Clinical Oncology(1992) 4:222-227 © 1992The Royal College of Radiologists
Clinical Oncology
Original Article Combined External B e a m and Intracavitary Radiotherapy in Oesophageal Carcinoma R. K. Agrawal 1, P. J. D. K. Dawes I and M. B. Clague 2 1Department of Clinical Oncology and 2Department of Surgery, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne NE4 6BE, UK
Abstract. Seventy patients (40 males, 30 female; age 36-87 years, median 72 years) who were unsuitable for surgery were referred to the Regional Radiotherapy Centre, Newcastle General Hospital with oesophageal carcinoma (54 squamous cell; tumour length 2-14 cm). Sixty-seven patients received combined external beam radiotherapy (20-50 Gy in 5-20 fractions over 1-4 weeks) followed by intracavitary radiation (66 patients received 10 Gy at 1 cm; the remaining 4 received less) using an endoscopically inserted afterloading technique at 6.4 Gy/hour. Swallowing was restored in 65 patients (92%), although 39 patients (55.7%) subsequently required dilatation. Four developed fistulae (1 day, 2 months, 11 months, 17 months post-treatment). The actuarial survival was 71% at 6 months and 42% at 1 year. The combined treatment is well tolerated, with few complications and provides good palliation.
Remote afterloading intraluminal brachytherapy for oesophageal carcinoma using a purpose-made applicator was described by Rowland and Pagliero [5]. In their hands it provides good palliation with minimal morbidity. Importantly, the treatment was given quickly and offered good radiation protection to the attending staff. In April 1987 a Rowland applicator was obtained by the Regional Radiotherapy Centre, Newcastle upon Tyne, for use with the low-dose-rate (LDR) Selectron previously installed to carry out gynaecological intracavitary treatments. This paper describes our experience using a schedule combining external beam and intraluminal radiotherapy.
Keywords: External radiotherapy; Intracavitary radiotherapy; Oesophageal carcinoma
The L D R Selectron unit used for oesophageal applications contains 24 x 1.48 GBq Caesium-137 sources supplied by Amersham International plc. These can be distributed over the 12 cm available in the Rowland oesophageal applicator. At the mid-point of the source train and 1 cm from the centre of the sources the dose-rate is 6.4 Gy/hour. The applicator is positioned endoscopically under screening with the patient in the left lateral position and heavily sedated. This allows a dose of 10 Gy at 1 cm to be given in 1.55 hours. External beam therapy is given using either a 6 or 8 MV linear accelerator. Two fields (parallel opposed anterior and posterior) were generally used for patients in poor general condition with three fields for those patients able to tolerate it. A range of external beam radiation doses was used (Fig. 1). Sixty-seven patients with a diagnosis of oesophageal carcinoma were treated with a combination of external beam and intraluminal radiotherapy between April 1987 and June 1989. In addition, three patients were treated with intraluminal radiotherapy alone. These latter patients were in poor general condition and two of them had distant metastases (one liver, one liver and lungs). Of these 70 patients, four had previously been treated by oesophagectomy alone and were referred for anastomotic recurrences.
INTRODUCTION The prognosis for patients with oesophageal cancer remains poor in spite of improvements in both surgical and external radiotherapy techniques. An overall 5-year survival of 4% to 6% for all cases was reported in large reviews [1]. Selected series of cases have been reported by McKeown [2] with particular emphasis on surgery, and Pearson [3] with the emphasis on radiotherapy. These series are representative of the best reported results and show that, even in carefully selected series, long-term survival of only 20%-25% is achievable. Important favourable prognostic indicators are being female, having a turnout less than 5 cm in length, having a noncircumferential turnout, and a lesion in the upper third of the oesophagus [3,4]. Correspondence and offprint requests to: R. K. Agrawal, Senior Registrar, Department of Clinical Oncology,NewcastleGeneral Hospital, Westgate Road, Newcastleupon Tyne NE4 6BE, UK.
MATERIAL AND METHODS
External Beam and Intracavitary Radiotherapy in Oesophageal Carcinoma
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The remaining 66 had been assessed by a surgeon or gastroenterologist and were considered inoperable (because of a tumour >8 cm in length, and significant intra-abdominal disease) or unfit for surgery because of age, frailty or associated cardio-respiratory disease. All 70 patients are included in the analysis but the subset of 67 patients receiving combined treatment has been compared with a subset of the historical control group. Forty male and 30 female patients were studied. Ages ranged from 36 to 87 years. The median age was 72 years and 64% were greater than 70 years (Fig. 2). Three patients had been treated previously for malignancy (one posterior third of tongue, two breast). In all cases the oesophageal tumour was a new primary tumour. All patients presented with dysphagia which had
Adeno
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lasted from i to 18 months. The median duration was 3 months. Oesophagoscopy and biopsy were performed on all patients. The length of the primary tumour ranged between 2 and 14 cm with a median of 6 cm (Fig. 3). Histological examination revealed 54 squamous cell carcinomas, 14 adenocarcinomas, one adenosquamous carcinoma, and in the remaining patient cytological examination showed malignant ceils (Fig. 4). Sixty-six of 70 patients were treated as planned using the LDR Selectron and received 10 Gy at I cm in 1.55 hours. In two patients, who suffered severe oesophagitis following external beam treatment to 50 Gy in 20 fractions over 4 weeks, the dose at 1 cm was reduced to 6.3 Gy in one case and 5 Gy in the other. In two patients the applicator was removed early as the patients could not tolerate it; they received 6.3 Gy and 5 Gy respectively (Fig. 5).
