Combined external and intraluminal radiotherapy in the treatment of advanced oesophageal cancer Kimmo Hujala a , Jukka Sipila ¨ b , Heikki Minn c , Pertti Ruotsalainen d , Reidar Grenman b, * a Department of Otorhinolaryngology, North Karelia Central Hospital, Joensuu, Finland b Department of Otorhinolaryngology – Head and Neck Surgery, Turku University Central Hospital, P.O. Box 52, FIN-20521 Turku, Finland c Turku PET Centre, Turku University Central Hospital, Turku, Finland d Department of Oncology and Radiotherapy, Turku University Central Hospital, Turku, Finland Received 24 August 2001; received in revised form 25 April 2002; accepted 10 June 2002 Abstract Background and purpose: Oesophageal cancer still has a dismal prognosis. Radical surgery is by far the most successful treatment but most patients are not operable at the time of diagnosis and for these patients external beam radiotherapy with or without concurrent chemotherapy offers the best choice for cure or palliation. In patients with advanced oesophageal cancer, intraluminal brachytherapy has been proposed as a complementary method to increase local control. Patients and methods: Between 1989 and 1999, 40 patients with inoperable oesophageal cancer were treated with combined external and intraluminal radiation therapy in Turku University Central Hospital. The external radiation was performed with a median total dose of 40 Gy given in 20 fractions. On the average a week after the external radiation a median total dose of 10 Gy intraluminal radiation therapy was given in 4 fractions. Results: The intraluminal brachytherapy could be performed without technical difficulties and no major complications were seen. In many cases (16 out of 40 patients, 40%), the symptoms could be relieved immediately and in most cases the progression of the disease could be delayed as evidenced by post-treatment serial endoscopy. No major complications were encountered. The 1- and 2-year survival rates were 30 and 17.5%, respectively. All patients alive at 2 years can be considered as long-term survivors. Median follow-up was 86 months. Conclusions: Intraluminal brachytherapy is a safe and efficient treatment modality which offers a potential means of cure for selected patients with oesophageal cancer. q 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Esophageal cancer; External beam radiotherapy; Intraluminal brachytherapy 1. Introduction Advanced oesophageal cancer is a disease with a very high mortality. Traditionally, the only curative means of treatment has been radical surgery. However, at most 30– 40% of the patients are operable at the time of diagnosis [2,16]. For others, multimodal treatment consisting of neoadjuvant or concurrent chemotherapy and radiotherapy possibly followed by surgery may offer the best chance for permanent local control [7]. External radiotherapy without chemotherapy has, however, been the primary method of controlling oesophageal cancer in many centres. The side- effects, such as radiation oesophagitis and pneumonitis [2], and the radiosensitivity of the adjacent spinal cord limit the total dose of radiation, thus compromising the efficacy of this therapy [5]. The 3- and 5-year survival achieved by use of external radiotherapy only was 27 and 21%, respectively, in a study conducted by Sykes et al. [15]. Often the aim of the treatment remains palliative concen- trating on decrease of the tumour mass and on maintaining the swallowing capability. This can be accomplished by use of external and/or intraluminar radiation therapy together with oesophageal stenting, dilatation, and laser procedures. The laser procedures are shown to be very beneficial in maintaining the swallowing capability in the short term. The disadvantage of this treatment modality is the need for frequent procedures because of the continuous growth of the primary tumour [11,13]. Stents have also been shown to have a beneficial impact on the swallowing function [14]. They are used, e.g., after other treatments, in order to prevent stricture formation. Obstruction after stenting is, however, relatively common, and this can be caused by migration of the stent, blockage by food bolus, tumour over- growth or by benign obstruction with granulation tissue, Radiotherapy and Oncology 64 (2002) 41–45 0167-8140/02/$ - see front matter q 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S0167-8140(02)00149-4 www.elsevier.com/locate/radonline * Corresponding author.