FRACTIONATED HIGH-DOSE-RATE INTRALUMINAL BRACHYTHERAPY IN PALLIATION OF ADVANCED ESOPHAGEAL CANCER

Purpose: To optimize the dose of fractionated brachytherapy for pallia tion of advanced esophageal cancer. Methods and Materials: One hundred and seventy-two patients with advanced esophageal cancer were randomi zed to receive 12 Gy/2 fractions (group A); 16 Gy/2 fractions (group B ) and 18 Gy/3 fractions (group C) by high dose rate intraluminal brach ytherapy (HDRILBT). Treatment was given weekly and dose prescribed at 1 cm from the source axis. Patients were followed up monthly and asses sed for dysphagia relief and development of complications. Results: Tw enty-two patients died before completing treatment due to advanced dis ease and poor general condition. The overall survival was 19.4% at the end of 12 months for the whole group (A-9.8%, B-22.46%, C-35.32%;p > 0.05). The dysphagia-free survival was 28.9% at 12 months for the whol e group (A-10.8%, B-25.43%, C-38.95%; p > 0.05). Forty-three patients developed fibrotic strictures needing dilatation (A-5 of 35, B-15 of 6 0, C-23 of 55; p = 0.032). Twenty seven patients had persistent lumina l disease (A-11, B-6, C-10), 15 of which progressed to fistulae (A-7, B-2, C-6; p = 0.032). There was no effect of age, sex, race, histology , performance status, previous dilation, presenting dysphagia score, p resenting weight, grade, tumor length, and stage on overall survival, dysphagia-free, and complication-free survival (p > 0.05). On a multiv ariate analysis, brachytherapy dose (p = 0.002) and tumor length (p = 0.0209) were found to have a significant effect on overall survival; b rachytherapy dose was the only factor that had an impact on local tumo r control (p = 0.0005), while tumor length was the only factor that ha d an effect on dysphagia-free survival (p = 0.0475). When compared to other forms of palliation currently available (bypass surgery, laser, chemotherapy, intubation, external radiotherapy), fractionated brachyt herapy gave the best results with a median survival of 6.2 months. Con clusions: Fractionated brachytherapy is the best modality for palliati on of advanced esophageal cancer. It offers the best palliation to pat ient when compared to all other modalities currently available. The op timal brachytherapy dose ranges between 16 Gy in two fractions and 18 Gy in three fractions given a week apart. (C) 1998 Elsevier Science In c.