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Nakanishi K, Yamamoto S, Yabe T, Yogo K, Noguchi Y, Okudaira K, Kawachi N, Kataoka J. Estimating blurless and noise-free Ir-192 source images from gamma camera images for high-dose-rate brachytherapy using a deep-learning approach. Biomed Phys Eng Express 2023; 10:015006. [PMID: 37948761 DOI: 10.1088/2057-1976/ad0bb2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/10/2023] [Indexed: 11/12/2023]
Abstract
Objective. Precise monitoring of the position and dwell time of iridium-192 (Ir-192) during high-dose-rate (HDR) brachytherapy is crucial to avoid serious damage to normal tissues. Source imaging using a compact gamma camera is a potential approach for monitoring. However, images from the gamma camera are affected by blurring and statistical noise, which impact the accuracy of source position monitoring. This study aimed to develop a deep-learning approach for estimating ideal source images that reduce the effect of blurring and statistical noise from experimental images captured using a compact gamma camera.Approach. A double pix2pix model was trained using the simulated gamma camera images of an Ir-192 source. The first model was responsible for denoising the Ir-192 images, whereas the second model performed super resolution. Trained models were then applied to the experimental images to estimate the ideal images.Main results. At a distance of 100 mm between the compact gamma camera and the Ir-192 source, the difference in full width at half maximum (FWHM) between the estimated and actual source sizes was approximately 0.5 mm for a measurement time of 1.5 s. This difference has been improved from approximately 2.7 mm without the use of DL. Even with a measurement time of 0.1 s, the ideal images could be estimated as accurately as in the 1.5 s measurements. This method consistently achieved accurate estimations of the source images at any position within the field of view; however, the difference increased with the distance between the Ir-192 source and the compact gamma camera.Significance. The proposed method successfully provided estimated images from the experimental images within errors smaller than 0.5 mm at 100 mm. This method is promising for reducing blurring and statistical noise from the experimental images, enabling precise real-time monitoring of Ir-192 sources during HDR brachytherapy.
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Affiliation(s)
- Kohei Nakanishi
- Department of Integrated Health Science, Nagoya University Graduate School of Medicine, Japan
| | | | - Takuya Yabe
- Takasaki Institute for Advanced Quantum Science, Foundational Quantum Technology Research Directorate, National Institutes for Quantum Science and Technology (QST), Japan
| | - Katsunori Yogo
- Department of Integrated Health Science, Nagoya University Graduate School of Medicine, Japan
| | - Yumiko Noguchi
- Department of Radiological Technology, Nagoya University Hospital, Japan
| | - Kuniyasu Okudaira
- Department of Radiological Technology, Nagoya University Hospital, Japan
| | - Naoki Kawachi
- Takasaki Institute for Advanced Quantum Science, Foundational Quantum Technology Research Directorate, National Institutes for Quantum Science and Technology (QST), Japan
| | - Jun Kataoka
- Faculty of Science and Engineering, Waseda University, Japan
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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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Sur R, Than NW, Taggar A, Sripadam R, Sun Myint A. Organ and Function Preservation in Gastrointestinal Malignancies. Clin Oncol (R Coll Radiol) 2023:S0936-6555(23)00225-X. [PMID: 37357120 DOI: 10.1016/j.clon.2023.06.012] [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: 11/06/2022] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 06/27/2023]
Abstract
Radiation plays an important role in organ preservation for gastrointestinal malignancies, with a watch and wait strategy enabling surgery to be avoided in patients who are not suitable or who are refusing surgery. Brachytherapy boost allows the radiation dose to be escalated, which plays a pivotal role in the successful outcome of achieving organ preservation. Here we describe the role of brachytherapy in two common gastrointestinal malignancies (oesophagus and rectum). Their indications and how the brachytherapy procedures are carried out, together with the dose and fractionation commonly used are discussed. The use of brachytherapy needs to be included in the training curriculum at all academic centres so that its use is developed by the newer generation of radiation oncologists. Its current non-use due to bias, lack of training and availability is no longer justified, given the overwhelming published evidence for the role of brachytherapy to improve organ preservation for both radical treatment and palliation in gastrointestinal malignancies.
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Affiliation(s)
- R Sur
- Division of Radiation Oncology, Department of Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - N W Than
- Molecular and Clinical Cancer Medicine Department, University of Liverpool, Liverpool, UK; Clatterbridge Cancer Centre, Liverpool, UK
| | - A Taggar
- Department of Radiation Oncology, University of Toronto, Odette Cancer Centre, Toronto, Ontario, Canada
| | - R Sripadam
- Clatterbridge Cancer Centre, Liverpool, UK
| | - A Sun Myint
- Molecular and Clinical Cancer Medicine Department, University of Liverpool, Liverpool, UK; Clatterbridge Cancer Centre, Liverpool, UK.
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Brachytherapy for Oesophageal Carcinoma: A Comprehensive Review of Literature and Techniques. JOURNAL OF RADIOTHERAPY IN PRACTICE 2021. [DOI: 10.1017/s1460396920001120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Abstract
Introduction:
Oesophageal carcinoma is one of the fatal cancers mainly because of its rapid spread and poor prognosis. Treatment modalities involves a multimodality approach, including surgery, radiation therapy and chemotherapy. Radiation therapy includes brachytherapy in the form of intraluminal radiation therapy. Brachytherapy permits delivery of high tumouricidal doses to superficial cancerous growth of the oesophagus while delivering much lower doses to the surrounding tissue. It is mostly given in combination with external beam radiation in patients with poor performance scores not likely to tolerate an aggressive chemoradiation regimen or as a boost to concurrent chemoradiotherapy. It is very effective in terms of local tumour control as well as in relieving symptoms in advanced/recurrent disease. Intraoperative brachytherapy and seed brachytherapy have also been tried to address the nodal disease.
Methods:
We undertook a review of the available literature and techniques developed in the past three decades to emphasise the role of brachytherapy in curative or palliative settings in the treatment of oesophageal carcinoma.
Conclusion:
Oesophageal brachytherapy will remain a tangible treatment of oesophageal cancer, although it is less commonly used due to high expertise requirement, lack of established evidence, risk of life-threatening complications and lack of interest in brachytherapy. It offers quick and useful palliation for a prolonged period, along with good quality of life and superior dosimetry. Use of novel applicators may allow dose escalation and lower toxicity. Seed brachytherapy is also emerging as a promising option in nodal recurrences.
