Intraluminal Irradiation Research Articles

Prospective randomized comparative study between EBRT alone and EBRT with ILRT boost in locally advanced unresectable esophageal cancer - Tertiary rural Indian cancer center experience

Background: Local recurrence within the gross tumor volume following a conventional radiation dose of 50 Gy is a major hurdle in achieving a better prognosis for esophageal carcinoma. Consequently, there remains a lack of consensus globally regarding the optimal dose for definitive concurrent chemoradiotherapy. Certain studies propose that radiation dose escalation could enhance clinical outcomes. Aims and Objectives: The current study aimed to compare the safety and effectiveness of external beam radiotherapy (EBRT) alone versus EBRT with intraluminal radiotherapy (ILRT) boost. Materials and Methods: A total of 60 patients with locally advanced unresectable squamous cell carcinoma of the esophagus were prospectively enrolled in this study. A comparison was conducted between 50 Gy EBRT alone and 50 Gy EBRT with 8 Gy ILRT boost, alongside weekly concurrent chemotherapy, to assess the response and toxicities. Results: On initial assessment, a complete response (CR) was achieved in 76.66% of patients in the ILRT boost arm and 70% in the EBRT alone arm (P=0.559). At the 6th-month follow-up, 60% of patients in the ILRT boost arm and 50% in the EBRT alone arm still had a CR. No statistically significant differences were observed between the two arms in terms of leukopenia (P=0.576), nephrotoxicity (P=1.0), radiation dermatitis (P=0.615), vomiting (P=0.921), and diarrhea (P=1.0). Five patients in the ILRT boost arm and three in the EBRT alone arm experienced stricture, while no cases of fistula formation were reported. Conclusion: Dose escalation with ILRT can result in an enhanced CR accompanied by manageable toxicity, ultimately leading to improved locoregional control.

Toxicity and Local-Regional Control of Two Fractionation Schedules with Concurrent Chemotherapy and Intraluminal Brachytherapy for Oesophageal Carcinoma: A Pilot Study

Introduction: Oesophageal cancer is the seventh most common cancer worldwide and the sixth highest cause of cancer-related mortality. Radiation plays an important role in the multimodality treatment of carcinoma of the oesophagus. Aim: To compare locoregional control and toxicity of two External Beam Radiation Therapy (EBRT) fractionation schedules of concurrent chemoradiotherapy and high-dose intraluminal brachytherapy in patients with oesophageal carcinoma at a single institute. Materials and Methods: The present study was a pilot study including a total of 33 participants with histologically confirmed oesophageal cancer. Patients were prospectively randomised into two groups. Arm I: EBRT with a total dose of 46 Gy delivered in 23 fractions at a rate of 2 Gy per fraction over 4.3 weeks, along with Concurrent Injection of Cisplatin (CDDP) 100 mg/m2 on days 1 and 22, followed by Intraluminal Radiation Therapy (ILRT) with 6 Gy per session weekly. Arm II: EBRT with a total dose of 30 Gy delivered in 10 fractions at a rate of 3 Gy per fraction over two weeks and CDDP 100 mg/m2 on day 1 only. The primary endpoint of this study was to compare the locoregional response and toxicities (both acute and late) in the two arms at the end of radiotherapy and six months. Results: At the end of the two-month follow-up, no statistically significant difference was found in the response between the two arms (p-value=0.2697). Dysphagia relief was comparable in both arms; however, this difference was not statistically significant (p-value=0.9235). Conclusion: The responses in both arms were comparable, and further randomised trials with larger sample sizes should be encouraged.

Optimisation of Organ Preservation treatment strategies in patients with rectal cancer with a good clinical response after neoadjuvant (chemo)radiotherapy: Additional contact X-ray brachytherapy versus eXtending the observation period and local excision (OPAXX) — protocol for two multicentre, parallel, single-arm, phase II studies

IntroductionStandard treatment for patients with intermediate or locally advanced rectal cancer is (chemo)radiotherapy followed by total mesorectal excision (TME) surgery. In recent years, organ preservation aiming at improving quality of...

