Intraluminal brachytherapy in the management of squamous carcinoma of the esophagus

Systematic review of brachytherapy for symptom palliation

PURPOSE

Brachytherapy is most often applied in the curative or salvage setting, but many forms of brachytherapy can be helpful for symptom palliation. Declining utilization is seen, for multiple reasons, such as lack of awareness, insufficient expertise, or poor access to equipment. High level evidence for many types of palliative brachytherapy has been lacking. The objective of the current study was to review the evidence for utilization and efficacy of brachytherapy to palliate symptoms from cancer.

MATERIALS AND METHODS

We performed a systematic search in EMBASE and MEDLINE for English-language articles published from January 1980 to May 2022 that described brachytherapy used for a palliative indication in adults with a diagnosis of cancer (any subtype) and at least one symptom related outcome. Individual case reports and conference abstracts were excluded. All publications were independently screened by two investigators for eligibility.

RESULTS

The initial search identified 3637 abstracts of which 129 were selected for in-depth review. The number of studies (total number of patients) included in the final analysis varied widely by tumor site with the majority (68.2%) involving either lung or esophageal cancer. Despite a limited number of prospective trials that assessed the efficacy of brachytherapy for symptom management, there was a positive effect on palliation of symptoms across all tumor types. There was no clear trend in the number of publications over time. The most commonly cited symptom indications for palliation by brachytherapy were dysphagia, dyspnea, pain and bleeding.

CONCLUSIONS

Brachytherapy can provide palliation for patients with advanced cancer, across different tumor sites and clinical scenarios. However, high level evidence in the literature to support palliative applications of brachytherapy is lacking or limited for many tumor sites. There appears to be a strong publication bias towards positive studies in favor of brachytherapy. Beyond anecdotal reports and individual practices, outcomes research can further our understanding of the role of brachytherapy in palliating advanced cancers of all types, and should be encouraged.

Malignant Bowel Obstruction: Reappraising the Value of Surgery

Urgent palliative surgery in the setting of advanced malignancy is associated with significant morbidity, mortality, and cost. Malignant bowel obstruction is the most frequent indication for such intervention. Traditional surgical dogma is often invoked to justify associated risks and cost, but little evidence exists to support surgical over nonsurgical approaches. Evolving evidence may provide more meaningful guidance for treatment selection.

Value in palliative cancer surgery: A critical assessment

Emergency operations are associated with increased morbidity, mortality, and cost compared to elective operations. Palliative and emergent surgery for patients with advanced malignancies is associated with additional risk and remains controversial. Emergent or palliative interventions can be broadly categorized according to indication. Tumor related complications (bleeding, obstruction, or perforation) merit specific consideration, as do specific presentations such as pneumoperitoneum, pneumatosis intestinalis, or peritonitis from other causes that may arise during active therapy for malignancies. Although nonoperative, endoscopic, and interventional treatment modalities are frequently available, surgery remains the only effective therapy in selected situations such as small intestinal obstruction and tumor perforation. Selection of patients for surgery requires consideration of factors including overall prognosis, performance status, and patients' priorities. Selection and risk assessment tools underscore the limited capacity of patients' with higher risk features for durable recovery but do not supplant nuanced clinical judgment. J. Surg. Oncol. 2016;114:311-315. © 2016 Wiley Periodicals, Inc.

[Curietherapy in the palliative treatment of esophageal cancer]