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Folkert MR, Gottumukkala S, Nguyen NT, Taggar A, Sur RK. Review of brachytherapy complications - Upper gastrointestinal tract. Brachytherapy 2020; 20:1005-1013. [PMID: 33358330 DOI: 10.1016/j.brachy.2020.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/29/2020] [Accepted: 11/23/2020] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
| | | | - Nhu Tram Nguyen
- McMaster University, Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Amandeep Taggar
- University of Toronto, Odette Cancer Centre, Toronto, Ontario, Canada
| | - Ranjan Kumar Sur
- McMaster University, Juravinski Cancer Centre, Hamilton, Ontario, Canada
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Kissel M, Chirat E, Annede P, Burtin P, Fumagalli I, Bronsart E, Mignot F, Schernberg A, Dumas I, Haie-Meder C, Chargari C. Esophageal brachytherapy: Institut Gustave Roussy's experience. Brachytherapy 2020; 19:499-509. [PMID: 32444283 DOI: 10.1016/j.brachy.2020.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 03/18/2020] [Accepted: 04/03/2020] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Manon Kissel
- Radiotherapy Department, Gustave Roussy, Villejuif, France.
| | - Erick Chirat
- Radiotherapy Department, Gustave Roussy, Villejuif, France
| | - Pierre Annede
- Radiotherapy Department, Gustave Roussy, Villejuif, France
| | - Pascal Burtin
- Gastroenterology Department, Gustave Roussy, Villejuif, France
| | | | | | - Fabien Mignot
- Radiotherapy Department, Gustave Roussy, Villejuif, France
| | | | - Isabelle Dumas
- Radiotherapy Department, Gustave Roussy, Villejuif, France
| | | | - Cyrus Chargari
- Radiotherapy Department, Gustave Roussy, Villejuif, France
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Rovirosa A, Marsiglia H, Lartigau E, Zimmermann P, Chirat E, Delapierre M, Briot E, Gerbaulet A. Endoluminal High-Dose-Rate Brachytherapy with a Palliative aim in Esophageal Cancer: Preliminary Results at the Institut Gustave Roussy. TUMORI JOURNAL 2018; 81:359-63. [PMID: 8804454 DOI: 10.1177/030089169508100511] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Ten patients with advanced esophageal carcinoma were treated with endoluminal high-dose-rate brachytherapy at the Institut Gustave Roussy. Eight of them had recurrences after external beam radiotherapy. They were treated with a high-dose rate iridium-192 source. Five patients received 6 sessions of 4 Gy, 4 patients 3 sessions of 4 Gy, and 1 patient received 3 sessions of 8 Gy. The interval time between each session was 1 week. Seventy percent of patients improved their dysphagia, with 80% endoscopic tumor response. The Karnofsky index was improved in most of the patients. The mean survival was 4 months, and dysphagiafree survival was 2.5 months. Two patients had treatment toxicity but only a transitory WHO G1 esophagitis. Endoesophageal high-dose-rate curietherapy seems an effective technique in palliative treatments. We found low toxicity and an excellent tolerance to treatment in previously irradiated patients. The efficacy of the treatment is highly dependent on a precise tumor volume evaluation.
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Affiliation(s)
- A Rovirosa
- Servicio De Oncología Radoterápica, Hospital Clinic I Universitari, Barcelona, Spain
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Nag P, Gurjar OP, Bhandari V, Gupta KL, Bagdare P, Goyal H. Intraluminal brachytherapy boost following external beam radiotherapy with concurrent chemotherapy of oesophagus carcinoma: Results of a prospective observational study. Cancer Radiother 2018; 22:163-166. [PMID: 29615371 DOI: 10.1016/j.canrad.2017.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 09/19/2017] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- P Nag
- Roentgen-SAIMS Radiation Oncology Centre, Sri Aurobindo Institute of Medical Sciences, 453555 Indore, Madhya Pradesh, India
| | - O P Gurjar
- Roentgen-SAIMS Radiation Oncology Centre, Sri Aurobindo Institute of Medical Sciences, 453555 Indore, Madhya Pradesh, India.
| | - V Bhandari
- Roentgen-SAIMS Radiation Oncology Centre, Sri Aurobindo Institute of Medical Sciences, 453555 Indore, Madhya Pradesh, India
| | - K L Gupta
- Roentgen-SAIMS Radiation Oncology Centre, Sri Aurobindo Institute of Medical Sciences, 453555 Indore, Madhya Pradesh, India
| | - P Bagdare
- Roentgen-SAIMS Radiation Oncology Centre, Sri Aurobindo Institute of Medical Sciences, 453555 Indore, Madhya Pradesh, India
| | - H Goyal
- Roentgen-SAIMS Radiation Oncology Centre, Sri Aurobindo Institute of Medical Sciences, 453555 Indore, Madhya Pradesh, India
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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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Clinical implementation of a novel applicator in high-dose-rate brachytherapy treatment of esophageal cancer. J Contemp Brachytherapy 2016; 8:319-25. [PMID: 27648086 PMCID: PMC5018528 DOI: 10.5114/jcb.2016.61933] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 07/24/2016] [Indexed: 11/17/2022] Open
Abstract
PURPOSE In this study, we present the clinical implementation of a novel transoral balloon centering esophageal applicator (BCEA) and the initial clinical experience in high-dose-rate (HDR) brachytherapy treatment of esophageal cancer, using this applicator. MATERIAL AND METHODS Acceptance testing and commissioning of the BCEA were performed prior to clinical use. Full performance testing was conducted including measurements of the dimensions and the catheter diameter, evaluation of the inflatable balloon consistency, visibility of the radio-opaque markers, congruence of the markers, absolute and relative accuracy of the HDR source in the applicator using the radiochromic film and source position simulator, visibility and digitization of the applicator on the computed tomography (CT) images under the clinical conditions, and reproducibility of the offset. Clinical placement of the applicator, treatment planning, treatment delivery, and patient's response to the treatment were elaborated as well. RESULTS The experiments showed sub-millimeter accuracy in the source positioning with distal position at 1270 mm. The digitization (catheter reconstruction) was uncomplicated due to the good visibility of markers. The treatment planning resulted in a favorable dose distribution. This finding was pronounced for the treatment of the curvy anatomy of the lesion due to the improved repeatability and consistency of the delivered fractional dose to the patient, since the radioactive source was placed centrally within the lumen with respect to the clinical target due to the five inflatable balloons. CONCLUSIONS The consistency of the BCEA positioning resulted in the possibility to deliver optimized non-uniform dose along the catheter, which resulted in an increase of the dose to the cancerous tissue and lower doses to healthy tissue. A larger number of patients and long-term follow-up will be required to investigate if the delivered optimized treatment can lead to improved clinical outcomes.
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Afterloading: The Technique That Rescued Brachytherapy. Int J Radiat Oncol Biol Phys 2015; 92:479-87. [DOI: 10.1016/j.ijrobp.2015.02.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 02/09/2015] [Indexed: 11/21/2022]
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Nguyen NTA, Timotin E, Hunter R, Hann C, Puksa S, Sur RK. Endotracheal brachytherapy alone: An effective palliative treatment for tracheal tumors. Brachytherapy 2015; 14:543-8. [PMID: 25858905 DOI: 10.1016/j.brachy.2015.02.193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 02/07/2015] [Accepted: 02/11/2015] [Indexed: 11/17/2022]
Affiliation(s)
- Nhu-Tram A Nguyen
- Department of Oncology, Division of Radiation Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, Ontario, Canada.