Brachytherapy for Oesophageal Carcinoma: A Comprehensive Review of Literature and Techniques

AbstractIntroduction:Oesophageal carcinoma is one of the fatal cancers mainly because of its rapid spread and poor prognosis. Treatment modalities involves a multimodality approach, including surgery, radiation therapy and chemotherapy. Radiation therapy includes brachytherapy in the form of intraluminal radiation therapy. Brachytherapy permits delivery of high tumouricidal doses to superficial cancerous growth of the oesophagus while delivering much lower doses to the surrounding tissue. It is mostly given in combination with external beam radiation in patients with poor performance scores not likely to tolerate an aggressive chemoradiation regimen or as a boost to concurrent chemoradiotherapy. It is very effective in terms of local tumour control as well as in relieving symptoms in advanced/recurrent disease. Intraoperative brachytherapy and seed brachytherapy have also been tried to address the nodal disease.Methods:We undertook a review of the available literature and techniques developed in the past three decades to emphasise the role of brachytherapy in curative or palliative settings in the treatment of oesophageal carcinoma.Conclusion:Oesophageal brachytherapy will remain a tangible treatment of oesophageal cancer, although it is less commonly used due to high expertise requirement, lack of established evidence, risk of life-threatening complications and lack of interest in brachytherapy. It offers quick and useful palliation for a prolonged period, along with good quality of life and superior dosimetry. Use of novel applicators may allow dose escalation and lower toxicity. Seed brachytherapy is also emerging as a promising option in nodal recurrences.

20 TREATMENT OPTIMIZATION AND PROGNOSTIC FACTORS IN ADVANCED ESOPHAGEAL CANCER

Abstract Esophageal cancer is a disease with high mortality due to advanced stage at the time of diagnosis in patients with poor general condition and/or multiple comorbidities which makes them unsuitable for radical treatment. The goal of this clinical trial is finding optimal treatment for this group of patients. Methods Hypothesis of this clinical trial is that sequential use of high dose rate intraluminal brachytherapy, external beam radiotherapy and chemotherapy decreases symptoms of disease, improves quality of life and prolongs overall survival in patients with esophageal cancer that are not candidates for radical treatment. We have included patients with esophageal cancer that are not candidates for radical treatment. Statistical analysis was done only for the patients that have completed planned treatment and not for the intent to treat population. Therefore, statistical analysis was done for 39 patients, 22 in control group and 17 in interventional group. Results In a survival analysis adapted for AJCC stage of the disease, addition of sequential chemotherapy improves overall survival statistically significant (P = 0.004). Sequential use of high dose rate intraluminal brachytherapy and external beam radiotherapy decreases the degree of: dysphagia (P = 0.001), odynophagia (P = 0.002) and regurgitation (P = 0.008) statistically significant. Decrease of a pain degree is statistically significant only with the use of sequential chemotherapy (P = 0.031). Sequential use of chemotherapy does not improve control over dysphagia (P = 0.872), odynophagia (P = 0.872) and regurgitation (P = 0.872) any further. Patients of female gender have greater improvement of regurgitation score (P = 0.068), pain score (P = 0.09) and quality of life (P = 0.019). Conclusion Sequential use of high dose rate intraluminal brachytherapy and external beam radiotherapy provides a safe use of high radiotherapy doses with minimal exposure of organs at risk, according to dose-volume histogram analysis. Sequential use of chemotherapy, after high dose rate intraluminal brachytherapy and external beam radiotherapy, improves overall survival in patients with esophageal cancer that are not candidates for radical treatment, in comparison to patients who do not receive chemotherapy (P = 0.09).

Short-Course External Beam Radiotherapy Versus Brachytherapy for Palliation of Dysphagia in Esophageal Cancer: A Matched Comparison of Two Prospective Trials.

