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Soliman YY, Kundranda M, Kachaamy T. Endoscopic Palliative Therapies for Esophageal Cancer. Gastrointest Endosc Clin N Am 2024; 34:91-109. [PMID: 37973233 DOI: 10.1016/j.giec.2023.07.003] [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] [Indexed: 11/19/2023]
Abstract
Endoscopic palliation of dysphagia for patients with inoperable esophageal cancer is complex, highly dependent on local expertise, and best done in a multidisciplinary fashion. Systemic therapy is the standard of care because it has been shown to improve survival. Esophageal stenting has traditionally been the most used endoscopic modality. Some modalities such as laser and photodynamic therapy are rarely used. There has been an increasing amount of data on cryotherapy, especially for patients with mild-to-moderate dysphagia on systemic chemotherapy. This article will discuss the latest evidence guiding the palliation of esophageal cancer.
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Affiliation(s)
- Youssef Y Soliman
- Gastroenterology, City of Hope Phoenix, 14200 W Celebrate Life Way, Goodyear, AZ 85338, USA
| | - Madappa Kundranda
- Gastrointestinal Oncology, Banner MD Anderson Cancer Center, Banner Gateway Medical Center, 2946 East Banner Gateway Drive, Gilbert, AZ 85324, USA
| | - Toufic Kachaamy
- Gastroenterology, City of Hope Phoenix, 14200 W Celebrate Life Way, Goodyear, AZ 85338, USA.
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Merchant SJ, Kong W, Mahmud A, Booth CM, Hanna TP. Palliative Radiotherapy for Esophageal and Gastric Cancer: Population-Based Patterns of Utilization and Outcomes in Ontario, Canada. J Palliat Care 2023; 38:157-166. [PMID: 35043749 PMCID: PMC10026159 DOI: 10.1177/08258597211072946] [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] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Patients with incurable esophageal and gastric cancer may develop local symptoms for which palliative radiotherapy (PRT) may be considered. We sought to evaluate patterns in utilization and outcomes of patients receiving PRT for incurable esophageal and gastric cancer in Ontario, Canada using health administrative data. METHODS Linked health administrative databases were used to identify patients receiving PRT for incurable esophageal and gastric cancer. Primary outcomes were utilization and delivery of PRT, utilization of endoscopic dilation with or without stent insertion after completion of PRT and survival from 1) date of diagnosis and 2) start of PRT. RESULTS We identified 2500 patients who received PRT. Mean age was 70 ± 13 years and the majority (75%, n = 1873/2500) were male. Over half of the patients had a diagnosis of gastric cancer (58%, n = 1453/2500) and began PRT within 6 months of cancer diagnosis (85%, n = 2125/2500). Of the 2500 patients in the cohort, 2174 patients received EBRT with few receiving brachytherapy (n = 326) or EBRT and brachytherapy combined (n = 88). Over the study period, there was an increase in the number of patients receiving PRT (136 in 2007 to 290 in 2016), as well as in the use of advanced conformal radiotherapy techniques. Only 5% (115/2500) required dilation with or without stent insertion after completion of PRT. Median overall and cancer-specific survival of the cohort was 205 days and 209 days from date of diagnosis and 108 days and 110 days from start of PRT. CONCLUSIONS PRT is an important treatment for patients with incurable esophageal and gastric cancer who present with local symptoms. Utilization of PRT and advanced EBRT techniques increased over the study period. Few patients require endoscopic dilation with or without stent insertion after completion of PRT suggesting that PRT provides favorable symptom control.
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Affiliation(s)
- Shaila J Merchant
- Division of General Surgery and Surgical Oncology, Department of Surgery, Queen's University, Kingston, Ontario, Canada
- Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
| | - Weidong Kong
- Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
| | - Aamer Mahmud
- Division of Radiation Oncology, Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Christopher M Booth
- Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
- Division of Medical Oncology, Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Timothy P Hanna
- Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
- Division of Radiation Oncology, Department of Oncology, Queen's University, Kingston, Ontario, Canada
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Zhan PL, Canavan ME, Ermer T, Pichert MD, Li AX, Maduka RC, Kaminski MF, Johung KL, Boffa DJ. Utilization and Outcomes of Radiation in Stage IV Esophageal Cancer. JTO Clin Res Rep 2022; 3:100429. [PMID: 36483656 PMCID: PMC9722471 DOI: 10.1016/j.jtocrr.2022.100429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/20/2022] [Accepted: 10/24/2022] [Indexed: 11/07/2022] Open
Abstract
Introduction For patients with stage IV esophageal cancer, esophageal radiation may be used selectively for local control and palliation. We aimed to understand patterns of radiation administration among patients with stage IV esophageal cancer and any potential survival associations. Methods In this retrospective cohort study, the National Cancer Database was queried for patients with metastatic stage IV esophageal cancer diagnosed between 2016 and 2019. Patterns of radiation use were identified. Survival was determined through Kaplan-Meier analysis of propensity score-matched pairs of patients who did and did not receive radiotherapy and time-to-event models. Results Overall, 12,088 patients with stage IV esophageal cancer were identified, including 32.7% who received esophageal radiation. The median age was 65 (interquartile range [IQR]: 58-73) years, and 82.6% were male. Among the irradiated patients, the median total radiation dose was 35 (IQR: 30-50) Gy administered in a median of 14 (IQR: 10-25) fractions given in 22 (IQR: 14-39) days. Overall, esophageal radiation was not associated with better survival (log-rank p = 0.41). When stratified by radiation dose, a survival advantage (over no radiation) was found in the 1144 patients (29% of the irradiated patients) who received 45 to 59.9 Gy (time ratio = 1.28, 95% confidence interval: 1.20-1.37, p < 0.001) and the 88 patients (2.2%) who received 60 to 80 Gy (time ratio = 1.37, 95% confidence interval: 1.11-1.69, p = 0.003). Conclusions One-third of the patients with metastatic stage IV esophageal cancer in the National Cancer Database received esophageal radiation. Most received a radiation dose that, although consistent with palliative regimens, was not associated with a survival advantage. Further study is warranted to understand the indications for radiation in stage IV esophageal cancer and potentially reevaluate the most appropriate radiation dose for palliation.