| | - Emilia Timotin
- Department of Oncology, Division of Radiation Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Robert Hunter
- Department of Oncology, Division of Radiation Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Crystal Hann
- Department of Oncology, Division of Radiation Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Serge Puksa
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ranjan K Sur
- Department of Oncology, Division of Radiation Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, Ontario, Canada
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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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Folkert MR, Cohen GN, Wu AJ, Gerdes H, Schattner MA, Markowitz AJ, Ludwig E, Ilson DH, Bains MS, Zelefsky MJ, Goodman KA. Endoluminal high-dose-rate brachytherapy for early stage and recurrent esophageal cancer in medically inoperable patients. Brachytherapy 2013; 12:463-70. [PMID: 23434221 DOI: 10.1016/j.brachy.2012.12.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 12/21/2012] [Accepted: 12/27/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE The management of superficial primary and recurrent esophageal cancer (EC) in medically inoperable patients is complex. Endoluminal high-dose-rate (HDR) brachytherapy has shown mixed results in terms of toxicity and local control. In this study, we examined the outcomes and toxicities in a set of patients with superficial primary and recurrent EC treated with a consistent HDR technique. METHODS AND MATERIALS Between 8/2008 and 7/2011, 14 patients were treated with HDR intraluminal brachytherapy, 10 (71.4%) with recurrent disease, and 4 (28.6%) with previously unirradiated lesions. Patients received three weekly fractions to a median dose of 12 Gy (range, 10-15 Gy); dose was prescribed to 7-mm median depth with mucosal dose limited to 8-10 Gy using a 12-14-mm applicator. RESULTS Median followup was 15.4 months. Overall freedom from failure (OFFF) and overall survival (OS) at 18 months were 30.8% (95% confidence interval [CI]: 5.2, 56.4) and 72.7% (95% CI: 45.3, 100), respectively. For patients with recurrent disease, OFFF and OS at 18 months were 11.1% (95% CI: 0, 32.1) and 55.6% (95% CI: 15.4, 95.8), respectively. For patients with previously unirradiated disease, OFFF and OS at 18 months were 75.0% (95% CI: 31.6, 100) and 100.0%, respectively. Eight (57.1%) patients had Grade 1 acute adverse effects; 6 (42.9%) patients had chronic Grade 1 adverse effects; 1 (7.1%) patient developed Grade 2 stricture. Grade 3 tracheoesophageal fistula occurred in 1 (7.1%) patient. One patient died before completion of treatment of unrelated causes. CONCLUSIONS HDR endoluminal brachytherapy is a well-tolerated treatment for superficial primary and recurrent EC in medically inoperable patients.
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Affiliation(s)
- Michael R Folkert
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY
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Ekman S, Dreilich M, Lennartsson J, Wallner B, Brattström D, Sundbom M, Bergqvist M. Esophageal cancer: current and emerging therapy modalities. Expert Rev Anticancer Ther 2008; 8:1433-48. [PMID: 18759695 DOI: 10.1586/14737140.8.9.1433] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
During the last few years, there has been a gradual increase in treatment options for patients with esophageal malignancies. Several clinical studies have been performed, covering not only radiation and chemotherapy, but also the introduction of novel biological agents into the treatment arsenal. Patients with esophageal carcinoma are now offered second-line and sometimes even third-line treatments, and the number of research protocols is increasing. Despite the newly awakened interest in this malignancy, the overall 5-year survival rate has remained at approximately 10% since the 1980s. This review contains a compilation of available studies of esophageal malignancies and discusses current treatment options as well as newly developed therapies targeted at growth factor receptors.
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Affiliation(s)
- Simon Ekman
- Department of Oncology, Uppsala University Hospital, S-751 85 Uppsala, Sweden.
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17
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Kumar S, Dimri K, Khurana R, Rastogi N, Das KJM, Lal P. A randomised trial of radiotherapy compared with cisplatin chemo-radiotherapy in patients with unresectable squamous cell cancer of the esophagus. Radiother Oncol 2007; 83:139-47. [PMID: 17445928 DOI: 10.1016/j.radonc.2007.03.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2006] [Revised: 03/16/2007] [Accepted: 03/22/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND PURPOSE Following our phase II experience, a randomised trial was undertaken to evaluate the efficacy of adding chemotherapy to radiotherapy in patients with unresectable squamous cell cancer of the esophagus. PATIENTS AND METHODS Patients randomised to the RT group received 50 Gy/25 fx/5 weeks of teletherapy followed 1-2 weeks later with 12 Gy/2 fx of high-dose-rate intra-lumenal brachytherapy spaced a week apart. Following the first 3 years of recruitment, due to unexpected late morbidity, brachytherapy was excluded and the protocol modified to 66 Gy/33 fx/6.5 weeks. The CRT group received identical radiotherapy with concurrent weekly cisplatin at 35 mg/m(2) for 6-7 cycles. RESULTS Between April 1999 and December 2005, 125 patients were randomised to a RT (n=60) or CRT group (n=65). Radiotherapy treatment was completed in 78% (47/60) of the RT group and 89% (58/65) of the CRT group (P=0.10). Six or more cycles of cisplatin could be delivered in 63% (41/65), which resulted in RTOG grade 3 neutropenia of 3%. Late morbidity in the form of ulcers (5% vs. 15% odds ratio 0.29, 95% CI 0.08-1.11, P=0.08) and strictures (13% vs. 28%, odds ratio 0.40, 95% CI 0.16-1.01, P=0.05) was observed in the RT and CRT groups, respectively. At a median follow up of 23 months of all patients alive (range 6-82 months) and with 95/125 events, the median, 1, 2 and 5 year projected survival was 7.1 months, 32.3%, 22.8% and 13.7% vs. 13.4 months, 57.6%, 38.9% and 24.8% for the RT and CRT groups, respectively (hazard ratio 0.65, 95% CI 0.44-0.98, P=0.038). CONCLUSIONS The addition of concurrent cisplatin to radiotherapy resulted in a modest improvement in survival and was associated with manageable additional acute and late morbidity.
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Affiliation(s)
- Shaleen Kumar
- Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
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18
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Pasquier D, Mirabel X, Adenis A, Rezvoy N, Hecquet G, Fournier C, Coche-Dequeant B, Prevost B, Castelain B, Lartigau E. External beam radiation therapy followed by high-dose-rate brachytherapy for inoperable superficial esophageal carcinoma. Int J Radiat Oncol Biol Phys 2006; 65:1456-61. [PMID: 16863928 DOI: 10.1016/j.ijrobp.2006.02.049] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2005] [Revised: 02/14/2006] [Accepted: 02/22/2006] [Indexed: 02/05/2023]
Abstract
PURPOSE The aim of this study was to retrospectively evaluate the feasibility, efficacy, and tolerance of external beam radiotherapy followed by high-dose-rate brachytherapy in inoperable patients with superficial esophageal cancer. PATIENTS AND METHODS From November 1992 to May 1999, 66 patients with superficial esophageal cancer were treated with exclusive radiotherapy. The median age was 60 years (range, 41-85). Fifty-three percent of them were ineligible for surgery owing to synchronous or previously treated head-and-neck cancer. Most of the patients (n = 49) were evaluated with endoscopic ultrasonography (EUS) or computed tomography (CT). The mean doses of external beam radiotherapy and high-dose rate brachytherapy were 57.1 Gy (+/-4.83) and 8.82 Gy (+/-3.98), respectively. The most frequently used regimen was 60 Gy followed by 7 Gy at 5 mm depth in two applications. RESULTS Among patients evaluated with EUS or CT, the complete response rate was 98%. The 3-, 5-, and 7-year survival rates were 57.9%, 35.6%, and 26.6%, respectively. Median overall survival was 3.8 years. The 5-year relapse-free survival and cause-specific survival were 54.6% and 76.9%. The 5-year overall, relapse-free, and cause-specific survival of the whole population of 66 patients was 33%, 53%, and 77%, respectively. Local failure occurred in 15 of 66 patients; 6 were treated with brachytherapy. Severe late toxicity (mostly esophageal stenosis) rated according to the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer scale occurred in 6 of 66 patients (9%). CONCLUSION This well tolerated regimen may be a therapeutic alternative for inoperable patients with superficial esophageal cancer. Only a randomized study could be able to check the potential benefit of brachytherapy after external beam radiation in superficial esophageal cancer.