Les patients atteints du cancer de l’œsophage ont souvent une maladie localement avancée, la dysphagie est le symptôme majeur chez la plupart de ces patients, plusieurs modalités thérapeutiques ont été utilisées pour améliorer cette dysphagie. Le but de ce travail est d’étudier l'efficacité et la tolérance de la curiethérapie haut débit de dose (HDR) endo-luminale dans le traitement palliatif des cancers de l’œsophage inopérable. Sur une période de 15 ans, l’étude a inclus les patients atteints de cancer de l’œsophage inopérable et/ou métastatique avec une dysphagie, sans extension à l'hypopharynx ou a la trachée et qui ont bénéficié d'une curiethérapie HDR avec ou sans radiothérapie externe à visée palliative. Au total 46 patients ont été inclus dans l’étude, 58,7% étaient des hommes, 42,2% avaient une dysphagie grade 2 et 37,8% étaient aphagiques, 78,6% des patients étaient performance satus PS 2, l'amaigrissement à été trouvé chez 81,4%, la localisation de la tumeur était surtout au niveau du tiers moyen et inférieur dans 97,8%, la hauteur médiane de la tumeur était de 7 cm (5,5-9), le carcinome épidermoïde était le type histologique le plus fréquent chez 31 patients (70,5%). Après un médiane de suivi de 5 mois, l'amélioration de la dysphagie a été retrouvée chez 76% des malades (p1]. L′incidence la plus élevée est observée dans certains pays notamment en Asie et en Afrique, et l′incidence dans les pays développés occidentaux est en augmentation [2]. Selon le registre du cancer de Rabat 2006-2008, le cancer de l’œsophage est rare et constitue 1,5% de tous les cancers chez l'homme [3]. Le taux de survie globale à 5 ans est de 8%, avec 80% des décès liés à l’évolution locale de la maladie [4]. Pour la minorité des patients avec une maladie localisée, le traitement par radiochimiothérapie concomitante avec ou sans chirurgie permet une amélioration de la survie [5]. Plus de 50% des patients atteints de cancer de l′œsophage ont une maladie inopérable au moment du diagnostic due à une tumeur localement avancée, des métastases ou un mauvais état général avec une médiane de survie globale de 2,5 à 9,9 mois [6]. La majorité de ces patients ont besoin de soins palliatifs pour soulager la dysphagie qui est présente chez plus de 70% des patients et qui est responsable d'une dégradation importante de la qualité de vie [7]. À l′heure actuelle, plusieurs modalités de prise en charge sont disponibles pour le traitement palliatif de cette dysphagie. Les options de traitement les plus couramment utilisées comprennent le placement de stent métallique [8–10], le traitement au laser [11], et la curiethérapie avec ou sans radiothérapie externe et ou éventuellement une chimiothérapie [12–15]. Une méta-analyse a conclu qu'il n'y a pas de supériorité claire de l'une des méthodes utilisées dans la palliation du cancer de l’œsophage, le choix de l'une de ces méthodes dépend de l'expérience du centre et de l’état du patient. Cette méta-analyse a aussi démontré que la pose d'une prothèse métallique expansible et la curiethérapie étaient les deux méthodes de référence, la première étant la plus rapide pour améliorer la dysphagie, mais la seconde constitue une réelle alternative pouvant améliorer la survie et la qualité de vie [16]. Un inconvénient du traitement au laser est la nécessité de répéter les séances afin d'obtenir et de maintenir le bénéfice [17, 18]. Dans notre centre la curiethérapie est souvent utilisée pour pallier à la dysphagie. Le but de notre travail est de déterminer l'efficacité et la tolérance de la curiethérapie dans le traitement palliatif du cancer de l’œsophage.

Role of stenting in the palliation of gastroesophageal junction cancer: A brief review

Gastroesophageal junction cancer has an increasing incidence in western countries. It is inoperable when first manifested in more than 50% of cases. So, palliation is the only therapeutic option for the advanced disease to relieve dysphagia and its consequences in weakened patients with an estimated mean survival under 6 mo. This article has tried to identify trends focusing on current information about the best palliative treatment, with an emphasis on the role of stenting. Self-expanding stent placement, either metal or plastic, is the main management option. However, this anatomical location creates some particular problems for stent safety and effectiveness which may be overcome by properly designed novel stents. The stents ensure a good quality of life and must be preferred over other alternative methods of loco-regional modalities, i.e., external radiation, laser thermal or photodynamic therapy. Although stent placement is generally a simple, safe and effective method, there are sometimes complications, increasing the morbidity and mortality rate. Bypass operative procedures have now been abandoned as a first choice. The stomach instead of the colon must be used for a bypass operation when it is needed. Chemotherapy, despite the toxicity, and intraluminal radiation (brachytherapy) have a well-defined role.

Patient-reported outcomes evaluating palliative radiotherapy and chemotherapy in patients with oesophageal cancer: a systematic review

BACKGROUND

Patient-reported outcomes (PROs) and assessments of treatment-related toxicity provide important information on the effect of palliative chemotherapy and/or radiotherapy. The aim of this study was to review the effect of palliative radiotherapy and/or chemotherapy on symptoms and quality of life assessed by PROs and measurement of toxicity for patients with oesophageal cancer.

METHODS

The Central, Medline and Embase databases (1990 to November 2011) were systematically searched for prospective studies of palliative chemotherapy and/or radiotherapy in patients with advanced oesophageal cancer with PRO- and/or toxicity outcomes. The risks of bias were assessed.