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Affiliation(s)
- Peter Lee Zhan
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Maureen E. Canavan
- Cancer Outcomes Public Policy and Effectiveness Research Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Theresa Ermer
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew D. Pichert
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew X. Li
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Richard C. Maduka
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Michael F. Kaminski
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Kimberly L. Johung
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Daniel J. Boffa
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
- Corresponding author Address for correspondence: Daniel J. Boffa, MD, MBA, P.O. Box 208062, New Haven, CT 06520-8062.
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Mohapatra S, Santharaman A, Gomez K, Pannala R, Kachaamy T. Optimal Management of Dysphagia in Patients with Inoperable Esophageal Cancer: Current Perspectives. Cancer Manag Res 2022; 14:3281-3291. [PMID: 36448034 PMCID: PMC9701451 DOI: 10.2147/cmar.s362666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/08/2022] [Indexed: 08/30/2023] Open
Abstract
The majority of patients with esophageal cancer are diagnosed at an advanced, incurable stage. Palliation of symptoms, specifically dysphagia, is a crucial component to improve quality of life and optimize nutritional status. Despite multiple available treatment modalities, there is not one accepted or recommended to be the preferred treatment option. Palliative management is often decided by a multidisciplinary team considering factors including local availability, preference, patient life expectancy, and symptom severity. Systemic therapies such as chemotherapy are the most commonly used palliative modalities. Oncologists are most familiar with radiation for dysphagia palliation, especially for advanced metastatic cancer patients with good performance status. One common approach used by endoscopist is self-expandable metal stents. This is preferred for patients with short-term survival and poor functional status as it provides rapid relief of dysphagia. Cryotherapy is a relatively new endoscopic ablative modality and appears to be a promising option for dysphagia palliation, but more data is needed for wider adoption. This review summarizes the current literature on endoscopic and non-endoscopic treatment options for malignant dysphagia.
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Affiliation(s)
- Sonmoon Mohapatra
- Department of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Aadhithyaraman Santharaman
- Department of Internal Medicine, Saint Peter’s University Hospital, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, NJ, 08901, USA
| | - Krista Gomez
- Department of Gastroenterology and Hepatology, Cancer Treatment Centers of America, Phoenix, AZ, 85338, USA
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Toufic Kachaamy
- Department of Gastroenterology and Hepatology, Cancer Treatment Centers of America, Phoenix, AZ, 85338, USA
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Wu X, Li Y, Zhang K, Guo Z, Li Y, Zhao F, Zhang T, Chen X, Wei H, Zhang W, Wang P, Pang Q. Immunotherapy with or without radiotherapy for metastatic or recurrent esophageal squamous cell carcinoma: a real-world study. Clin Transl Radiat Oncol 2022; 38:130-137. [DOI: 10.1016/j.ctro.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/17/2022] Open
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Sridharan S, Day F, Loh J, Lynam J, Smart J, Holt B, Mandaliya H, Bonaventura A, Kumar M, Martin J. Phase I trial of hypofractionated chemoradiotherapy in the palliative management of esophageal and gastro-esophageal cancer. Radiat Oncol 2022; 17:158. [PMID: 36104707 PMCID: PMC9472395 DOI: 10.1186/s13014-022-02127-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 09/05/2022] [Indexed: 12/24/2022] Open
Abstract
Background Many patients with incurable esophageal cancer (ECa) present with dysphagia as their predominant symptom. Currently there is no consensus on how best to initially manage this scenario with multiple therapeutic options available. We aimed to assess the safety and efficacy of using hypofractionated radiotherapy given over a progressively shorter timeframe with concurrent carboplatin and paclitaxel in the management of patients with ECa and dysphagia. Methods In this phase I trial we enrolled patients with histologically proven squamous cell carcinoma or adenocarcinoma of the esophagus or the gastro-esophageal junction with symptomatic dysphagia from local disease and not for curative treatment. Patients needed to be 18 years or older, have an ECOG performance status of 0–2 and be suitable to receive carboplatin and paclitaxel chemotherapy. Patients were placed in four progressively shorter radiation schedules culminating in 30 Gy in 10 fractions in a step wise manner, all with concurrent carboplatin AUC 2 and paclitaxel 50 mg/m2 chemotherapy delivered weekly with the radiation therapy. The primary endpoint was the development of the dose limiting toxicities (DLTs) esophageal perforation or febrile neutropenia. Secondary endpoints were relief of dysphagia, time to improvement of dysphagia, dysphagia progression free survival and overall survival. Results Eighteen patients were enrolled in the study between October 2014 and March 2019. There were no DLTs experienced during the trial. The most common grade 3 + acute toxicity experienced by patients were nausea and vomiting (both in 4/18 patients). The most common radiation specific acute toxicity experienced was esophagitis with 67% of patients experiencing grade 1–2 symptoms. All patients experienced improvement in dysphagia. The median time to dysphagia improvement was 3 weeks from the start of chemoradiotherapy (CTRT) (range 2–10 weeks). The median dysphagia free survival was 5.8 months with a median overall survival of 8.9 months. Conclusion Hypofractionated palliative CTRT with 30 Gy/10# of radiation therapy with concurrent weekly carboplatin and paclitaxel chemotherapy is well tolerated and provides a good response in improvement of dysphagia. Further studies need to be undertaken which provide both symptomatic improvement in the primary tumor but also control of the metastatic burden in these patients. Clinical Trial Registration: This trial was prospectively registered with www.anzctr.org.au Identifier: ACTRN12614000821695.
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Palliative radiotherapy and quality of life in patients with locally advanced thoracic esophageal cancer: a single centre experience from Central India. Rep Pract Oncol Radiother 2022; 27:104-112. [PMID: 35402038 PMCID: PMC8989437 DOI: 10.5603/rpor.a2021.0136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/07/2021] [Indexed: 12/09/2022] Open
Abstract
Background Patients with locally advanced esophageal squamous cell carcinoma (LAESCC ) have decreased quality of life (QoL) and, thus, require palliative external beam radiotherapy (EBRT). The present study was performed to evaluate the QoL in patients with LAESCC undergoing palliative EBRT. Materials and methods This was a prospective, observational study performed over a period of 18 months (from December 2018 to May 2020) in the Department of Radiation Oncology. Seventy patients with LAESCC received EBRT (30 Gy in 10 fractions, at 3 Gy per fraction over 2 weeks). Patients were followed-up at monthly intervals for 3 months. The dysphagia and odynophagia scores were calculated at baseline and follow-up visits. The QoL was assessed with 18-item EORTC QLQ-OES questionnaire at baseline and 3 months. Results Over the study period, significant decrease in mean dysphagia and odynophagia score was observed (p-value < 0.0001). On post-hoc analysis, significant decrease in both dysphagia and odynophagia score was observed between baseline and at the end of study and between various follow-up visits (p-value < 0.0001). Moreover, there was a significant increase in mean body weight (p-value < 0.0001). At 3 months, there was a significant decrease in dysphagia (p-value < 0.0001), eating (p-value < 0.0001), reflux (p-value = 0.005), pain (p-value < 0.0001), and saliva (p-value = 0.01) domains of EORTC QLQ-OES18 questionnaire. Conclusion In patients with LAESCC, EBRT leads to significant decrease in dysphagia and odynophagia, and increase in body weight. These changes indirectly lead to improved QoL.