Short-course external beam radiotherapy (EBRT) and intraluminal brachytherapy are both accepted treatments for the palliation of dysphagia in patients with incurable esophageal cancer. We compared the effects of both treatments from two prospective studies. We performed a multicenter prospective cohort study of patients with metastasized or otherwise incurable esophageal cancer requiring palliation of dysphagia from September 2016 to March 2019. Patients were treated with EBRT in five fractions of 4 Gy. Data were compared with all patients treated with a single brachytherapy dose of 12 Gy in the SIREC (Stent or Intraluminal Radiotherapy for inoperable Esophageal Cancer) trial, both between the original cohorts and between 1:1 propensity score-matched cohorts. The primary end point was an improvement of dysphagia at 3 months without reintervention. The secondary end points included toxicity and time-to-effect. A total of 115 patients treated with EBRT and 93 patients who underwent brachytherapy were eligible for analysis. In the original cohorts, dysphagia improved after EBRT in 79% of patients compared with 64% after brachytherapy (p= 0.058). Propensity score matching resulted in 69 patients in each cohort well-balanced at baseline. Improvement of dysphagia was observed in 83% after EBRT versus 64% after brachytherapy (p= 0.048). In responding patients, improvement of dysphagia at 2 weeks was observed in 67% after EBRT compared with 35% after brachytherapy, and the maximum effect was reached after 4 weeks in 55% and 33%, respectively. Severe toxicity occurred in 3% of patients after EBRT compared with 13% after brachytherapy. Short-course EBRT appears at least as effective as brachytherapy in the palliation of dysphagia in patients with esophageal cancer.

ENDOBRONCHIAL METASTASIS FROM OSTEOSARCOMA

SESSION TITLE: Disorders of the Pleura SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Lung is the most frequent site for metastasis from osteosarcoma. Usually, the presentation is with well-defined parenchymal nodules, and unusually with pleural deposits, calcification, or mediastinal nodes. Metastases from osteosarcoma presenting as an isolated endobronchial lesion is discretely rare. CASE PRESENTATION: 36 Y/O man with a diagnosis of osteosarcoma presented with dry cough. The patient CT chest showed a left lower lobe mass with central calcification (figure). The patient underwent bronchoscopy for evaluation left lower lobe mass. The bronchoscopy showed left lower lobe superior segment endobronchial lesion. Hot snare and cryo probe used to debulck the endo bronchial lesion (figure). The lesion was extending deep in the airway and EBUS confirmed the depth of the lesion with the finding for central calcification (figure). Pathology confirmed the diagnosis of metastatic small cell osteosarcoma (figure). DISCUSSION: Airway metastasis of tumors usually rare. The incidence of such metastasis is estimated to be approximately 2%; the most common primary malignancies being renal cell, colorectal, cervical, breast carcinoma, and malignant melanoma.This case presenting an extension of small cell small cell Osteosarcom mass in the left lower lobe into the airway confirmed with EBUS. CONCLUSIONS: Airway inspection is an important test for patient with metastatic tumors to the lung close to a major airways. This will give the chance for a baseline evaluation of the airway for any future progress of disease or future complication of the disease such as hemoptysis. Inexplicable pulmonary manifestations should prompt an early evaluation including bronchoscopy and early institution of local therapy for possible palliation. Reference #1: Mogulkoc N, Goker E, Atasever A, et al. Endobronchial metastasis from osteosarcoma of bone: treatment with intraluminal radiotherapy. Chest. 1999;116:1811–1814 Reference #2: Rubio ER, Chang EE, David O, et al. Pulmonary osteosarcoma: endoscopic management. J Bronchol. 2001;8:277–281 DISCLOSURES: No relevant relationships by Abdul Hamid Alraiyes, source=Web Response No relevant relationships by Mohamed Elrifai, source=Web Response No relevant relationships by Arun Kadamkulam Syriac, source=Web Response

S-2. Treatment Results for 41 Cases of Endobronchial Carcinoma : with a New Applicator of Intraluminal Irradiation Using ^ Iridium Thin Wires(Present Status of Endoscopic Treatment of Lung Cancer)

S-2. Treatment Results for 41 Cases of Endobronchial Carcinoma : with a New Applicator of Intraluminal Irradiation Using ^ Iridium Thin Wires(Present Status of Endoscopic Treatment of Lung Cancer)

EQD2 and Overall Treatment Time in the High Dose Rate Brachytherapy of the Advanced Nasopharyngeal Carcinoma