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Affiliation(s)
- David Pasquier
- Department of Radiotherapy, Centre Oscar Lambret, University Lille II, Lille, France.
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19
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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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20
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Sharma V, Donde B. Therapeutic options for esophageal cancer. J Gastroenterol Hepatol 2005; 20:163-4. [PMID: 15610468 DOI: 10.1111/j.1440-1746.2004.03607.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Anagnostopoulos G, Baltas D, Pantelis E, Papagiannis P, Sakelliou L. The effect of patient inhomogeneities in oesophageal192Ir HDR brachytherapy: a Monte Carlo and analytical dosimetry study. Phys Med Biol 2004; 49:2675-85. [PMID: 15272681 DOI: 10.1088/0031-9155/49/12/014] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The effect of patient inhomogeneities surrounding the oesophagus on the dosimetry planning of an upper thoracic oesophageal 192Ir HDR brachytherapy treatment is studied. The MCNPX Monte Carlo code is used for dosimetry in a patient-equivalent phantom geometry and results are compared in terms of isodose contours as well as dose volume histograms with corresponding calculations by a contemporary treatment planning system software featuring a full TG-43 dose calculation algorithm (PLATO BPS version 14.2.4). It is found that the presence of patient inhomogeneities does not alter the delivery of the planned dose distribution to the planning treatment volume. Regarding the organs at risk, the common practice of current treatment planning systems (TPSs) to consider the patient geometry as a homogeneous water medium leads to a dose overestimation of up to 13% to the spinal cord and an underestimation of up to 15% to the sternum bone. These findings which correspond to the dose region of about 5-10% of the prescribed dose could only be of significance when brachytherapy is used as a boost to external beam therapy. Additionally, an analytical dosimetry model, which is efficient in calculating dose in mathematical phantoms containing inhomogeneity shells of materials of radiobiological interest, is utilized for dosimetry in the patient-equivalent inhomogeneous phantom geometry. Analytical calculations in this work are in good agreement with corresponding Monte Carlo results within the bone inhomogeneities of spinal cord and sternum bone but, like treatment planning system calculations, the model fails to predict the dose distribution in the proximal lung surface as well as within the lungs just as the TPS does, due to its inherent limitation in treating lateral scatter and backscatter radiation.
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Affiliation(s)
- G Anagnostopoulos
- Department of Medical Physics & Engineering, Strahlenklinik, Klinikum Offenbach, 63069 Offenbach, Germany.
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22
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Abstract
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.
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23
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Soejima T, Nishimura H, Ejima Y, Sasaki R, Yoden E, Yamada K, Sugimura K. Case of radiation-induced esophageal ulcer worsened after endoscopic biopsy. Dis Esophagus 2003; 15:266-8. [PMID: 12445004 DOI: 10.1046/j.1442-2050.2002.00257.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal ulcer is one of the most important late complications of the esophagus treated with radiation therapy, especially with intraluminal brachytherapy. We encountered a patient with esophageal cancer treated with external radiation therapy and intraluminal brachytherapy, who developed radiation ulcer and who had severe dysphagia soon after endoscopic biopsy of the ulcer edge. A 55-year-old man was diagnosed as esophageal cancer without symptoms. He received 60 Gy/30 Fr of external radiation therapy and 12 Gy/3 Fr of intraluminal brachytherapy at a point of 5 mm in depth from the mucosa surface. He developed an asymptomatic esophageal ulcer 13 months after treatment, and endoscopic biopsy was obtained from the edge of the ulcer. Thereafter, swallowing difficulties appeared, and endoscopy revealed severe esophageal stenosis and a deep ulcer. A possibility that the biopsy contributed to worsening the ulcer can be considered. Except for cases where relapse is apparent, endoscopic biopsy is considered to be avoided.
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Affiliation(s)
- T Soejima
- Department of Radiology, Kobe Graduate University School of Medicine, Kobe, Japan.
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24
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Churn M, Jones B, Myint AS. 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. Clin Oncol (R Coll Radiol) 2002; 14:117-22. [PMID: 12069118 DOI: 10.1053/clon.2001.0006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- M Churn
- Clatterbridge Centre for Oncology, Wirral, Merseyside, UK.
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25
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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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26
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Maier A, Tomaselli F, Gebhard F, Rehak P, Smolle J, Smolle-Jüttner FM. Palliation of advanced esophageal carcinoma by photodynamic therapy and irradiation. Ann Thorac Surg 2000; 69:1006-9. [PMID: 10800784 DOI: 10.1016/s0003-4975(99)01440-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND We wanted to determine the role of photodynamic therapy in a multimodal approach for the treatment of patients with advanced cancer of the esophagus. METHODS We reviewed the cases of 119 patients with nonresectable esophageal carcinoma who underwent endoluminal palliation. Twenty-one patients required initial dilation and tumor obliteration with a neodymium: yttrium-aluminum-garnet laser prior to therapy. Forty-four patients received photodynamic therapy followed by brachyradiotherapy, and 75 patients were treated with brachyradiotherapy. In both groups, some patients also received external-beam irradiation. RESULTS Photodynamic therapy produced a significant difference in relieving stenosis caused by tumor stenosis (mean, 6.6 mm; p = 0.0000). The dysphagia score improved by one to three levels in all patients, with a significant difference in favor of PDT (p = 0.0003). The mean number of overall treatment sessions was four (range, one to seven). The rate of major complications was 9.2%. Four esophageal perforations occurred, three after intervention and one spontaneously 5 months later. Four esophagorespiratory tract fistulas developed several months after combined PDT and irradiation. The mean overall survival was 7.7 months, and analysis of variance revealed a significant difference in favor of PDT and external-beam irradiation (p = 0.0129 and p = 0.0001, respectively). CONCLUSIONS Photodynamic therapy has been shown to be an effective palliative treatment of advanced esophageal cancer. However, proper patient selection is necessary to prevent serious complications.
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Affiliation(s)
- A Maier
- Department of Surgery, Karl-Franzens University Medical School, Graz, Austria
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Maingon P, d'Hombres A, Truc G, Barillot I, Michiels C, Bedenne L, Horiot JC. High dose rate brachytherapy for superficial cancer of the esophagus. Int J Radiat Oncol Biol Phys 2000; 46:71-6. [PMID: 10656375 DOI: 10.1016/s0360-3016(99)00377-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- P Maingon
- Radiotherapy Department, Centre Georges-François-Leclerc, Dijon, France.