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The Evolving Role of Hypofractionated Radiotherapy in Older Adults with Gastrointestinal Cancers. Semin Radiat Oncol 2022; 32:159-167. [DOI: 10.1016/j.semradonc.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Ólafsdóttir HS, Klevebro F, Ndegwa N, Alexandersson von Döbeln G. Short-course compared to long-course palliative radiotherapy for oesophageal cancer: a single centre observational cohort study. Radiat Oncol 2021; 16:153. [PMID: 34399793 PMCID: PMC8365913 DOI: 10.1186/s13014-021-01880-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/06/2021] [Indexed: 11/18/2022] Open
Abstract
Background Common symptoms of oesophageal cancer are dysphagia, pain, and bleeding. These symptoms can be relieved with palliative radiotherapy. The aim of this study was to analyse the outcome of two different palliative radiotherapy schedules. Methods We conducted a retrospective cohort study on palliative radiotherapy for oesophageal cancer given at Karolinska University Hospital. Patients included were treated with either short-course (20 Gy in 4 Gy fractions daily, 5 consecutive workdays) or long-course (30–39 Gy in 3 Gy fractions, 10–13 consecutive workdays) palliative external beam radiotherapy between January 2009 and December 2013. The primary endpoint was dysphagia relief and secondary endpoints were adverse events, re-interventions, and overall survival. Cox regression analyses were used to estimate the effect of treatment schedule on survival. Results A total of 128 patients received external beam radiotherapy under the study period, of these 75 (58.6%) received short-course radiotherapy and 53 (41.4%) long-course radiotherapy. Sixteen (30.8%) patients experienced dysphagia relief after short-course radiotherapy and 9 (22.0%) patients after long-course radiotherapy (p = 0.341). Acute toxicity was less frequent after short-course radiotherapy than after long-course radiotherapy, particularly oesophagitis (35.4% vs. 56.0%, p = 0.027) and nausea/emesis (18.5% vs. 36.0% p = 0.034). Re-interventions tended to be more common after short-course radiotherapy (32.0%) than after long-course radiotherapy (18.9%) (p = 0.098). There was no difference in overall survival between the two groups. Conclusions Short- and long-course palliative radiotherapy for oesophageal cancer were equally effective to relieve dysphagia and no difference was seen in overall survival. Acute toxicity was, however, more frequent and more severe after long-course radiotherapy. Our results suggest that short-course radiotherapy is better tolerated with equal palliative effects as long-course radiotherapy.
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Affiliation(s)
- Halla Sif Ólafsdóttir
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 141 52, Huddinge, Sweden. .,Cancer Theme, Karolinska University Hospital, 171 64, Stockholm, Sweden.
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 141 52, Huddinge, Sweden.,Cancer Theme, Karolinska University Hospital, 171 64, Stockholm, Sweden
| | - Nelson Ndegwa
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 141 52, Huddinge, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Gabriella Alexandersson von Döbeln
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 141 52, Huddinge, Sweden.,Cancer Theme, Karolinska University Hospital, 171 64, Stockholm, Sweden
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Kawamoto T, Nakamura N, Saito T, Tonari A, Wada H, Harada H, Kubota H, Nagakura H, Heianna J, Miyazawa K, Yamada K, Tago M, Fushiki M, Nozaki M, Uchida N, Araki N, Sekii S, Kosugi T, Takahashi T, Shikama N. Palliative brachytherapy and external beam radiotherapy for dysphagia from esophageal cancer: a nationwide survey in Japan. Jpn J Clin Oncol 2021; 51:950-955. [PMID: 33624768 DOI: 10.1093/jjco/hyab015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 01/31/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND International guidelines recommend brachytherapy for patients with dysphagia from esophageal cancer, whereas brachytherapy is infrequently used to palliate dysphagia in some countries. To clarify the availability of palliative treatment for dysphagia from esophageal cancer and explain why brachytherapy is not routinely performed are unknown, this study investigated the use of brachytherapy and external beam radiotherapy for dysphagia from esophageal cancer. METHODS Japanese Radiation Oncology Study Group members completed a survey and selected the treatment that they would recommend for hypothetical cases of dysphagia from esophageal cancer. RESULTS Of the 136 invited facilities, 61 completed the survey (44.9%). Four (6.6%) facilities performed brachytherapy of the esophagus, whereas brachytherapy represented the first-line treatment at three (4.9%) facilities. Conversely, external beam radiotherapy alone and chemoradiotherapy were first-line treatments at 61 and 58 (95.1%) facilities, respectively. In facilities that performed brachytherapy, the main reason why brachytherapy of the esophagus was not performed was high invasiveness (30.2%). Definitive-dose chemoradiotherapy with (≥50 Gy) tended to be used in patients with expected long-term survival. CONCLUSIONS Few facilities routinely considered brachytherapy for the treatment of dysphagia from esophageal cancer in Japan. Conversely, most facilities routinely considered external beam radiotherapy. In the future, it will be necessary to optimize external beam radiotherapy.