The aim of this study is to evaluate the decrease of EQD2 (biologically equivalent dose in 2 Gy fraction) and its correlation with local control of tumour in the treatment of the advanced nasopharyngeal carcinoma (NPC) when the overall treatment time is prolonged. A retrospective study was carried out on 43 advanced NPC (stage Ⅲ and Ⅳ) treated with fractionated High Dose Rate (HDR)–Brachytherapy boost, following external beam radiation therapy and chemotherapy in the period from 2009 to 2015. All patients were irradiated using a cobalt unit and a technique that employed two laterals, opposed fields with a dose of (66 ± 4) Gy. It was followed by HDR –Intra Luminal Radiotherapy after having a gap. The total EQD2 prescribed was (84.75 ± 7) Gy (range, 75–100.5 Gy). The probabilities of disease recurrence within a median follow-up of 24 months (range, 10–78 months) are expected as 0.12, 0.48 and 0.97 (P=0.05) for the overall treatment time of 75, 150 and 250 days respectively. The relative risk of local recurrence of Stage IV NPC patient is about 2.30 times higher than stage Ⅲ patients. The increase of total treatment time may be of different origin resulting in the fall of EQD2. It was observed that the recurrence of disease is significant (P < 0.05) when the overall treatment time is above 100 days where EQD2 lost becomes more than 0.10 Gy/day. The relative risk of disease recurrence of Stage Ⅳ is observed higher than stage Ⅲ nasopharyngeal patients.

EP-1612: Intraluminal radiotherapy in the treatment of inoperable cancer of the esophagus

EP-1612: Intraluminal radiotherapy in the treatment of inoperable cancer of the esophagus

The role of stenting in the palliation of gastroesophageal junction cancer: A brief review

Gastroesophageal junction cancer has an increasing incidence in western countries. It is inoperable when first manifested in more than 50% of cases. So, palliation is the only therapeutic option for the advanced disease to relieve dysphagia and its consequences in weakened patients with an estimated mean survival under 6 mo. This article has tried to identify trends focusing on current information about the best palliative treatment, with an emphasis on the role of stenting. Self-expanding stent placement, either metal or plastic, is the main management option. However, this anatomical location creates some particular problems for stent safety and effectiveness which may be overcome by properly designed novel stents. The stents ensure a good quality of life and must be preferred over other alternative methods of loco-regional modalities, i.e., external radiation, laser thermal or photodynamic therapy. Although stent placement is generally a simple, safe and effective method, there are sometimes complications, increasing the morbidity and mortality rate. Bypass operative procedures have now been abandoned as a first choice. The stomach instead of the colon must be used for a bypass operation when it is needed. Chemotherapy, despite the toxicity, and intraluminal radiation (brachytherapy) have a well-defined role.

A novel biliary stent loaded with 125I seeds in patients with malignant biliary obstruction: Preliminary results versus a conventional biliary stent

Stenting is a palliative therapy method for relieving malignant biliary obstruction. The aim of this study was to evaluate the safety and effectiveness of an irradiation stent compared to a conventional biliary stent in patients with biliary obstruction caused by both primary and metastatic adenocarcinomas. Participants were randomly assigned to receive treatment with a biliary irradiation stent (irradiation stent group) or a conventional biliary stent (control group). After stent implantation, the outcomes were measured in terms of relief of obstructive jaundice, survival time, complications related to the procedure. A p value of less than 0.05 indicated a significant difference. The stents were successfully placed in all the 23 patients. The obstructive jaundice was relieved in all patients except three in the control group. The median and mean overall survivals in the irradiation stent group were higher than those in the control group (7.40 months versus 2.50 months, 8.03 months versus 3.36 months, p=0.006). The patients with stent patent at 3, 6, and 12 months in the irradiation stent group were 11 (91.7%), 7 (58.3%), and 1 (8.3%), respectively. While in the control group, 4 (36.4%), 1 (9.1%), and 0 (0%), respectively. There were no significant differences in the complications related to stent insertion between the two groups. This interim analysis shows that treatment with the biliary intraluminal irradiation stent in patients with biliary obstruction caused by adenocarcinomas appears safe and technically feasible, has benefits in relieving jaundice, and seems to extend survival when compared to a conventional biliary stent.

