Radiation Oncology/Esophagus/Advanced Stage

Locally Advanced Esophageal Cancer

RT +/- chemotherapy

 * 2nd Scandinavian trial
 * Randomized. 97 patients, inoperable localized esophageal CA. Arm 1) RT vs. Arm 2) Neoadjuvant bleomycin/cisplatin
 * 1992 PMID 1379740 -- "Bleomycin/cis-platin as neoadjuvant chemotherapy before radical radiotherapy in localized, inoperable carcinoma of the esophagus. A prospective randomized multicentre study: the second Scandinavian trial in esophageal cancer." (Hatlevoll R, Radiother Oncol. 1992 Jun;24(2):114-6.)
 * Outcome: 1-year OS RT 29% vs. CRT 18% (NS); improved swallowing at 3 months 38% vs. 23% (NS)
 * Conclusion: No benefit for adding bleomycin/cisplatin to RT alone

External Beam
About 50-60% report palliation of dysphagia with RT alone or 60-80% with RT+chemo.


 * Toronto, 2000 PMID 10974382 -- "A prospective trial of short-course radiotherapy plus chemotherapy for palliation of dysphagia from advanced esophageal cancer." (Hayter CR, Radiother Oncol. 2000 Sep;56(3):329-33.)
 * Phase I/II. 22 pts w/ dysphagia from advanced incurable esophageal CA. Treated with Short Course RT + Chemo. RT 30/10, with concurrent 5FU (1000mg/m2) + mito C.
 * 32% with transient worsening of dysphagia. Median time to normalization of swallowing of 5wks.  Median time of dysphagia free interval was 11wks.  73% remained dysphagia free until death.
 * Conclusion: short course RT + chemo can be effective

Brachytherapy

 * SIREC Randomized Trial (1999-2002)
 * 2004 PMID 15500894 -- "Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial." (Homs MY, Lancet. 2004 Oct 23-29;364(9444):1497-504.)
 * 209 pts w/ dysphagia from inoperable esophageal CA randomized to 12 Gy single dose brachy vs stent placement.
 * Dysphagia improved more rapidly after stent placement but long term relief was better w/ brachy. Stent placement had higher complications (33% vs 21%, SS) - mainly due to late hemorrhage.  Median survival equivalent.  QOL survey favored brachy.
 * Conclusion: Stent placement as initial treatment reserved for pts w/ short life expectancy.