High-dose-rate intraluminal brachytherapy prior to external radiochemotherapy in locally advanced esophageal cancer: preliminary results

Esophageal cancer: Treatment advances and need for screening

ABSTRACT

Esophageal cancer is a challenging malignancy that often is diagnosed in advanced stages, resulting in a poor prognosis. This article provides a comprehensive review of the two main types of esophageal cancer, esophageal squamous cell carcinoma and esophageal adenocarcinoma, and reviews epidemiology, risk factors, pathogenesis, diagnostic modalities, staging systems, and established and emerging treatments. Recent advancements in treatment for resectable and unresectable esophageal cancer also are explored. These include immunotherapy, targeted therapy, sentinel lymph node mapping, radiogenomics, palliative measures, and screening measures.

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.

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.

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.