RESULTS

Of 2677 records identified, only 32 included PROs, of which eight were randomised controlled trials. In studies with sufficient standard of PRO (n = 18), either Health Related Quality of Life (HRQL) (n = 14) or patient-reported dysphagia (n = 4), were assessed. Docetaxel added to cisplatin + fluorouracil (CF) improved HRQL compared to CF only, even though toxicity increased. Epirubicin added to CF resulted in longer preserved HRQL than its comparator in two trials, and non-inferiority in one. All phase II chemotherapy studies reported maintained HRQL or improved dysphagia combined with low level of toxicity. Brachytherapy resulted in better HRQL compared to stent placement in two trials, and external radiotherapy relieved dysphagia. The quality of the HRQL methodology and the interpretation and presentation of the PRO results varied, and clinical significance was seldom discussed.

CONCLUSION

PRO endpoints are seldom used and further studies of homogenous patient groups with valid measures and methodology of PROs should be encouraged in the evaluation of palliative treatment. Brachytherapy, external radiotherapy and combination chemotherapy improved HRQL and dysphagia in the few identified studies with sufficient PRO methodology.

Individualized, multimodal palliative treatment of inoperable esophageal cancer: clinical impact of photodynamic therapy resulting in prolonged survival

BACKGROUND AND OBJECTIVE

In esophageal carcinoma palliative treatment is often required due to advanced tumor stage or patient-related factors. The main goal of our retrospective single center study was to evaluate the effect of an individualized multimodal palliative treatment, focusing on the efficacy of different treatment options.

MATERIALS AND METHODS

Between 1999 and 2009, 640 patients suffering from esophageal carcinoma were referred to our division. Two hundred fifty out of those (39.1%) were treated with palliative intention by using a individualized, multimodal concept including endoscopic dilatation, photodynamic therapy (PDT), endoluminal brachytherapy, external radiation, chemotherapy, stenting, feeding tube, and palliative resection.

RESULTS

There were 37 women (14.9%) and 211 men (85.1%). The treatment included PDT in 171 cases (in 118 as first measure), stenting in 124 (38), dilatation in 83 (24), endoluminal brachytherapy in 92 (20), feeding enterostomy in 40 (14), external radiation in 67 (23), chemotherapy in 57 (29), and palliative resection in 3 patients. The mean number of palliative treatments per patient was 2.6. Mean survival time for the collective was 34 months. Distant metastases and nodal positivity were connected with a significantly reduced survival. If PDT was used in the first place, median survival was 50.9 months compared to 17.3 months if other options were used as initial modality (P = 0.012).

CONCLUSION

By using an individualized multimodal approach, an acceptable mean survival time can be achieved in advanced esophageal cancer treated with palliative intention. PDT, if used as initial endoluminal treatment in patients without gross tumor infiltration into the mediastinum, the great vessels or the tracheo-bronchial tree, enables a considerable beneficial effect in the palliative setting.

High-dose-rate intraluminal brachytherapy during preoperative chemoradiation for locally advanced rectal cancers

AIM: To determine the feasibility and safety of high dose rate intraluminal brachytherapy (HDR-ILBT) boost during preoperative chemoradiation for rectal cancer.

METHODS: Between 2008 and 2009, thirty-six patients with locally advanced rectal cancer (≥ T3 or N+), were treated initially with concurrent capecitabine (825 mg/m² oral twice daily) and pelvic external beam radiotherapy (EBRT) (45 Gy in 25 fractions), then were randomized to group A; HDR-ILBT group (n = 17) to receive 5.5-7 Gy × 2 to gross tumor volume (GTV) and group B; EBRT group (n = 19) to receive 5.4 Gy × 3 fractions to GTV with EBRT. All patients underwent total mesorectal excision.

RESULTS: Grade 3 acute toxicities were registered in 12 patients (70.6%) in group A and in 8 (42.1%) in group B. Complete pathologic response of T stage (ypT0) in group A was registered in 10 patients (58.8%) and in group B, 3 patients (15.8%) had ypT0 (P < 0.0001). Sphincter preservation was reported in 6/9 patients (66.7%) in group A and in 5/10 patients (50%) in group B (P < 0.01). Overall radiological response was 68.15% and 66.04% in Group A and B, respectively. During a median follow up of 18 mo, late grade 1 and 2 sequelae were registered in 3 patients (17.6%) and 4 patients (21.1%) in the groups A and B, respectively.

CONCLUSION: HDR-ILBT was found to be effective dose escalation technique in preoperative chemoradiation for rectal cancers, with higher response rates, downstaging and with manageable acute toxicities.