(P105) Improving Clinical Outcomes in Definitive Treatment of Esophageal Cancer Using a Novel Endoesophageal 3-Tube HDR Technique

April 15, 2014
Oncology, Oncology Vol 28 No 1S, Volume 28, Issue 1S

To review our local control (LC), survival, and swallowing outcomes using an innovative endoesophageal brachytherapy technique. Further, we conducted a dose-volume comparison for clinical target volume (CTV) using the standard 1-tube vs our novel 3-tube technique.

John F. Greskovich, MD, Matt D. Kolar, MS, Allan Wilkinson, PhD, Andrew Godley, PhD; Cleveland Clinic

Purpose and Objectives: To review our local control (LC), survival, and swallowing outcomes using an innovative endoesophageal brachytherapy technique. Further, we conducted a dose-volume comparison for clinical target volume (CTV) using the standard 1-tube vs our novel 3-tube technique.

Materials and Methods: We retrospectively reviewed the initial 13 medically unresectable, stage 0–IVA esophageal cancer patients treated with endoesophageal high-dose-rate (HDR) brachytherapy using a novel 3-tube technique. Five patients were treated with definitive HDR alone, and eight were treated with definitive combined external beam radiation therapy (EBRT) plus HDR. Two of eight EBRT + HDR patients received concurrent cisplatin/5-fluorouracil (5-FU) at weeks 1 and 4 of EBRT. Kaplan-Meier analysis was used to determine disease-free survival (DFS), overall survival (OS), and LC. The dose-volume relationship for CTV and implant volume for the 1-tube vs 3-tube technique planned with V100 of 90% in our initial patient was completed. Dice’s coefficient (DC) was calculated in 11 patients who underwent 43 total HDR applications and 36 3-tube vs 7 1-tube procedures.

Results: Of 13 medically unresectable patients, 11 were male and 2 were female, with a mean age of 72 years (range: 52–90 yr). Histology was adenocarcinoma in nine patients and squamous cell carcinoma in four patients. Tumor was located in the distal, middle, and proximal one-third of the esophagus in 10 patients, 2 patients, and 1 patient, respectively. Stage 0, 1A, 1B, 2A, 2B, 3A, and 4A occurred in one, one, six, one, one, two, and one of the patients, respectively. The HDR-alone dose was 25–30 Gy (mode 30 Gy) in 5–6 weekly fractions of 5 Gy/fx. The HDR dose after EBRT was 10–25 Gy (mode 15 Gy) in 2–5 weekly fractions. The EBRT dose was 50–64 Gy (mode 50 Gy). Of the five stage 0–1B HDR-alone patients, four are alive without disease (no evidence of disease [NED]); one is alive with distant failure (DF) in the lung/pleura. No local failures (LFs) occurred in five HDR-alone patients. Of the eight stage 1B–4A HDR + EBRT patients, five are alive with NED, one is alive with NED after cryotherapy for LF, and two are dead of distant failure in the liver. One of eight HDR + EBRT patients has LF but was salvaged with cryotherapy. Overall, 2 of 13 patients experienced LF after HDR +/− EBRT. At a median follow-up of 17.4 months, 18-month OS is 92.3%, 18-month DFS is 74%, and 18-month LC is 81%. No fistulas were seen. Two of 13 patients required dilatation for stricture. Eleven of 13 patients denied dysphagia, and 2 of 13 patients had grade 2 dysphagia, one requiring a stent.

The V100, V150, V200, and V300 were 90.0%, 73.5%, 62.3%, and 46.0% vs 90.2%, 66.7%, 41.5%, and 17.7%, for the 1-tube vs 3-tube technique, respectively. For the 3-tube technique, the implant volume was 50% smaller (V100: 42.7 cc vs 83.8 cc; V150: 22.2 cc vs 42.9 cc; V200: 13.1 cc vs 26.0 cc; V300: 5.6 cc vs 12.3 cc). The DC significantly improved to 0.38 from 0.30 for 3- vs 1-tube, respectively (P < .058).

Conclusions: A novel 3-tube endoesophageal HDR technique improved the dose homogeneity and DC in our initial 13 patients. Our initial OS and LC data suggest the potential for an improved therapeutic ratio using a novel 3-tube HDR technique as a component of definitive treatment for stage I–IVA esophageal cancer.

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