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28
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Abstract
Some of the major changes in radiotherapy over the last years are reviewed in this paper. Radiotherapy has played a role in the changes in oncological practice including an increase in organ-sparing treatment and achieving good local control and improving survival. About half of all breast cancer patients are now treated with breast conserving therapy. Organ preservation, usually with multimodality therapy, has also been further developed in the treatment of cancers in the head and neck, anus, bladder and soft tissue sarcomas. Developments in radiobiology have led to the development of new fractionation schedules. Hyperfractionation allows an increase in the tumour dose whilst sparing normal tissues and accelerated fractionation combats accelerated tumour proliferation during treatment. Advances in accelerator technology and computerized treatment planning have enabled the development of three-dimensional conformal radiotherapy. This gives the oportunity to spare normal tissues and escalate the dose to the tumour. Quality control and standardization of dosimetry and treatment delivery at departmental and international level has also improved treatment results.
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Affiliation(s)
- N S Russell
- Department of Radiotherapy, The Netherlands Cancer Intitute/Antoni van Leeuwenhoekhuis, Plesmanlaan 121, Amsterdam, 1066 CX, The Netherlands
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29
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Gossner L, May A, Sroka R, Stolte M, Hahn EG, Ell C. Photodynamic destruction of high grade dysplasia and early carcinoma of the esophagus after the oral administration of 5-aminolevulinic acid. Cancer 1999. [DOI: 10.1002/(sici)1097-0142(19991115)86:10<1921::aid-cncr7>3.0.co;2-n] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Chidel MA, Rice TW, Adelstein DJ, Kupelian PA, Suh JH, Becker M. Resectable esophageal carcinoma: local control with neoadjuvant chemotherapy and radiation therapy. Radiology 1999; 213:67-72. [PMID: 10540642 DOI: 10.1148/radiology.213.1.r99oc1767] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE To evaluate the usefulness of neoadjuvant chemotherapy and radiation therapy before esophagectomy for invasive cancer of the esophagus or gastroesophageal junction (GEJ). MATERIALS AND METHODS The authors conducted a retrospective analysis of 154 patients who underwent esophagectomy for invasive cancer between September 1, 1991, and December 31, 1995. The end points evaluated were overall, disease-free, local-regional relapse-free, and systemic relapse-free survival. RESULTS Seventy of the 154 patients received neoadjuvant combined-modality therapy (CMT) consisting of concurrent cisplatin and fluorouracil administration and accelerated, hyperfractionated radiation therapy. The remaining 84 patients underwent immediate esophagectomy. With a median follow-up of 34.7 months, the 3-year overall, disease-free, and distant metastatic relapse-free survival rates were 38.0%, 41.9%, and 56.0%, respectively. Although neoadjuvant therapy did not appear to prevent distant metastases, there was a dramatic effect on local control. After CMT, the 5-year local control rate was 90% compared to 64% after surgery (P < .001). Tumors in the GEJ recurred more frequently (P = .01); however, multivariate analysis showed CMT was the only independent predictor of local control. Postoperative mortality was 15.7% after CMT versus 5.9% without CMT (P = .05). CONCLUSION Local control of esophageal cancer is excellent following neoadjuvant chemotherapy and radiation therapy. However, the effects of CMT on overall and disease-free survival are less clear due to significant differences between the treatment groups.
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MESH Headings
- Adenocarcinoma/mortality
- Adenocarcinoma/secondary
- Adenocarcinoma/surgery
- Adenocarcinoma/therapy
- Adult
- Aged
- Aged, 80 and over
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Carcinoma, Squamous Cell/mortality
- Carcinoma, Squamous Cell/secondary
- Carcinoma, Squamous Cell/surgery
- Carcinoma, Squamous Cell/therapy
- Chemotherapy, Adjuvant
- Cisplatin/administration & dosage
- Disease-Free Survival
- Dose Fractionation, Radiation
- Esophageal Neoplasms/mortality
- Esophageal Neoplasms/pathology
- Esophageal Neoplasms/surgery
- Esophageal Neoplasms/therapy
- Esophagectomy
- Fluorouracil/administration & dosage
- Humans
- Lymphatic Metastasis
- Middle Aged
- Neoplasm Recurrence, Local
- Radiotherapy, Adjuvant
- Radiotherapy, High-Energy
- Retrospective Studies
- Survival Rate
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Affiliation(s)
- M A Chidel
- Department of Radiation Oncology, Cleveland Clinic Foundation, OH 44195, USA
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31
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Yorozu A, Dokiya T, Oki Y. High-dose-rate brachytherapy boost following concurrent chemoradiotherapy for esophageal carcinoma. Int J Radiat Oncol Biol Phys 1999; 45:271-5. [PMID: 10487545 DOI: 10.1016/s0360-3016(99)00184-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- A Yorozu
- Department of Radiology, National Tokyo Medical Center, Japan
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32
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Yorozu A, Dokiya T, Oki Y, Suzuki T. Curative radiotherapy with high-dose-rate brachytherapy boost for localized esophageal carcinoma: dose-effect relationship of brachytherapy with the balloon type applicator system. Radiother Oncol 1999; 51:133-9. [PMID: 10435804 DOI: 10.1016/s0167-8140(99)00040-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND PURPOSE This study analyzed the feasibility, local control and toxicity in potentially curable patients with esophageal carcinoma treated with a combination of external irradiation and high-dose-rate (HDR) brachytherapy using a balloon type applicator system to minimize hot spots on the mucosa. MATERIALS AND METHODS During the 9 years, 124 patients with esophageal carcinoma and no apparent extraesophageal spread were treated with 40-60 Gy of external irradiation followed by 8-24 Gy of HDR brachytherapy. The fraction size of brachytherapy was 4-6 Gy. We developed a new applicator with 15 mm external diameter inflatable balloons. The reference point was a point 12.5 mm depth from the mid source. The study end points were local control, late toxicity and palliative effect. RESULTS All 124 patients completed the planned radiotherapy. Local control rate was 69/124 (56%). There was a trend toward better local control rate for T1 lesions with increasing dose via brachytherapy. Of 69 patients with local control, treatment-related ulcers occurred in 28 patients, leading to death in four. The incidence of ulcers increased with increasing brachytherapy dose; 1/6 with 12 Gy, 16/43 with 16 Gy, 6/ 12 with 20 Gy, 4/5 with 24 Gy. Esophageal benign strictures occurred in ten patients and in all cases developed from ulcers. The incidence of freedom from dysphagia was not dose-dependent. CONCLUSION A combination of external irradiation and HDR brachytherapy with the balloon type applicator was feasible and well tolerated. Although better local control was achieved by a higher dose of brachytherapy, the higher dose caused more severe esophageal injury.