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Affiliation(s)
- Terufumi Kawamoto
- Department of Radiation Oncology, Juntendo University Hospital, Tokyo, Japan
| | - Naoki Nakamura
- Department of Radiation Oncology, St. Marianna University School of Medicine Hospital, Kawasaki, Japan
| | - Tetsuo Saito
- Department of Radiation Oncology, Arao Municipal Hospital, Kumamoto, Japan
| | - Ayako Tonari
- Department of Radiation Oncology, Kyorin University Hospital, Mitaka, Japan
| | - Hitoshi Wada
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Hideyuki Harada
- Division of Radiation Therapy, Radiation and Proton Therapy Center, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Hikaru Kubota
- Department of Radiation Oncology, Kobe University Hospital, Kobe, Japan
| | | | - Joichi Heianna
- Department of Radiation Oncology, Ryukyu University Hospital, Nishihara, Japan
| | | | - Kazunari Yamada
- Department of Radiation Oncology, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Masao Tago
- Department of Radiology, Teikyo University Hospital, Tokyo, Japan
| | - Masato Fushiki
- Department of Radiation Oncology, Nagahama City Hospital, Nagahama, Japan
| | - Miwako Nozaki
- Department of Radiation Oncology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Nobue Uchida
- Department of Radiation Oncology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Norio Araki
- Department of Radiation Oncology, Kyoto Medical Center, Kyoto, Japan
| | - Shuhei Sekii
- Department of Radiation Oncology, Kita-Harima Medical Center, Ono, Japan
| | - Takashi Kosugi
- Department of Radiation Oncology, Fujieda Municipal General Hospital, Fujieda, Japan
| | - Takeo Takahashi
- Department of Radiation Oncology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Naoto Shikama
- Department of Radiation Oncology, Juntendo University Hospital, Tokyo, Japan
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Jeene PM, Vermeulen BD, Rozema T, Braam PM, Lips I, Muller K, van Kampen D, Homs MY, Oppedijk V, Berbée M, van Rossum PS, el Sharouni S, Siersema PD, Hulshof MC. Short-Course External Beam Radiotherapy Versus Brachytherapy for Palliation of Dysphagia in Esophageal Cancer: A Matched Comparison of Two Prospective Trials. J Thorac Oncol 2020; 15:1361-1368. [DOI: 10.1016/j.jtho.2020.04.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/24/2020] [Accepted: 04/25/2020] [Indexed: 01/21/2023]
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Vermeulen BD, Jeene PM, Sijben J, Krol R, Rütten H, Bogers JA, Braam PM, Siersema PD. Low-Dose Versus High-Dose Radiation Therapy for the Palliation of Dysphagia From Esophageal Cancer: A Multicenter Retrospective Cohort Study. Pract Radiat Oncol 2020; 10:e255-e263. [PMID: 31669401 DOI: 10.1016/j.prro.2019.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/18/2019] [Accepted: 10/16/2019] [Indexed: 12/18/2022]
Abstract
PURPOSE Clinical evidence regarding optimal radiation dose for palliation of dysphagia from esophageal cancer is generally lacking. In an effort to investigate optimal radiation dose, we assessed 2 different radiation schedules for palliation of dysphagia. METHODS AND MATERIALS We performed a multicenter, retrospective study comparing low-dose radiation therapy (LR: 5 x 4 Gy external beam radiation therapy [EBRT]) with high-dose radiation therapy (HR: 10 x 3 Gy EBRT and 12-Gy single-dose intraluminal brachytherapy) for palliation of dysphagia in patients with inoperable or metastasized esophageal cancer. Primary outcome was improvement of dysphagia at 6 weeks after start of radiation therapy. Additional outcomes were persistent and recurrent dysphagia during patients' remaining life, severe adverse events, and survival. RESULTS In total, 292 patients (LR, n = 117; HR, n = 175) were included in this study. After matching, 144 patients (72 in each group) were compared. Improvement of dysphagia at 6 weeks was achieved in 50% of patients after LR and in 66% after HR (P = .071). Persistent or recurrent dysphagia occurred in 64% of patients after LR and in 42% after HR (P = .012). No difference in the rate of severe adverse events was found (P = .889). Median survival was 88 days (95% confidence interval, 64-112) after LR and 177 days (95% confidence interval, 131-223) after HR (P < .001). CONCLUSIONS This study shows that both LR and HR were well tolerated and effective in short-term relief of dysphagia in patients with inoperable or metastasized esophageal cancer. HR was associated with better long-term relief of dysphagia compared with LR. Our findings suggest that HR could be considered for patients with a longer life expectancy, but prospective studies are required.
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Affiliation(s)
- Bram D Vermeulen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | | | - Jasmijn Sijben
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Robin Krol
- Department of Gastroenterology and Hepatology, Rijnstate Ziekenhuis, Arnhem, the Netherlands
| | - Heidi Rütten
- Department of Radiotherapy, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Pètra M Braam
- Department of Radiotherapy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
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Palliation of dysphagia in metastatic oesogastric cancers: An international multidisciplinary position. Eur J Cancer 2020; 135:103-112. [PMID: 32563014 DOI: 10.1016/j.ejca.2020.04.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/20/2020] [Accepted: 04/27/2020] [Indexed: 12/31/2022]
Abstract
Malignant dysphagia is the most common symptom in advanced oesogastric cancers patients. Relief of dysphagia allows quality of life improvement, nutritional replenishment and potentially improves prognosis. Chemotherapy alone is effective and should be prioritised in patients with metastatic disease a good performance status, and its impact on dysphagia should be determined before further interventions are planned. Regarding local treatments, the insertion of a covered self-expandable metallic stent is the most commonly used alternative, as it allows for the rapid relief of severe dysphagia. Although several randomised trials have highlighted the role of oesophageal brachytherapy, this technique is often not easily accessible. Contemporary trials are ongoing to better define the role of external radiation therapy. While awaiting these results, external radiation therapy can be considered as a second-best option for patients with a life-expectancy > 3 months. It is important to offer nutritional support and to integrate quality of life measures in the palliative management of dysphagia. This multidisciplinary international position paper aims to propose a decision-making process and highlight randomised trials for the management of malignant dysphagia in metastatic oesogastric cancer patients.