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Clinical Oncology
Original Article Combined External B e a m and Intracavitary Radiotherapy in Oesophageal Carcinoma R. K. Agrawal 1, P. J. D. K. Dawes I and M. B. Clague 2 1Department of Clinical Oncology and 2Department of Surgery, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne NE4 6BE, UK
Abstract. Seventy patients (40 males, 30 female; age 36-87 years, median 72 years) who were unsuitable for surgery were referred to the Regional Radiotherapy Centre, Newcastle General Hospital with oesophageal carcinoma (54 squamous cell; tumour length 2-14 cm). Sixty-seven patients received combined external beam radiotherapy (20-50 Gy in 5-20 fractions over 1-4 weeks) followed by intracavitary radiation (66 patients received 10 Gy at 1 cm; the remaining 4 received less) using an endoscopically inserted afterloading technique at 6.4 Gy/hour. Swallowing was restored in 65 patients (92%), although 39 patients (55.7%) subsequently required dilatation. Four developed fistulae (1 day, 2 months, 11 months, 17 months post-treatment). The actuarial survival was 71% at 6 months and 42% at 1 year. The combined treatment is well tolerated, with few complications and provides good palliation.
Remote afterloading intraluminal brachytherapy for oesophageal carcinoma using a purpose-made applicator was described by Rowland and Pagliero [5]. In their hands it provides good palliation with minimal morbidity. Importantly, the treatment was given quickly and offered good radiation protection to the attending staff. In April 1987 a Rowland applicator was obtained by the Regional Radiotherapy Centre, Newcastle upon Tyne, for use with the low-dose-rate (LDR) Selectron previously installed to carry out gynaecological intracavitary treatments. This paper describes our experience using a schedule combining external beam and intraluminal radiotherapy.
Keywords: External radiotherapy; Intracavitary radiotherapy; Oesophageal carcinoma
The L D R Selectron unit used for oesophageal applications contains 24 x 1.48 GBq Caesium-137 sources supplied by Amersham International plc. These can be distributed over the 12 cm available in the Rowland oesophageal applicator. At the mid-point of the source train and 1 cm from the centre of the sources the dose-rate is 6.4 Gy/hour. The applicator is positioned endoscopically under screening with the patient in the left lateral position and heavily sedated. This allows a dose of 10 Gy at 1 cm to be given in 1.55 hours. External beam therapy is given using either a 6 or 8 MV linear accelerator. Two fields (parallel opposed anterior and posterior) were generally used for patients in poor general condition with three fields for those patients able to tolerate it. A range of external beam radiation doses was used (Fig. 1). Sixty-seven patients with a diagnosis of oesophageal carcinoma were treated with a combination of external beam and intraluminal radiotherapy between April 1987 and June 1989. In addition, three patients were treated with intraluminal radiotherapy alone. These latter patients were in poor general condition and two of them had distant metastases (one liver, one liver and lungs). Of these 70 patients, four had previously been treated by oesophagectomy alone and were referred for anastomotic recurrences.
INTRODUCTION The prognosis for patients with oesophageal cancer remains poor in spite of improvements in both surgical and external radiotherapy techniques. An overall 5-year survival of 4% to 6% for all cases was reported in large reviews [1]. Selected series of cases have been reported by McKeown [2] with particular emphasis on surgery, and Pearson [3] with the emphasis on radiotherapy. These series are representative of the best reported results and show that, even in carefully selected series, long-term survival of only 20%-25% is achievable. Important favourable prognostic indicators are being female, having a turnout less than 5 cm in length, having a noncircumferential turnout, and a lesion in the upper third of the oesophagus [3,4]. Correspondence and offprint requests to: R. K. Agrawal, Senior Registrar, Department of Clinical Oncology,NewcastleGeneral Hospital, Westgate Road, Newcastleupon Tyne NE4 6BE, UK.
MATERIAL AND METHODS
External Beam and Intracavitary Radiotherapy in Oesophageal Carcinoma
223 40-
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30
31a39
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> 5210
>10
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Dose (Gy)
Fig. 1. Range of external beam radiation doses.
Fig. 3. Tumour length.
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The remaining 66 had been assessed by a surgeon or gastroenterologist and were considered inoperable (because of a tumour >8 cm in length, and significant intra-abdominal disease) or unfit for surgery because of age, frailty or associated cardio-respiratory disease. All 70 patients are included in the analysis but the subset of 67 patients receiving combined treatment has been compared with a subset of the historical control group. Forty male and 30 female patients were studied. Ages ranged from 36 to 87 years. The median age was 72 years and 64% were greater than 70 years (Fig. 2). Three patients had been treated previously for malignancy (one posterior third of tongue, two breast). In all cases the oesophageal tumour was a new primary tumour. All patients presented with dysphagia which had
Adeno
AdenoSquamous Fig. 4. Histology.
Malig
lasted from i to 18 months. The median duration was 3 months. Oesophagoscopy and biopsy were performed on all patients. The length of the primary tumour ranged between 2 and 14 cm with a median of 6 cm (Fig. 3). Histological examination revealed 54 squamous cell carcinomas, 14 adenocarcinomas, one adenosquamous carcinoma, and in the remaining patient cytological examination showed malignant ceils (Fig. 4). Sixty-six of 70 patients were treated as planned using the LDR Selectron and received 10 Gy at I cm in 1.55 hours. In two patients, who suffered severe oesophagitis following external beam treatment to 50 Gy in 20 fractions over 4 weeks, the dose at 1 cm was reduced to 6.3 Gy in one case and 5 Gy in the other. In two patients the applicator was removed early as the patients could not tolerate it; they received 6.3 Gy and 5 Gy respectively (Fig. 5).
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