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Affiliation(s)
- A Yorozu
- Department of Radiology, National Tokyo Medical Center, Japan
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Datta NR, Kumar S, Nangia S, Hukku S, Ayyagari S. A non-randomized comparison of two radiotherapy protocols in inoperable squamous cell carcinoma of the oesophagus. Clin Oncol (R Coll Radiol) 1998; 10:306-12. [PMID: 9848331 DOI: 10.1016/s0936-6555(98)80083-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We report an audit of two different telebrachytherapy schedules in inoperable carcinoma of the oesophagus. Between October 1990 and December 1996, 108 patients with a Karnofsky performance status > or = 50 were selected from our database on the basis of intention to treat by telebrachytherapy. Teletherapy in the low dose group L (55 patients) consisted of 35 Gy in 15 fractions over 3 weeks, while that in the high dose group H (53 patients) consisted of 50 Gy in 25 fractions over 5 weeks. The choice of teletherapy dose was based on physician preference. The high dose rate intraluminal radiotherapy that followed 2 weeks later was identical in both groups and consisted of two applications of 6 Gy, a week apart. The pretreatment disease characteristics of the patients in both arms were similar. Relief of dysphagia was obtained in 49% of the patients in group L and in 75% of those in group H (chi2: P = 0.004). The median dysphagia-free interval was 0 and 7 months in groups L and H respectively (log-rank: P = 0.06), while the median overall survival was identical at 8 months (log-rank: P = 0.21) for both groups. The probability of survival at 1, 2 and 5 years was 34.8% versus 35.8%, 14.5% versus 13.9% and 0% versus 10% for groups L and H respectively. Morbidity in the form of ulcers, strictures and fistulae were observed in 9%, 7% and 5% of patients in group L compared with 8%, 8% and 13% in groups H respectively. This audit suggests that the protocol used in group H, when compared with group L, results in a greater proportion of patients being rendered dysphagia free, with a statistical trend towards a greater sustainment of dysphagia relief on follow-up.
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Affiliation(s)
- N R Datta
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Abstract
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.
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Affiliation(s)
- G Calais
- Clinique d'oncologie et radiothérapie, centre hospitalier et universitaire, hôpital Bretonneau, Tours, France
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35
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Wobst A, Audisio RA, Colleoni M, Geraghty JG. Oesophageal cancer treatment: studies, strategies and facts. Ann Oncol 1998; 9:951-62. [PMID: 9818067 DOI: 10.1023/a:1008273110272] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Esophageal cancer is among the ten most frequent cancers in the world. Once diagnosis is established prognosis is poor with five-year survival rates below 10%. Over the last few years, the evidence--base for treatment of oesophageal cancer has changed with the publication of several important articles in this field. This article reviews these and other relevant publications with focus on current evidence which holds potential for an improvement in survival in oesophageal cancer patients. Prevention and early detection represent the mainstay in the ongoing struggle to improve prognosis, which is most stringently linked to tumor stage. Other efforts have been dedicated to optimise surgical treatment, radiotherapy and chemotherapy and to discover the most efficient combinations of these treatment modalities. Strong but not unanimous evidence in favour of a multimodality approach with chemoradiotherapy followed by surgery has accumulated in recent years, and confirmatory trials are presently ongoing. A pathological complete response to chemoradiotherapy has been identified to significantly enhance survival. Among the strategies to achieve higher response rates, variations in the administration of the most commonly used drugs rather than higher drug and radiation dosages seem promising. Occult lymphatic spread has been recognized as a major source of recurrence and has been successfully targeted by three field surgical dissection and extended field radiotherapy. In search of the optimal treatment for patients with oesophageal cancer, a variety of different tracks are being pursued. This review outlines and analyses current treatment approaches and investigates how recent advances may impact on patient management.
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Affiliation(s)
- A Wobst
- Department of Surgery, European Institute of Oncology, Milan, Italy
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36
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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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37
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Nath R, Wilson LD. Advances in brachytherapy. Cancer Treat Res 1998; 93:191-211. [PMID: 9513782 DOI: 10.1007/978-1-4615-5769-2_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- R Nath
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT 06510, USA
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38
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Calais G, Dorval E, Louisot P, Bourlier P, Klein V, Chapet S, Reynaud-Bougnoux A, Huten N, De Calan L, Aget H, Le Floch O. Radiotherapy with high dose rate brachytherapy boost and concomitant chemotherapy for Stages IIB and III esophageal carcinoma: results of a pilot study. Int J Radiat Oncol Biol Phys 1997; 38:769-75. [PMID: 9240645 DOI: 10.1016/s0360-3016(97)00077-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Radiotherapy (RT) and concomitant chemotherapy (CT) is the standard treatment for non resectable esophageal cancer. Usual total radiation dose is 50 Gy. In order to enhance local control rate a Phase II study was initiated to evaluate the feasibility of a combined treatment with an external radiation dose of 60 Gy and three cycles of concomitant CT, using the three main active drugs (CDDP, 5 FU and MMC), followed by a high dose rate (HDR) brachytherapy delivering 10 Gy. METHODS AND MATERIALS Fifty-three patients, 48 men and 5 women, were entered in this study. Stages were evaluated with CT scan and with endoscopic sonography. Fifteen were Stage IIB, 38 Stage III. Treatment consisted of conventional fractionated RT to a total dose of 60 Gy delivered with 2 Gy per fraction, one fraction per day and five fractions per week. The CT regimen was a combination of Cisplatinum (CDDP) 20 mg/m2 and 5 Fluorouracil (5FU) 600 mg/m2 continuous infusion, from days 1-4 Mitomycin C (MMC) was given at 6 mg/m2 on day 1. Three cycles were administered on days 1, 22, and 43. Brachytherapy was delivered one week after the end of external radiation therapy. RESULTS Full radiation therapy dose was delivered for 94% of the patients. CT compliance, evaluated on the mean relative dose-intensity was 85% for CDDP, 81% for 5FU and 51% for MMC. Overall grade 3 and 4 WHO toxicity rates were 23% and 7%, respectively. Haematologic toxicity was the most limiting factor. One patient died from treatment toxicity. Local control rate at one year was 74%. Three-year actuarial survival rate was 27%. Distant metastasis was the main cause of treatment failure. Swallowing score was good for 75% of the patients. Stage, performance status and weight loss were prognostic factors. CONCLUSION This regimen with high dose RT, HDR brachytherapy and concomitant CT is feasible; however, a high level of haematologic toxicity was observed with the CDDP, 5FU and MMC regimen. Despite a poor compliance with CT, treatment results are very encouraging for patients with locally advanced disease.
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Affiliation(s)
- G Calais
- Clinique d'Oncologie et Radiothérapie, Centre Hospitalier et Universitaire de Tours, France
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39
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Abstract
Brachytherapy, or placing radioactive sources either temporarily or permanently into or near a malignant tumor, is a long-established cancer treatment method. During the past 25 years, brachytherapy has become safer and more versatile than earlier radium therapy, and its indications have increased dramatically during this period. One estimate is that at least 5-10% of all patients needing radiation therapy require brachytherapy. The site-specific clinical indications and methods for brachytherapy implementation are described.