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Martin EJ, Bruggeman AR, Nalawade VV, Sarkar RR, Qiao EM, Rose BS, Murphy JD. Palliative Radiotherapy Versus Esophageal Stent Placement in the Management of Patients With Metastatic Esophageal Cancer. J Natl Compr Canc Netw 2020; 18:569-574. [DOI: 10.6004/jnccn.2019.7524] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 12/11/2019] [Indexed: 11/17/2022]
Abstract
Background:Patients with advanced esophageal cancer often experience pain and dysphagia, yet the optimal palliative management remains unclear. This retrospective study evaluated outcomes and adverse effects of palliative radiotherapy (RT) compared with esophageal stenting among a cohort of U.S. veterans with metastatic esophageal cancer.Patients and Methods:We identified 1,957 veterans in the United States with metastatic esophageal cancer who received palliative RT to the esophagus or esophageal stenting, and assessed the risks of severe adverse effects, including esophageal fistula formation, perforation, obstruction, hemorrhage, and esophagitis. We determined palliative efficacy by evaluating pain and dysphagia scores before and after intervention. Multivariable analyses were used to control for potential confounding factors.Results:In our cohort, 1,593 patients underwent RT and 364 underwent esophageal stenting. The cumulative incidence of any severe adverse effect at 6 months was higher among patients who received stents compared with those who received RT (21.7% vs 12.4%;P<.0010). In multivariable analysis, patients who received stents had an increased risk of any severe adverse effect, including fistula, perforation, and hemorrhage (allP<.0500). Multivariable analysis also showed that, compared with stenting, RT was associated with more rapid and durable pain relief (P<.0010) with no difference in relief of dysphagia over time when accounting for pretreatment dysphagia scores (P=.1029).Conclusions:Compared with esophageal stenting, RT was associated with a decreased risk of adverse effects, greater pain relief, and equivalent relief of moderate to severe dysphagia over time. Unmeasured patient- or tumor-related factors could have influenced the choice of intervention, thereby impacting our study outcomes. To our knowledge, this is the largest study to date analyzing the comparative risks and benefits of palliative RT and esophageal stenting among patients with metastatic esophageal cancer.
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Affiliation(s)
- Emily J. Martin
- 1Department of Medicine, University of California, Los Angeles, Los Angeles, California; and
| | - Andrew R. Bruggeman
- 2Department of Radiation Medicine and Applied Sciences, University of California, San Diego, San Diego, California
| | - Vinit V. Nalawade
- 2Department of Radiation Medicine and Applied Sciences, University of California, San Diego, San Diego, California
| | - Reith R. Sarkar
- 2Department of Radiation Medicine and Applied Sciences, University of California, San Diego, San Diego, California
| | - Edmund M. Qiao
- 2Department of Radiation Medicine and Applied Sciences, University of California, San Diego, San Diego, California
| | - Brent S. Rose
- 2Department of Radiation Medicine and Applied Sciences, University of California, San Diego, San Diego, California
| | - James D. Murphy
- 2Department of Radiation Medicine and Applied Sciences, University of California, San Diego, San Diego, California
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15
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Borg D, Sundberg J, Brun E, Kjellén E, Petersson K, Hermansson M, Johansson J, Eberhard J, Johnsson A. Palliative short-course hypofractionated radiotherapy followed by chemotherapy in esophageal adenocarcinoma: the phase II PALAESTRA trial. Acta Oncol 2020; 59:212-218. [PMID: 31564184 DOI: 10.1080/0284186x.2019.1670861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: The majority of patients with incurable esophageal adenocarcinoma suffer from dysphagia. We assessed a novel treatment strategy with initial short-course radiotherapy followed by chemotherapy with the primary aim to achieve long-term relief of dysphagia.Methods: This phase II trial included treatment-naîve patients with dysphagia due to esophageal adenocarcinoma not eligible for curative treatment. External beam radiotherapy with 20 Gy in five fractions to the primary tumor was followed by four cycles of chemotherapy (FOLFOX regimen). Dysphagia was assessed using a five-grade scale.Results: From October 2014 to May 2018 a total of 29 patients were enrolled. The rate of dysphagia improvement was 79%, median duration of improvement 6.7 months (12.2 months for responders) and median overall survival 9.9 months. In the pre-specified per protocol analysis (23 patients) the rate of dysphagia improvement was 91%, median duration of improvement 12.2 months (14.0 months for responders) and median overall survival 16.0 months. The most common grade 3-4 adverse events were neutropenia (29%), infection (25%), anorexia (11%), esophagitis (11%) and fatigue (11%).Conclusion: Initial palliative short-course radiotherapy followed by chemotherapy is a promising treatment strategy that can provide long-lasting relief of dysphagia in patients with esophageal adenocarcinoma.
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Affiliation(s)
- David Borg
- Department of Clinical Sciences Lund, Division of Oncology and Pathology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Jan Sundberg
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - Eva Brun
- Department of Clinical Sciences Lund, Division of Oncology and Pathology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Elisabeth Kjellén
- Department of Clinical Sciences Lund, Division of Oncology and Pathology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Kristoffer Petersson
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund University, Lund, Sweden
| | - Michael Hermansson
- Department of Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Jan Johansson
- Department of Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Jakob Eberhard
- Department of Clinical Sciences Lund, Division of Oncology and Pathology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Anders Johnsson
- Department of Clinical Sciences Lund, Division of Oncology and Pathology, Lund University, Skåne University Hospital, Lund, Sweden
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Fountoulakis A, Souglakos J, Vini L, Douridas GN, Koumarianou A, Kountourakis P, Agalianos C, Alexandrou A, Dervenis C, Gourtsoyianni S, Gouvas N, Kalogeridi MA, Levidou G, Liakakos T, Sgouros J, Sgouros SN, Triantopoulou C, Xynos E. Consensus statement of the Hellenic and Cypriot Oesophageal Cancer Study Group on the diagnosis, staging and management of oesophageal cancer. Updates Surg 2019; 71:599-624. [DOI: 10.1007/s13304-019-00696-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/26/2019] [Indexed: 12/13/2022]
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17
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Deressa BT, Tigeneh W, Bogale N, Buwenge M, Morganti AG, Farina E. Short-Course 2-Dimensional Radiation Therapy in the Palliative Treatment of Esophageal Cancer in a Developing Country: A Phase II Study (Sharon Project). Int J Radiat Oncol Biol Phys 2019; 106:67-72. [PMID: 31622698 DOI: 10.1016/j.ijrobp.2019.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 09/29/2019] [Accepted: 10/03/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE Patients with locally advanced and metastatic esophageal cancer are usually affected by cancer-related symptoms, which worsen their performance status and quality of life. The aim of this study was to determine the efficacy of short-course accelerated radiation therapy for symptomatic palliation in a low resourced setting where only a 2-dimensional radiation therapy (RT) technique was available. METHODS AND MATERIALS A phase II trial based on Simon's 2-stage design was planned. A total dose of 12 Gy in 4 fractions, twice per day, over 2 days, ≥8 hours apart, using a 2-dimensional conventional RT technique was delivered with a Cobalt 60 unit (Equinox, Best Theratronics, Ottawa, Ontario). Symptoms were graded using the International Atomic Energy Agency scoring system. RESULTS A total of 17 patients were treated (male/female = 10/7; median age, 50.0 years; range, 27-78 years; histology: 6 adenocarcinomas and 11 squamous cell carcinomas; tumor site: 4 gastresophageal junction and 13 esophagus). The most frequent baseline symptoms were dysphagia or regurgitation (100%), odynophagia (76%), and chest or back pain (53%). At 1 month after RT, all patients were alive with palliative response rates (complete plus partial) for dysphagia, regurgitation, odynophagia, and chest or back pain of 76%, 82%, 69%, and 56%, respectively. No patients presented acute ≥G3 toxicity. CONCLUSIONS Short-course accelerated radiation therapy treatment, planned and delivered using a conventional 2-dimensional RT technique, was effective and well tolerated for the symptomatic palliation of locally advanced or metastatic esophageal cancer. This schedule may be useful for RT centers in developing countries to reduce treatment times, costs, and patient waiting times before treatment.
