External beam radiation plus intraluminal brachytherapy in locally advanced, inoperable carcinoma esophagus: A retrospective study from tertiary cancer care center

ABSTRACT

Background: Worldwide, an estimated 572,034 esophageal cancer cases and 508,585 deaths occurred in 2018 and it accounts for approximately 3.2% of all malignancy. Because esophagus has no serosal covering with extensive, longitudinal connecting system of lymphatic plexus, direct invasion to contiguous structures and lymph node metastasis occurs early. Unresectable or metastatic disease at the time of diagnosis is seen in approximately 80% of patients, with cure rate <15% and thus making carcinoma of esophagus is one of the most dreaded malignancies. As most of the patients are diagnosed in locally advanced or metastatic stage, so curative surgical resection is not an option. Hence, in these groups of patients, other treatment modalities including concurrent chemoradiation have been tried. However, many of these patients are in a poor general condition so that radical concurrent chemoradiation as an alternative surgical resection could not be offered. In this group of patients, only radiotherapy (RT) is an option in intention to improve quality of life and to increase disease-free survival (DFS) if possible. As there is more chance local failure when patients treated with only external beam RT (EBRT), increasing dose to tumor may improve local control. Intraluminal brachytherapy (ILBT) is an important treatment option for dose escalation along with EBRT in the treatment of locally advanced and inoperable carcinoma esophagus. ILBT provides focal dose escalation, rapid reduction tumor, rapid restoration of swallowing function with sparing of surrounding normal tissue, and potentially improving therapeutic ratio. Hence, based on these facts, following EBRT, ILBT is an effective adjuvant modality to delivered high tumoricidal dose which can facilitate good local control, DFS with acceptable toxicity. We have used ILBT alone as palliative RT and combined modality with EBRT as radical treatment approach. Objectives: The aim of our study is to evaluate efficacy and safety of external beam radiation plus ILBT in locally advanced, inoperable carcinoma of esophagus in terms of improving local control, DFS, toxicity, and quality of life. Materials and Methods: A total of 58 carcinoma esophagus patients treated with EBRT plus ILBT in our RT department from 2012 to 2015 analyzed retrospectively. EBRT, total dose of 40 Gy/20 fractions, delivered in 4 weeks, using anteroposterior posteroanterior portal in cobalt-60 machine. Two–three weeks after completion of EBRT, ILBT was done using esophageal budgie. The total dose of brachytherapy was 10 Gy in two fractions, 1 week apart, 5 Gy in each fraction. EBRT and ILBT treatment completed in 8–9 weeks. Response assessed by clinical assessment, upper gastrointestinal endoscopy, and contrast-enhanced computed tomography chest and abdomen initially at 3 months and then at 6 months. Results: Local disease control seen in 65% of patients. With a median follow-up of 15 months, the median DFS was 8 months and median overall survival was 14 months. Regional nodal failure and distant metastasis were seen in 35% and 46% of patients, respectively. The incidence of acute mucositis was seen in 75% of patients and late toxicity is seen in 25% of cases. Swallowing function preserved in >87% of patients. Conclusion: In patients with locally advanced carcinoma of esophagus and poor performance status who are unable to tolerate radical concurrent chemoradiation, combination of EBRT plus ILBT produces good local control, DFS, and durable relief of dysphagia with acceptable toxicity.