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Affiliation(s)
- B Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee 53226, USA
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40
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Schraube P, Fritz P, Wannenmacher MF. Combined endoluminal and external irradiation of inoperable oesophageal carcinoma. Radiother Oncol 1997; 44:45-51. [PMID: 9288857 DOI: 10.1016/s0167-8140(97)00083-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE Higher radiation doses to oesophageal cancer might be possible by the steep dose gradient of an afterloading source. Structures at risk are not impaired by endoesophageal brachytherapy. Our experiences with endoesophageal afterloading in combination with external beam treatment are reported. METHODS AND MATERIALS Fifty-four patients were treated by this technique. All patients suffered from an inoperable oesophageal carcinoma (7 adenocarcinoma, 47 squamous-cell carcinoma). Patients were scheduled by tumour stage and medical condition into a curative group (21 patients) and into a palliative group (33 patients). Mean sum doses of 60.3 Gy (range 58-70 Gy) percutaneously and an additional endoluminal dose of 13.6 Gy (range 10-20 Gy) were applied endoluminally in the curative group and 44.9 Gy (range 14-53 Gy) plus 17.5 Gy (range 5-30 Gy), respectively, in the palliative group. Overall treatment time was 10 weeks (range 4.6-14.3 weeks) for the curative group and 9.3 weeks (range 4.1-13.9 weeks) for the palliative group. RESULTS Six weeks after the end of therapy a radiological remission could be observed in 32/33 of the palliatively treated patients (10 complete, 22 partial, 1 none). In 13 patients of this group a local progression was observed after a median time of 7.1 months. Median survival of this group was 9 months. A radiological remission occurred in 18/21 of the curatively treated patients (11 complete, 7 partial, 3 none). Median time to local progression (12 patients) was 4.5 months in this group and median survival was 7.7 months. The difference in time to progression reached a significant level (P = 0.05). The only favourable factors for survival were an incomplete or complete radiological remission (median survival 7.5 versus 11.4 months, P = 0.003) and stage I/II or III/IV (median survival 7.4 versus 12.6 months, P = 0.0024). The prior estimation of the treatment goal was not confirmed by survival data (curative, 7.7 months versus palliative, 9.0 months (not significant)). Eight of 54 minor and 8/54 (15%) major adverse events were observed. In four of these patients major complications were caused by progressive tumour. CONCLUSIONS Endoesophageal afterloading combination with percutaneous irradiation is a feasible save treatment in inoperable cases. A good local tumour regression and functional results can be reached. The data suggest that higher endoluminal doses extend the time to local progression. In comparison with the literature survival can not be increased by this treatment technique. The best way to combine both treatment modalities has not yet been found.
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Affiliation(s)
- P Schraube
- Department of Radiotherapy, University of Heidelberg, Germany
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41
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Fritz P, Wannenmacher M. [Radiotherapy in the multimodal treatment of esophageal carcinoma. A review]. Strahlenther Onkol 1997; 173:295-308. [PMID: 9235637 DOI: 10.1007/bf03038912] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The curative potential of exclusively applied surgery or radiotherapy on esophageal carcinoma is exhausted. The 5-year survival rate of surgically treated esophageal carcinoma is stagnant at 20 to 30%, that for radiotherapeutically treated esophageal carcinoma at < or = 10%. The unchanged bad prognoses motivate the search for multimodal therapeutical concepts in order to improve the results of basic therapies. METHOD, RESULTS AND CONCLUSIONS While neither perioperative radiotherapy nor perioperative chemotherapy were able to improve the treatment results significantly, a progress in the field of primary and preoperative radiochemotherapy emerges. On locally restricted tumors the latest findings show that a simultaneous radiochemotherapy with Cisplatin is more effective than radiotherapy alone. 20 to 30% histologically verified complete remissions can be reached through preoperative radiochemotherapy. These results will influence future treatment concepts. Brachytherapy can be taken into consideration in highly palliative situations as exclusive method of treatment or for support of laser treatment or bouginage for removal of stenosis. As the number of clinically controlled studies is not sufficient the importance of the brachytherapy boost for potentially curative intentions is not yet clear. Up to now the intraluminal hyperthermia is a underestimated method for improving the results of radiotherapy. Our overview summarizes all presently published randomized studies and relevant phase I/II-studies.
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Affiliation(s)
- P Fritz
- Abteilung Strahlentherapie, Universität Heidelberg
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42
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Micaily B, Miyamoto CT, Freire JE, Brady LW. Intracavitary brachytherapy for carcinoma of the esophagus. SEMINARS IN SURGICAL ONCOLOGY 1997; 13:185-9. [PMID: 9143056 DOI: 10.1002/(sici)1098-2388(199705/06)13:3<185::aid-ssu5>3.0.co;2-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Local control of unresectable esophageal carcinomas remains a significant problem in spite of aggressive treatments. External beam radiation therapy, chemotherapy, and combined modality treatment have all been employed with limited success. Here we review the existing literature and our own experience with external beam radiation followed by low-dose-rate or high-dose-rate intracavitary radiation for carcinoma of esophagus. The addition of intracavitary brachytherapy to external beam irradiation is well tolerated, causes no significant toxicity, and improves local control. Low-dose-rate intracavitary boost compared to high-dose-rate intracavitary boost has the advantage of a greater margin of safety, requires a single application, does not require highly sophisticated computerized technology, and is accompanied with fewer high-grade toxicities. Combined modality therapy consisting of concomitant infusional chemotherapy, external beam irradiation, and low-dose-rate intracavitary boost needs to be investigated.
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Affiliation(s)
- B Micaily
- Department of Radiation Oncology, Allegheny University of Health Sciences, Philadelphia, Pennsylvania 19102-1192, USA
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44
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Taal BG, Aleman BM, Koning CC, Boot H. High dose rate brachytherapy before external beam irradiation in inoperable oesophageal cancer. Br J Cancer 1996; 74:1452-7. [PMID: 8912544 PMCID: PMC2074787 DOI: 10.1038/bjc.1996.564] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
To induce fast relief of dysphagia in patients with oesophageal cancer high dose rate (HDR) brachytherapy was applied before external radiotherapy in a prospective study. Seventy-four patients with inoperable oesophageal cancer (36 squamous cell, 38 adenocarcinoma) were treated with a combination of 10 Gy HDR brachytherapy, followed by 40 Gy in 4 weeks external beam radiotherapy (EBRT), starting 2 weeks later. Tumour response, as measured by endoscopy and/or barium swallow, revealed complete remission in 21 and partial response in 38 patients (overall response rate 80%). Improvement of dysphagia was induced by brachytherapy within a few days in 39%, and achieved at the end of treatment in 70% of patients. Further weight loss was prevented in 39 of the 59 patients who presented with weight loss. Pain at presentation improved in 12 out of 25 patients. Median survival was 9 months. No differences in either response rate or survival were found in squamous cell or adenocarcinoma. Side-effects were either acute with minimal discomfort in 32 (42%) or late with painful ulceration in five patients (7%), occurring after a median of 4 months. A fistula developed in six patients, all with concurrent tumour. In conclusion, brachytherapy before EBRT was a safe and effective procedure to induce rapid relief of dysphagia, especially when combined with EBRT.
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Affiliation(s)
- B G Taal
- Department of Gastroenterology, Netherlands Cancer Institute/Antoni van Leeuwenhoekhuis, Amsterdam, The Netherlands
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45
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Abstract
Surgery is a crucial part of therapy of oesophageal cancer. The many trials which are described focus on variations in surgical technique. A trend is found that results are better with more extensive procedures. Local control evidently is improved, but an effect on survival is not yet sufficiently shown. Combinations of neoadjuvant radiotherapy and/or chemotherapy with surgery are effective by downstaging offering seemingly better survival in responding patients. Interpretation of trial data, however, is difficult because of the relatively small numbers in individual studies; the differences of the used treatment modalities make an overview approach less reasonable. Great attention should be given in the future trial work to better standardization (interpretation of definitions). Directives for optimal staging should be described in all study protocols.