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Affiliation(s)
- Biniyam Tefera Deressa
- Radiotherapy Department, Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia; Department of Clinical Oncology, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | | | - Netsanet Bogale
- Radiotherapy Department, Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia
| | - Milly Buwenge
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Alessio G Morganti
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Eleonora Farina
- Radiation Oncology Unit, Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy.
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18
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Kakuta T, Kosugi SI, Ichikawa H, Hanyu T, Ishikawa T, Kanda T, Wakai T. Palliative interventions for patients with incurable locally advanced or metastatic thoracic esophageal carcinoma. Esophagus 2019; 16:278-284. [PMID: 30949884 DOI: 10.1007/s10388-019-00665-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 03/18/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND The aim of this study was to assess the clinical outcomes of palliative interventions for patients with incurable locally advanced or metastatic esophageal carcinoma. METHODS A total of 131 patients with thoracic esophageal carcinoma who underwent palliative interventions were enrolled. Insertion of a self-expandable metallic stent (SEMS), tube enterostomy for enteral nutrition (EN), and palliative esophagectomy (PE) were performed in 38, 65, and 28 patients, respectively. The clinicopathological characteristics and clinical outcomes of each group were retrospectively reviewed. RESULTS Patients in the EN group frequently received chemoradiotherapy (P < 0.01). SEMS insertion, but not PE or EN, improved the mean dysphagia score after the intervention (P < 0.01). For the SEMS, EN, and PE groups, the occurrence of intervention-related complications was 31.6, 10.8, and 96.4%, respectively, the median survival time was 88, 208, and 226 days (P < 0.01), and the mean ratio of duration of home care to survival time was 28.9, 38.5, and 39.6% (P = 0.95). CONCLUSIONS SEMS insertion effectively relieved obstructive symptoms, but had no survival benefit. Tube enterostomy showed a low complication rate and has the potential to improve survival in combination with additional treatment, with no palliation of obstructive symptoms.
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Affiliation(s)
- Tomoyuki Kakuta
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
| | - Shin-Ichi Kosugi
- Department of Digestive and General Surgery, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, 4132 Urasa, Minami-Uonuma, Niigata, 949-7302, Japan
| | - Hiroshi Ichikawa
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takaaki Hanyu
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takashi Ishikawa
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Tatsuo Kanda
- Department of Surgery, Sanjo General Hospital, Niigata, Japan
| | - Toshifumi Wakai
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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19
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Walterbos NR, Fiocco M, Neelis KJ, van der Linden YM, Langers AMJ, Slingerland M, de Steur WO, Peters FP, Lips IM. Effectiveness of several external beam radiotherapy schedules for palliation of esophageal cancer. Clin Transl Radiat Oncol 2019; 17:24-31. [PMID: 31193091 PMCID: PMC6517531 DOI: 10.1016/j.ctro.2019.04.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 04/21/2019] [Accepted: 04/22/2019] [Indexed: 01/11/2023] Open
Abstract
External beam radiotherapy provides good symptom control for esophageal cancer. A higher dose schedule is related to a longer time to second intervention. Life expectancy is valuable in selecting the optimal palliative treatment schedule.
Background and purpose Although external beam radiotherapy (EBRT) is frequently used for palliative treatment of patients with incurable esophageal cancer, the optimal schedule for symptom control is unknown. This retrospective study evaluated three EBRT schedules for symptom control and investigated possible prognostic factors associated with second intervention and overall survival (OS). Material and methods Patients with esophageal cancer treated with EBRT with palliative intent between January 2009 and December 2015 were evaluated. Univariate and multivariate Cox regression models estimated the effect of treatment schedule (20 Gy in 5 fractions, 30 Gy in 10 fractions or 39 Gy in 13 fractions) on OS. To study the effect of prognostic factors on time to second intervention (repeat EBRT, intraluminal brachytherapy or stent placement) a competing risk model with death as competing event was used. Results 205 patients received 20 Gy (31%), 30 Gy (38%) or 39 Gy (32%). Improvement of symptoms was observed in 72% with no differences between schedules. Median OS after 20 Gy, 30 Gy and 39 Gy was 4.6 months (95%CI 2.6–6.6), 5.2 months (95%CI 3.7–6.7) and 9.7 months (95%CI 6.9–12.5), respectively. Poor performance status (HR 2.25 (95%CI 1.53–3.29)), recurrent esophageal cancer (HR 1.69 (95%CI 1.15–2.47)) and distant metastasis (HR 1.73 (95%CI 1.27–2.35)) were significantly related to worse OS. Treatment with 30 Gy and 39 Gy was related to longer time to second intervention compared to 20 Gy (adjusted cause specific HR 0.50 (95%CI 0.25–0.99) and 0.27 (95%CI 0.13–0.56), respectively). Conclusions Palliative EBRT provides good symptom control in patients with symptomatic esophageal cancer. A higher dose schedule was related to a longer time to second intervention. Hence, selection based on life expectancy is vital to prevent unnecessary long treatment schedules in patients with expected short survival, and limit the chance of second intervention when life expectancy is longer.