Development of a new biliary intraluminal irradiation stent and the primary results of clinical application

To evaluate the feasibility, safety and efficiency of a new biliary intraluminal irradiation stent system loaded with (125)I seeds. The study was approved by the institutional ethics committee of our hospital, and informed consent was obtained from each patient. Patients with malignant biliary obstruction were treated with a new biliary irradiation stent system loaded with (125)I seeds according to a treatment plan system. All of the biliary seeds carrying devices combined with the matched biliary stents were placed by the procedures of percutaneous transhepatic biliary puncture. After stents implantation, all patients were followed-up. The whole biliary stent systems loaded with (125)I seeds were successfully placed in 12 patients, no (125)I seeds exfoliation during the procedure and no radioactive leakage by general emission computed tomography reexamination during the follow-up were observed. The obstructive jaundice relived and the systemic conditions improved remarkably in all patients. There were no complications related to the stents, such as biliary perforation or hemobilia, were observed. And no significant change in the blood routine and immune parameters detected before and after operation during the follow-up were observed. The median survival period was 7.40 months (95%CI 6.204 - 8.596) and the mean survival period was 8.03 months (95%CI 6.142 - 9.909). Development of a new biliary intraluminal irradiation stent system loaded with (125)I seeds is technically feasible and safe, treatment of this stent system has potential benefits of extending survival, however the long-term clinical efficacy needs to be certificated by further follow-up observation and control trials.

Occurrence of chronic esophageal ulcer after high dose rate intraluminal radiation therapy for esophageal cancer

Occurrence of chronic esophageal ulcer after high dose rate intraluminal radiation therapy for esophageal cancer

Esophageal intraluminal stents with ^125I seeds for advanced esophageal cancer

Objective To evaluate the therapeutic effect of esophageal intraluminal stents with ^125I seeds based on survival time and quality of life （QOL） of patients with advanced esophageal cancer. Methods A total of 37 patients with advanced esophageal cancer who underwent placement of esophageal ^125I irradiation stent were followed up. The QOL was evaluated by QLQ-C30 and QLQ-OES18 questionnaires before the procedure, and I week and 3 months after. Results The mean survival time of 37 patients was 28 weeks, with 3-month and 6-month survival rates at 94. 6% （35/37） and 51.4% （19/37）, respectively. Compared with the baseline, the scores of emotional functioning （EF） , cognitive functioning （CF） , global quality of life（QL）, fatigue（ FA）, pain（ PA）, financial difficulties（FI） and pain of QLQ-OES18 （OESPA） assessed 1 week after stent placement increased （ P 〈 0. 05 ） significantly and dysphapia of QLQ-OES18 （ OESDYS）, eating of QLQ-OES18 （ OESEAT）, trouble swallowing saliva of QLQ-OES18 （ OESSV ） and choked when swallowing of QLQ-OES18 （OESCH） decreased significantly （ P 〈 0. 05 ）. At 3 months after stent placement, the scores of FI increased significantly （ P 〈 0. 05 ） , and those of nausea or vomiting （NV） , OESDYS, OESEAT, OESSV and OESCH decreased significantly （ P 〈 0.05 ）. The scores of FI,OESDYS, OESCH, role functioning（RF）, EF, CF, FA and OESPA at 3 months were significantly different from those at 1 week after the procedure （P 〈 0. 05 ）. Other variables at 1 week and 3 months after the pro- cedure were not different from those before （P 〉 0. 05 ）. Conclusion Implantation of ^125I seeds combined with esophageal intraluminal stents may prolong survival time and improve QOL of patients with advanced esophageal cancer. Key words: Quality of life; Advanced esophageal cancer; Esophageal stent; Intraluminal irradiation

Endobronchial metallic clips to guide high-dose external-beam radiotherapy in radio-occult lung cancer

To the Editors: As a result of the increased sensitivity of videobronchoscopy (including narrow-band and video autofluorescence imaging) and a specific interest in surveillance of pre-invasive lesions, an increase in diagnosis of radiographically occult lung carcinoma (ROLC) can be anticipated. Described for the first time in the late 1970s by Martini and Melamed 1 and in the early 1980s by Cortese et al. 2, surgery still remains the treatment of choice for ROLC 3. However, patients can be functionally inoperable due to comorbidity, advanced age, multiple primary lesions or irresectable, centrally localised tumours, or because they refuse surgery 2. Therefore, varieties of endoscopic techniques, such as photodynamic therapy, cryotherapy, laser therapy, electrocautery and brachytherapy, were developed as alternatives to surgery 3–5. The combination of high-dose external-beam radiotherapy (EBRT) with intraluminal radiotherapy (IR) using low 6–8, middle 9 and high dose-rate 10 iridium-192, has been investigated in ROLC with promising results. EBRT has obvious advantages to surgery, as it is less invasive and better tolerated by the patient. A major issue is, however, the localisation of the tumour for the guidance of EBRT, since these tumours are radiologically occult. Previously, in those studies combining EBRT with IR 6–10 …