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Affiliation(s)
- T Lerut
- Department Thoracic Surgery, Catholic University Hospital Gasthuisberg, Leuven, Belgium
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46
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Sur RK, Donde B, Krawitz HE, Levin V. What influences the incidence of complications in esophageal cancer treated with telebrachytherapy? Response to Kumar et al., IJROBP 27:1069-1072; 1993. Int J Radiat Oncol Biol Phys 1995; 32:277. [PMID: 7721635 DOI: 10.1016/0360-3016(95)91427-t] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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47
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Yu L, Vikram B, Malamud S, Yudelman I, Nussbaum M, Beattie E. Chemotherapy rapidly alternating with twice-a-day accelerated radiation therapy in carcinomas involving the hypopharynx or esophagus: an update. Cancer Invest 1995; 13:567-72. [PMID: 7583705 DOI: 10.3109/07357909509024924] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Laboratory studies have suggested that rapidly alternating chemotherapy and radiation therapy might act synergistically. We undertook this study to evaluate the toxicity and effectiveness of this approach in patients with carcinoma involving the hypopharynx or esophagus. Between 1987 and 1991, we treated 47 patients (23 with carcinoma involving the hypopharynx and 24 with carcinoma involving the esophagus) by three cycles of chemotherapy (during weeks 1, 4, and 7) rapidly alternating with twice-a-day radiation therapy (during weeks 2, 5, and 8). Chemotherapy consisted of cisplatin 100 mg/m2 and 5-fluorouracil 3-4 g/m2 given over 4 days. Radiation therapy consisted of 180-200 cGy twice each day to 2000 cGy/cycle, total 6000 cGy over 7 weeks. The histology was squamous cell carcinoma in 44 patients and adenocarcinoma in 3 patients with esophagus cancer. Median follow-up is 2 years (range 1-5 years). The observed survival rate for all 47 patients was 54% at 1 year and 38% at 2 years. Acute toxicity was considerable. Twelve patients (25%) died during therapy from toxicity, without tumor progression, leaving 35 patients (18 hypopharynx, 17 esophagus) evaluable for response. Among the hypopharyngeal patients, 83% had a complete response, 11% had a partial response, and 6% had no response. Among the esophageal patients, 94% had a complete response, and 6% had a partial response. Local control was better for the esophageal patients than the hypopharyngeal patients (98% vs. 52% at 2 years, p = 0.038). The incidence of distant metastases was 25% at 2 years and not significantly different between the two groups. A high rate of local control was achieved, particularly in esophageal cancer, by delivering chemotherapy and radiation therapy in a rapidly alternating fashion. This was achieved at a considerable cost in terms of toxicity, however. Although our response rates and local control compare favorably with those of other recently published studies of combined modality therapy in esophagus or head and neck cancer, much additional work is required to reduce the toxicity and, in hypopharyngeal cancer, to further improve the local control.
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Affiliation(s)
- L Yu
- Beth Israel Medical Center, New York, New York, USA
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48
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Vikram B, Chadha M, Malamud S, Yu L. Patterns of failure in carcinoma of the upper esophagus after alternating chemoradiotherapy. Am J Surg 1994; 168:423-4. [PMID: 7977965 DOI: 10.1016/s0002-9610(05)80090-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Alternating chemoradiotherapy has recently been reported to produce encouraging results in patients with advanced head and neck cancer. We have treated 17 patients with squamous cell carcinoma of the upper esophagus by alternating chemoradiotherapy and by following the patients for 2 to 5 years, or until their death. Chemotherapy (cisplatin and 5-fluorouracil) was delivered during weeks 1, 4, and 7, and radiotherapy (180 to 200 cGy twice each day to 2,000 cGy) during weeks 2, 5, and 8 (total 6,000 cGy). Three patients (18%) died of toxicity (nadir sepsis). All 14 patients who survived the treatment achieved a complete response as shown by endoscopy and biopsy specimens, with restoration of swallowing, and none experienced a local relapse. Three patients died of distant metastases (actuarial incidence 32% at 3 years). The 5-year survival rate was only 16%, however, because 8 other patients with no evidence of the cancer died of a variety of other causes: radiation pneumonitis (1), chronic neutropenia (1), esophageal actinomycosis (1), pneumonia (2), stroke (1), myocardial infarction (1), and small-cell lung cancer (1). Conceivably, some further improvement in the results might occur from cytokines, stem cells, and brachytherapy (by decreasing deaths due to toxicity), but with so many causes of comorbidity it seems unlikely, for the foreseeable future, that the 5-year survival rate could be much improved by better treatment of esophageal cancer.
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Affiliation(s)
- B Vikram
- Radiation Oncology Department, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York 10461
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Lerut TE, de Leyn P, Coosemans W, Van Raemdonck D, Cuypers P, Van Cleynenbreughel B. Advanced esophageal carcinoma. World J Surg 1994; 18:379-87. [PMID: 8091779 DOI: 10.1007/bf00316818] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
From 1976 until 1990 a total of 212 patients with squamous cell carcinoma of the thoracic esophagus were referred for surgical treatment. Resectability was 84.1% (161 of 191). Actuarial 5-year survival in patients with negative lymph nodes was 51.2% versus 12.4% in lymph node-positive patients. Therefore advanced carcinoma was defined to compromise all patients with involved regional (N1) or distal lymph nodes (M+Ly) as well as patients with T4 tumors or solid organ metastasis (M+org) irrespective of their lymph node status. Comparing complete (R0) versus incomplete (R1-R2) resections for stage III and IV carcinoma revealed 20% and 0% five-year survivals, respectively. There was no 5-year survival in the stage IV group. When excluding solid organ metastasis, the median survival shifted from 8.5 months after incomplete (R1-R2) to 20 months after complete (R0) resection. In 1991 three-field lymphadenectomy was initiated that included bilateral cervical lymphadenectomy. Thirty-seven patients have been treated so far (23 squamous cell carcinoma, 14 adenocarcinomas). Cervical lymph nodes were positive in 24.3% with an incidence up to 28.5% for distal-third carcinoma. Subsequently, 6 patients (16%) moved from M0 to M+Ly status. Our results confirm the key role of surgery not only in improving survival and locoregional tumor control but in refining the accuracy of staging advanced carcinomas provided complete resection is possible.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- T E Lerut
- Department of Surgery, Catholic University Leuven, Belgium
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50
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Abstract
Eighty patients with carcinoma in the middle third of oesophagus and with acute radiation oesophagitis following external beam and intracavitary radiotherapy were managed by two different schedules. Group 1 (n = 40) received an antacid containing sodium alginate whereas Group 2 (n = 40) were given a 10% sucralfate suspension during 4 weeks. In Group 2, 32 patients had significant relief of symptoms within 7 days of treatment and most ulcers had healed by 12 days of treatment as seen on endoscopy. Patients in Group 1, on the other hand, showed little improvement of symptoms and had persistent ulcers even after 4 weeks of therapy. We conclude that sucralfate is useful in the management of acute radiation oesophagitis.
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Affiliation(s)
- R K Sur
- Department of Radiotherapy, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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