more rapid in locally controlling tumour growth and in relieving dysphagia. One of the more commonly used endoscopic procedures is laser therapy, which provides symptomatic relief with low complication rates. Recurrent dysphagia is a problem necessitating repeated treatment sessions. Self-expanding metal stents offer a high degree of palliation and are associated with fewer complications compared with prosthetic tubes. Longer palliation and perhaps even longer survival might be achieved by the combination of different therapies. Most promising are the combination of EBRT plus brachytherapy or chemoradiation. Now is the time to determine which treatment (combination) is best for individual patients.
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Affiliation(s)
- P D Siersema
- Dept. of Gastroenterology and Hepatology (Internal Medicine II), University Hospital Rotterdam-Dijkzigt, The Netherlands
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