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Affiliation(s)
- Natasja R Walterbos
- Department of Radiation Oncology, Leiden University Medical Center, Postzone K0-P, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Marta Fiocco
- Department of Biomedical Data Science, Section Medical Statistics, Leiden University Medical Center, Postzone S5-P, P.O. Box 9600, 2300 RC Leiden, The Netherlands.,Mathematical Institute, Leiden University, P.O. Box 9512, 2300 RA Leiden, The Netherlands
| | - Karen J Neelis
- Department of Radiation Oncology, Leiden University Medical Center, Postzone K0-P, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Yvette M van der Linden
- Department of Radiation Oncology, Leiden University Medical Center, Postzone K0-P, P.O. Box 9600, 2300 RC Leiden, The Netherlands.,Center of Expertise Palliative Care, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Alexandra M J Langers
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Postzone C4-P, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Marije Slingerland
- Department of Medical Oncology, Leiden University Medical Center, Postzone B3-P, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Wobbe O de Steur
- Department of Surgery, Leiden University Medical Center, Postzone K6-R, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Femke P Peters
- Department of Radiation Oncology, Leiden University Medical Center, Postzone K0-P, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Irene M Lips
- Department of Radiation Oncology, Leiden University Medical Center, Postzone K0-P, P.O. Box 9600, 2300 RC Leiden, The Netherlands
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20
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van der Bogt RD, Vermeulen BD, Reijm AN, Siersema PD, Spaander MCW. Palliation of dysphagia. Best Pract Res Clin Gastroenterol 2018; 36-37:97-103. [PMID: 30551864 DOI: 10.1016/j.bpg.2018.11.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 11/19/2018] [Indexed: 01/31/2023]
Abstract
Palliation of dysphagia is the cornerstone of palliative treatment in patients with incurable oesophageal cancer. Available palliative options for dysphagia are oesophageal stent placement and radiotherapy. In general, oesophageal stent placement is the preferred therapeutic option in patients with a relatively poor prognosis because of its rapid relief of dysphagia. Regardless of ongoing technical developments, recurrence of dysphagia and stent-related complications are still occurring. For patients with a relatively good prognosis, intra-luminal brachytherapy is advised because of its sustained palliation of dysphagia. Due to limited availability of intra-luminal brachytherapy in clinical practice, fractionated external beam radiation therapy is commonly applied as an alternative. Selection of the optimal palliative approach for patients remains however challenging as conclusive high-quality evidence is limited. Moreover, with the introduction of new palliative treatment options (e.g. palliative chemotherapeutic and radiotherapeutic options) and the concurrent change of patient characteristics, supporting evidence from large randomised studies is warranted.
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Affiliation(s)
- R D van der Bogt
- Department of Gastroenterology & Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands.
| | - B D Vermeulen
- Department of Gastroenterology & Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - A N Reijm
- Department of Gastroenterology & Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands.
| | - P D Siersema
- Department of Gastroenterology & Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - M C W Spaander
- Department of Gastroenterology & Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands.
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21
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Kawamoto T, Nihei K, Sasai K, Karasawa K. Palliative radiotherapy and chemoradiotherapy in stage IVA/B esophageal cancer patients with dysphagia. Int J Clin Oncol 2018; 23:1076-1083. [PMID: 30066207 DOI: 10.1007/s10147-018-1324-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/27/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Palliative therapeutic strategies in esophageal squamous cell carcinoma (ESCC) patients with dysphagia remain controversial. Only few studies have assessed therapeutic effect factors related to improvement in dysphagia score and nutrition-support-free survival (NSFS). OBJECTIVE The present study assessed the efficacy and therapeutic effect factors related to the use of palliative radiotherapy (RT) and chemoradiotherapy (CRT) in ESCC patients with dysphagia. METHODS We retrospectively evaluated 70 patients with stage IVA/B ESCC. Patients received RT of 30 Gy in 10 fractions or concurrent CRT using 5-fluorouracil plus cisplatin of 40 Gy in 20 fractions. The change in the dysphagia score from before to after treatment was assessed, and NSFS was evaluated. RESULTS The median follow-up duration was 6 months (range 1-41 months). The overall rate of improvement in the dysphagia score was 60%. The median NSFS was 7.5 months. Craniocaudal tumor length < 6 cm, tumor circumference < 3/4, and CRT of 40 Gy in 20 fractions were associated with a significant improvement in the dysphagia score (p = 0.0036, p = 0.0069, and p = 0.03, respectively). NSFS was significantly longer with CRT than with RT (p = 0.048). CONCLUSION Palliative RT and CRT are effective treatment options for ESCC patients with dysphagia. Craniocaudal tumor length < 6 cm, tumor circumference < 3/4, and CRT of 40 Gy in 20 fractions may improve dysphagia. CRT of 40 Gy in 20 fractions may improve NSFS.
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Affiliation(s)
- Terufumi Kawamoto
- Division of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 18-22-3 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan. .,Department of Radiation Oncology, Graduate School of Medicine, Juntendo University, Tokyo, Japan.
| | - Keiji Nihei
- Division of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 18-22-3 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Keisuke Sasai
- Department of Radiation Oncology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Katsuyuki Karasawa
- Division of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 18-22-3 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
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22
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Reijm AN, Didden P, Bruno MJ, Spaander MC. Early pain detection and management after esophageal metal stent placement in incurable cancer patients: A prospective observational cohort study. Endosc Int Open 2016; 4:E890-4. [PMID: 27540579 PMCID: PMC4988853 DOI: 10.1055/s-0042-111202] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 06/13/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Studies of esophageal self-expandable metal stents (SEMS) mainly focus on efficacy and recurrent dysphagia. Retrosternal pain has been described in up to 14 % of these patients, however, prospective daily pain assessment has not yet been performed. We conducted a prospective study to evaluate the occurrence and management of pain after esophageal SEMS deployment. PATIENTS AND METHODS A total of 65 patients who underwent SEMS placement for incurable malignant esophageal stenosis were included. Patients used a diary to record intensity of pain twice daily for 2 weeks, according to the Numeric Rating Scale (NRS). A pain score ≥ 4 was used to determine whether patients experienced significant pain. If pain occurred, acetaminophen was used and, in cases of ongoing pain, an opiate was prescribed. Dose, duration, and kind of analgesic were noted. RESULTS The rate of significant pain increased from 0 % at baseline to 60 % on Day 1 (P < 0.001), followed by 37 % and 25 % on Days 7 and 14, respectively. The rate of analgesics use increased from 20 % at baseline to 78 % on Day 1 (P < 0.001), followed by 72 % and 62 % on Days 7 and 14, respectively. The use of opiates increased from 14 % at baseline to 42 % on Day 1 (P < 0.001). No variables associated with SEMS related pain were found. CONCLUSIONS Two-thirds of patients experience significant pain after esophageal SEMS insertion and analgesics, including opiates, are frequently required. Patients need to be informed and preventive prescription of analgesia should be considered in order to improve quality of life.