Brachytherapy for Palliaton of Malignant Disease

Brachytherapy (intraluminal radiotherapy) has been in use for more than two decades as a boost after external beam radiation for the definite treatment of esophageal carcinoma. Recent studies have shown that brachytherapy as a sole treatment is an effective therapy for the palliation of dysphagia caused by inoperable esophageal carcinoma. In comparison to stent placement, which is currently the most widely used palliative treatment for esophageal cancer, single-dose brachytherapy has been shown to be a more effective but also safer treatment option for palliation of dysphagia. A broader use of brachytherapy for the palliative treatment of dysphagia from esophageal cancer, particularly in younger and female patients that have a shorter tumor length, no metastases, and a good performance score, is therefore warranted. New developments include the use of fractionated doses of brachytherapy and the use of stents that have a radioactive source included.

Long-term Observation of 64 Patients with Roentgenographically Occult Lung Cancer Treated with External Irradiation and Intraluminal Irradiation Using Low-dose-rate Iridium

Therapeutic results of intraluminal irradiation were analyzed in 64 patients with roentgenographically occult lung cancer (ROLC). The subjects were 64 patients who underwent intraluminal irradiation between 1987 and 2003. Radiotherapy was performed by combining external irradiation with intraluminal irradiation using low-dose-rate iridium (four 370-MBq wires) through a catheter with a spacer. The doses of radiation were 0-70 Gy (median value 46 Gy) by external irradiation and 10-60 Gy (median value 29.3 Gy) by intraluminal irradiation. The therapeutic effect was CR in 63 patients and PR in 1 patient, and local recurrence was observed in a PR case and in seven of the 63 patients who showed CR. The 5-year overall and relapse-free survival rates were 56 (95% CI, 43-69%) and 55% (95% CI, 43-68%), respectively. Fatal pulmonary hemorrhage was observed in one case. Considering the facts that ROLC often occurs as multiple cancers and that many patients with ROLC have reduced lung function, radiation therapy by a combination of intraluminal and external irradiation may replace surgery as the first choice for the treatment of this disease.

A randomised trial of external beam radiotherapy (EBRT)+/− intraluminal radiotherapy (ILT) in symptomatic NSCLC patients: quality of life and palliation of symptoms

A randomised trial of external beam radiotherapy (EBRT)+/− intraluminal radiotherapy (ILT) in symptomatic NSCLC patients: quality of life and palliation of symptoms

Second Line Palliative Endobronchial Radiotherapy with HDR Ir 192 in Recurrent Lung Carcinoma

PurposeTo observe the efficiency of reirradiation with high dose rate intraluminal brachytherapy in symptomatic palliation of recurrent endobronchial tumors.Materials and MethodsBetween January 1994 and June 1998, 21 patients diagnosed with recurrent endobronchial tumors following external beam radiotherapy were treated palliatively with high dose rate intraluminal irradiation at Hacettepe University Oncology Institute. A single fraction of 10 Gy was prescribed to the specified area in 9 patients and 15 Gy to 12.ResultsEndobronchial treatment improved the performance and reduced symptomatology in 17 (81%) patients. Ten dyspneic patients (10/14, 71%) recovered clinically with an accompanying radiological downstaging. The median symptomatic palliation was 45 days (range, 0 - 9 months), and the overall median survival was 5.5 months (range, 4 - 12 months). The palliative intrabronchial brachytherapy was well tolerated, with the exception of in one patient with a fatal hemorrhage, and another with medically salvaged bronchospasm and intrabronchial edema.ConclusionRecurrent patients with a history of previous thoracic external beam irradiation can be effectively palliated with high dose rate endobronchial reirradiation if the symptoms are directly related to the endobronchial tumor.