INTRALUMINAL BRACHYTHERAPY IN ESOPHAGEAL CANCER Dr Saeed Karimkhani

INTRALUMINAL BRACHYTHERAPY IN ESOPHAGEAL CANCER Dr Saeed Karimkhani Radiation oncologist

Local recurrence after chemoradiation in SCC & adeno

RTOG 92 -07 � 1999 49 patients stage II, III Chemoradiation as protocol RTOG 8501 -HDR ILBT(0. 2 – 0. 5 Gy/min) applicator external diameter (4 -6 mm) -fraction of 5 Gy/w during weeks 8, 9, and 10 (39)

5. 5 cm - At 1 cm from middwell position with equal dwell times The cumulative incidence of fistula 18%/year fistula =12% --- 6(3 fetal) 5 of 6 , TL=3 5 of 6 , 1/3 upper 5 of 6 , TD=15 Gy/3 f Stricture 4%

Local failure as the only site of failure 29% � Survival 1 y , 2 y, 3 y 49%, 31%, 29% � Local , regional recurrence , metastases = � RTOG 8501 Survival 5 y RTOG 8501 � 27% median 14 � month of local failure as the first site of failure � 45%

$Masanori Japan 2001 External irradiation (ERT) in 100 pts � 40– 65 Gy, fractions:$

Masanori Japan 2001 External irradiation (ERT) in 100 pts � 40– 65 Gy, fractions: 2. 2 (2. 0– 2. 5) without concurrent chemotherapy ILBT -LDR � Total dose 16. 4 Gy(10– 24. 3) in 2 -3 f each fraction 7. 1 Gy(6. 5– 8. 0) applicator diameter 1 cm , reference point at the mucosal surface of the esophagus Overall treatment time (days) 69. 9 (44– 92) �

23%tumor confined to sub mucosal muscle (superficial) � 80% 1/3 lower, 1/3 middle � 2 y , 5 y OS : 45. 8% , 12. 6% � for tumor≤ 5 cm: 59. 5% , 22. 6% for superficial type : 76. 6% , 20. 4% 2 y, 5 y local recurrence-free survival rates : � 52. 5% , 33. 9%

13 surviving patients, 8 disease free � , 5 alive with disease 87 died, 51 of locoregional recurrence � 12 of distant metastases 22 patients of other diseases CR rate tumors ≤ 5 cm 78. 3% (36/46) � tumors >5 cm was 59. 3% (32/54)

local control rate 2 y tumors of ≤ 5 cm � with > 20 Gy ILBT: 83% (5: 6) with <20 Gy ILBT: 26. 5% (9: 34) No severe ulcer or perforation of the � esophagus Esophageal stricture in 2 patients revealed � with endoscopical bougienage

Trial pts Tomohiko 43/94 Sharma Calais TE vun. G Dose rate HDR , LDR 50/100 LDR 53 HDR 70 HDR Pasquier Tessa 66 46/75 HDR Rohini 244/4 HDR results Better Survival T 1, T 2 , < 5 cm No late toxicity OS 3 y 27%+2 fistula Local recurrence 2 y 25% + 1 fistula OS 3 y 53% Better local control with dose > 74 GY a three-fold increase of late toxicity No diff OS 5 y

Multivariate Analysis of Treatment Outcome in Patients With Esophageal Carcinoma Treated With Definitive Radiotherapy. Article American Journal of Clinical Oncology. 26(4): 392 -397, August 2003. Kodaira, Takeshi M. D. ; Fuwa, Nobukazu M. D. ; Itoh, Yoshiyuki M. D. ; Kamata, Minoru M. D. ; Furutani, Kazuhisa M. D. ; Hatooka, Syunzo M. D. ; Shinoda, Masayuki M. D. Abstract: To evaluate patient characteristics and treatment factors influencing outcome of patients treated with definitive radiotherapy, we performed retrospective analysis. From 1983 to 2000, 154 patients who were diagnosed as esophageal carcinoma without distant metastasis received definitive radiotherapy with (N = 90) or without (N = 64) systemic chemotherapy. One hundred forty-two males and 12 females were entered in the analysis. Thirty-four patients received an additional boost of intracavitary brachytherapy (ICBT). The median patient age was 68 years (range: 46 -86). Disease stage was distributed as stage I, III, and IV for 33, 42, 33, and 45 patients, respectively. External beam radiotherapy was prescribed with a median 63 Gy (range: 38 -77. 8 Gy). The 2 - and 5 -year overall survival (OAS) and local control (LC) rates were 40. 8/18. 4% and 48. 6/28. 9%, respectively. In uni-/multivariate analyses, significant prognostic factors of OAS proved to be advanced T stage, absence of ICBT, and age less than 65 years. As for LC, adverse prognostic factors of uni/multivariate analysis were advanced T stage and poor performance status. The pretreatment T stage showed the most powerful influence on both survival and LC. Combination use of ICBT is proven to refine treatment outcome, although eligible criteria should be decided by a prospective study.