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Affiliation(s)
- Agnes N. Reijm
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Manon C.W. Spaander
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands,Corresponding author Manon C. W. Spaander Department of Gastroenterology and Hepatology (room Hs-312)Erasmus University Medical Centre‘s Gravendijkwal 230, 3015 CE RotterdamThe Netherlands+31 (0) 10 7035643+31 (0) 10 7035172
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23
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Welsch J, Kup PG, Nieder C, Khosrawipour V, Bühler H, Adamietz IA, Fakhrian K. Survival and Symptom Relief after Palliative Radiotherapy for Esophageal Cancer. J Cancer 2016; 7:125-30. [PMID: 26819634 PMCID: PMC4716843 DOI: 10.7150/jca.13655] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 11/01/2015] [Indexed: 12/17/2022] Open
Abstract
Purpose: The aim of this study was to assess the 6-months dysphagia-free survival, improvement in swallowing function, complication rate, and overall survival in patients with incurable esophageal cancer treated with palliative radiotherapy. Methods: We retrospectively reviewed data from 139 patients (median age 72 years) with advanced/recurrent incurable esophageal cancer, who were referred to 3 German radiation oncology centers for palliative radiotherapy between 1994 and 2014. Radiotherapy consisted of external beam radiotherapy (EBRT) with 30 - 40.5 Gy/2.5 - 3 Gy per fraction, brachytherapy alone (BT) with 15 - 25 Gy/5 - 7Gy per fraction/weekly and EBRT + BT (30 - 40.5 Gy plus 10 - 14 Gy with BT) in 65, 46, and 28 patients, respectively. Dysphagia-free survival (Dy-PFS) was defined as the time to worsening of dysphagia for at least one point, a new loco-regional failure or death of any cause. Results: Median follow-up time was 6 months (range 1-6 months). Subjective symptom relief was achieved in 72 % of patients with median response duration of 5 months. The 1-year survival rate was 30%. The 6-months Dy-PFS time for the whole group was 73 ± 4%. The 6-months Dy-PFS was 90 ± 4% after EBRT, 92 ± 5% after EBRT + BT and 37 ± 7% after BT, respectively (p<0.001). Five patients lived for more than 2 years, all of them were treated with EBRT ± BT. Ulceration, fistula and stricture developed in 3, 6 and 7 patients, respectively. Conclusions: Radiotherapy leads to symptom improvement in the majority of patients with advanced incurable esophageal cancer. The present results favor EBRT ± BT over BT alone. Due to the retrospective nature of this study, imbalances in baseline characteristics might have contributed to this finding, and further trials appear necessary.
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Affiliation(s)
- Julia Welsch
- 1. Department of Radiation Oncology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Philipp Günther Kup
- 1. Department of Radiation Oncology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Carsten Nieder
- 2. Department of Oncology and Palliative Medicine, Nordland Hospital Bodø, Norway; 3. Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Norway
| | - Veria Khosrawipour
- 4. Department of Surgery, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Helmut Bühler
- 1. Department of Radiation Oncology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Irenäus A Adamietz
- 1. Department of Radiation Oncology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany.; 5. Department of Radiation Oncology, Sankt Josef Hospital Bochum, Ruhr-University Bochum, Bochum, Germany.; 6. Department of Radiation Oncology, Ev-Krankenhaus Witten, Academic Hospital of the Witten/Herdecke University, Witten, Germany
| | - Khashayar Fakhrian
- 1. Department of Radiation Oncology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany.; 5. Department of Radiation Oncology, Sankt Josef Hospital Bochum, Ruhr-University Bochum, Bochum, Germany
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24
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Combined brachytherapy and external beam radiation: an effective approach for palliation in esophageal cancer. J Contemp Brachytherapy 2015; 7:453-61. [PMID: 26816502 PMCID: PMC4716132 DOI: 10.5114/jcb.2015.56765] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 12/03/2015] [Indexed: 01/24/2023] Open
Abstract
PURPOSE Palliation of dysphagia is a challenge in advanced esophageal cancer. The addition of external beam radiotherapy (EBRT) to intraluminal brachytherapy (ILBT) has shown significant improvement in dysphagia relief and symptom scores. The aim of the present study was to evaluate the efficacy of combined use of ILBT and EBRT. MATERIAL AND METHODS The medical records of 148 patients with advanced/metastatic esophageal cancer were screened from January 2008 to April 2014, and 74 patients were found eligible for the analysis. All patients received two fractions of 8 Gy each of ILBT, followed by EBRT. Patients were assessed for the symptom scores of dysphagia, odynophagia, regurgitation, and chest pain and weight was recorded periodically. RESULTS For a median follow-up of 6 months, the median OS was 9.5 months (95% CI: 7.5-10.5). The median dysphagia free survival was 6 months (95% CI: 4.8-7.1). The scores for dysphagia significantly improved after completion of 1(st) ILBT (p = 0.000), 2(nd) ILBT (p = 0.000), and at 3 months after EBRT compared to ILBT (p = 0.02). Overall 47% had improvement in dysphagia scores and 35% maintained the improvement of scores till last follow up. There was significant improvement in weight after completion of ILBT (p = 0.001) and at 3 months after completion of EBRT (p = 0.00). Twenty nine (39%) patients required nasogastric (NGT) insertions and 12 (16%) needed hospitalization for supportive care. 36.4% had complications in the form of stricture (27%), fistula (5.4%), and bleeding (4%). CONCLUSIONS Palliative radiotherapy is an effective alternative for palliation of dysphagia with improvement in symptom scores being evident and sustained. The results of this clinical audit were comparable with those from the trial setting.
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Glen P. The role of stents in the palliation of oesophageal cancer. BMJ Support Palliat Care 2015; 6:135-9. [DOI: 10.1136/bmjspcare-2014-000802] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 12/19/2014] [Indexed: 11/04/2022]
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