Abstract
Esophagectomy has been an integral and the only potentially curative option for management of esophageal cancers. Cross Trial showed 29% complete pathological response after neoadjuvant chemoradiation followed by surgical resection. Similar to rectal cancer, WW strategies may be beneficial in esophageal cancer and allow organ preservation. . Dose escalation in rectal cancer with brachytherapy has shown up to 90% cCR and the strategy for dose escalation in esophageal cancer with brachytherapy may improve cCR rates. We reviewed all patients that were treated at our institution in the last 6 years to assess control rates and toxicity to hypothesize whether a trial for dose escalation with brachytherapy can improve organ preservation in esophageal cancer.
25 consecutive patients treated with high dose rate esophageal brachytherapy from 1/2017-12/2023 were included. 5/25 (20%) were females and 20/25(80%) males. All patients had received previous radiation 46.8 Gy- 60 Gy (median 50.4 Gy) with concurrent chemotherapy. All patients underwent placement of brachytherapy catheters under endoscopy guidance and were treated after CT based planning. 96 fractions were treated in total. 7/25 (28%) patients received 5 fractions, 5/25 (20%) received 4 fractions, 9/25 (36%) received 3 fractions and 4/25 (16%) received 2 fractions of 5 Gy each. 7/96 (8%) fractions were treated with conventional 8mm single channel catheter and 89/96 (92%) were treated with single channel balloon catheter. 5 Gy prescription dose was chosen to keep mucosal dose 8-10 Gy per published literature. Median follow-up was 9 months (range 4-36 months). Data was collected on all patients to assess for local control, need for stent placement and fistula formation.
7/25 (28%) patients were alive at the time of this report. 50% of patients needed stent placement either due to local progression of disease or stricture formation at least temporarily. 80% of patients showed improvement in dysphagia. Rate of stricture formation requiring dilatation was 50%. 2 / 25 (8%) patients were found to have fistula formation. One patient developed tracheoesophageal fistula at 12 months. He had tracheal involvement at the initial diagnosis prior to chemoradiotherapy. Second patient that developed a mediastinal fistula at 4 months was treated for postoperative anastomotic recurrence and all his fractions were treated with narrow lumen conventional catheter. All patients with greater than 6 months control of the primary tumor were analyzed. They received EQD2>80 Gy (Range 80.8-88.6).
Endoluminal High Dose rate brachytherapy for esophageal cancer is an underutilized technique. In select patients, especially patients with recurrent or persistent disease locally only, it is a well-tolerated treatment option with low rates of toxicity. CT based planning and use of balloon catheters improves the efficacy of treatment. Prospective trials using target dose with EQD2>80 Gy will allow adequate target dose delivery to obtain clinical control allowing opportunity for organ preservation in esophageal cancer.