Rajeev Atri1, Anil Kumar Dhull2, N. Balasubramanian3, Narayan P. Patel4, Ashok Kumar Chauhan5, Vivek Kaushal6
Oesophageal Cancer is usually associated with late presentation and poor prognosis. Unfortunately, advanced disease at presentation is seen in around 70% oesophageal cancer patients with limited curative option. The main objective of treatment remains palliation. Different treatment modalities were tried in locally advanced oesophageal cancer, but the median survival remains less than 10 months.[1-3] A combination of these modalities in advanced cases has marginally improved the results. Radiotherapy can be external beam (EBRT) alone, intraluminal brachytherapy (ILBT) alone or combination of both and nowadays IMRT/IGRT with different fractionation schedules have some promising results and needs further exploration through large clinical studies.
MATERIAL AND METHODS
We evaluated the efficacy and safety of EBRT followed by ILBT in locally advanced unresectable cases of carcinoma oesophagus and compared it with EBRT alone arm with boost.
All the patients were administered three cycles of three weekly neoadjuvant chemotherapy (NACT) with TPF and further received a total target radiation absorbed dose of 40 Gy/20 fractions/4 weeks. All patients were divided in two arms of 30-each. In arm-1, patients received 3 sessions of ILBT boost of 5 Gy each, a week apart. In this arm, ILBT boost was given using state of the art MicroSelectron HDR brachytherapy machine with Iridium192 source. In arm-2, patients received EBRT boost of 20 Gy/10 fractions (Cobalt-60 Teletherapy machine) by three field isocentric technique using Simulix HP Simulator.
After completion of treatment, response was evaluated every month, in terms of local control, symptomatic relief like dysphagia, odynophagia, etc. All the patients were followed up regularly for five years.
Complete response at completion of treatment was 37% vs. 23% in arm-1 & arm-2 respectively although the results were statistically insignificant. There was marked difference in relief of dysphagia and odynophagia at the end of 1-year of completion of treatment and its proving the fact that brachytherapy has been widely performed for the palliation of dysphagia. At 5-year follow-up, 6-patients (20%) were having no evidence of disease (NED) in arm-1 while only 2-patients (6%) were disease-free in arm-2.
The overall prognosis in patients with locally advanced oesophageal cancer is generally very poor, with a mean survival of 2-10 months. HDR brachytherapy was found to contribute good palliation in a significant number of patients with inoperable oesophageal cancer. In some patients, total remission was achieved lasting more than six months.