Time to review the role of intraluminal brachytherapy for dose escalation after concurrent chemoradiation in cancer esophagus: A retrospective audit.

e16054 Background: Intraluminal brachytherapy (ILBT) for dose escalation after concurrent chemoradiation (CRT) in cancer esophagus is not routinely practiced. This is particularly attributable to radiotherapy toxicity in terms of strictures and fistulas. Cancer esophagus has poor locoregional control and overall survival rates in comparison to head and neck cancers. Dose escalation may be an option to counteract the high failure rates. Methods: A retrospective analysis was conducted for esophageal cancer patients treated between 2008 to 2016 planned for radical CRT to a minimum dose of 59.4 Gy in 33 fractions along with concurrent cisplatin 35 mg/m2 and 5 FU 375 mg/m2 on weekly basis. Further, the patients who received dose escalation after external beam radiotherapy (EBRT) completion by ILBT to a dose of 6 Gy in a single fraction to the pre EBRT volume were also analysed. The patient, tumor, treatment characteristics along with response rates, survival outcomes, and toxicities were evaluated and compared between the two groups - the patients who received ILBT and those who did not. Statistical significance between variables was analysed with the Chi-Square or Fischer’s exact test and t-test. Survival analysis was done by Log-Rank test. The analysis was done on a worst-case scenario basis where the patients lost to follow-up were considered dead. Results: The total number of patients treated by CRT was 69, out of which 13 patients received ILBT for dose escalation. The median age was 60 years (Range - 40 to 80 years) and the male: female ratio was 1.09, mean tumor length was 6.4 ± 2.4 cms (Range-1.5-12 cms). The commonest tumor site was the middle third observed in 58% patients. The median EBRT dose was 59.4 Gy (Range- 9 to 63 Gy). The median concurrent chemotherapy cycles were 5. The median follow-up period was 15 months (range 1-100 months). In terms of complete response rates, there was a trend towards significant improvement in patients receiving ILBT compared to those receiving EBRT alone (84.61% versus 57.49%, p=0.07). Also, the overall survival (OS) was significantly higher in the ILBT group (45.31 months versus 19.20 months; p = 0.005). The other patient, tumor, and treatment characteristics analyzed showed no significant impact on OS. There was no significant difference in the incidence of strictures (p=0.206) and severity (p=0.764) of strictures amongst both the groups. Grade ≥3 late toxicity was reported in 10 patients (17.85%) receiving EBRT alone and in 3 patients (23.07%) receiving ILBT. None of the patients receiving ILBT developed a fistula. Conclusions: The present study reveals a dramatic increase in OS by dose escalation with ILBT. The limitations of the present study were a small sample size and a lesser number of patients in the ILBT group. Recapitulating the concept of ILBT to increase the local tumoricidal dose may improve the survival rates.

20 TREATMENT OPTIMIZATION AND PROGNOSTIC FACTORS IN ADVANCED ESOPHAGEAL CANCER

Esophageal cancer is a disease with high mortality due to advanced stage at the time of diagnosis in patients with poor general condition and/or multiple comorbidities which makes them unsuitable for radical treatment. The goal of this clinical trial is finding optimal treatment for this group of patients. Methods Hypothesis of this clinical trial is that sequential use of high dose rate intraluminal brachytherapy, external beam radiotherapy and chemotherapy decreases symptoms of disease, improves quality of life and prolongs overall survival in patients with esophageal cancer that are not candidates for radical treatment. We have included patients with esophageal cancer that are not candidates for radical treatment. Statistical analysis was done only for the patients that have completed planned treatment and not for the intent to treat population. Therefore, statistical analysis was done for 39 patients, 22 in control group and 17 in interventional group. Results In a survival analysis adapted for AJCC stage of the disease, addition of sequential chemotherapy improves overall survival statistically significant (P = 0.004). Sequential use of high dose rate intraluminal brachytherapy and external beam radiotherapy decreases the degree of: dysphagia (P = 0.001), odynophagia (P = 0.002) and regurgitation (P = 0.008) statistically significant. Decrease of a pain degree is statistically significant only with the use of sequential chemotherapy (P = 0.031). Sequential use of chemotherapy does not improve control over dysphagia (P = 0.872), odynophagia (P = 0.872) and regurgitation (P = 0.872) any further. Patients of female gender have greater improvement of regurgitation score (P = 0.068), pain score (P = 0.09) and quality of life (P = 0.019). Conclusion Sequential use of high dose rate intraluminal brachytherapy and external beam radiotherapy provides a safe use of high radiotherapy doses with minimal exposure of organs at risk, according to dose-volume histogram analysis. Sequential use of chemotherapy, after high dose rate intraluminal brachytherapy and external beam radiotherapy, improves overall survival in patients with esophageal cancer that are not candidates for radical treatment, in comparison to patients who do not receive chemotherapy (P = 0.09).

Dose Intensified Chemoradiation and Intraluminal Brachytherapy Improve Outcomes in Middle Third Carcinoma Esophagus: Experience from a Regional Cancer Center

Introduction Esophageal cancer is known for its poor outcome despite multimodality treatment. In this study, we report our experience with concurrent capecitabine-based chemoradiotherapy followed by intraluminal brachytherapy (ILBT) for middle third esophageal cancer. Materials and Methods Twenty patients of histology-proven middle third esophageal cancer were treated with 45 Gray (Gy)/25 fraction (fr) of external beam radiation on telecobalt using two-dimensional technique with concurrent cisplatin 40 mg/m2 weekly with five such cycles along with tablet capecitabine 825 mg/m2 twice daily for the first 2 weeks and last 2 weeks of radiotherapy. This was followed by ILBT of 4 Gy × 3 fr placed 1 week apart from a total biologically effective dose of 60 Gy. Patients were followed up with clinical examination and serial barium swallow to assess response and toxicity. Results Out of 20 patients, disease-free survival at 2 years was 60%. At 5 years, the actuarial survival was 47% with five patients alive and two patients lost to follow-up at 3 years. One patient had grade 3 toxicity in the form of tracheoesophageal fistula (5%). Two patients had distal failure. Two patients had second primary tumor in the upper aerodigestive tract at the end of 7 years. Conclusion A combination of chemotherapy with cisplatin and capecitabine given concurrently with radical radiation therapy followed by ILBT boost is a safe and feasible protocol in the treatment of carcinoma esophagus involving middle third of esophagus. The local control and survival are comparable to historical studies with minimal toxicity.