Journal of Radiotherapy in Practice cambridge.org/jrp Literature Review Cite this article: Kulshrestha R, Gupta A, Sharma DN, and Singh K. (2021) Brachytherapy for Oesophageal Carcinoma: A Comprehensive Review of Literature and Techniques. Journal of Radiotherapy in Practice page 1 of 10. doi: 10.1017/S1460396920001120 Received: 11 October 2020 Revised: 19 November 2020 Accepted: 24 November 2020 Key words: brachytherapy applicators; oesophageal cancer; intraluminal radiation therapy (ILRT); intraoperative brachytherapy; seed brachytherapy Author for correspondence: Anil Gupta, Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, Delhi, 110029, India. E-mail: anilgupta87@outlook.com © The Author(s), 2021. Published by Cambridge University Press. Brachytherapy for Oesophageal Carcinoma: A Comprehensive Review of Literature and Techniques Rashi Kulshrestha 1 , Anil Gupta 2 , Daya Nand Sharma 2 and Kishore Singh 3 1 Radiation Oncology, BC Cancer Agency, Abbotsford, British Columbia, BC V2S 0C2, Canada; 2 Radiation Oncology, All India Institute of Medical Sciences, New Delhi, Delhi, 110029, India and 3 Radiation Oncology, Maulana Azad Medical College, New Delhi, Delhi, 110002, India Abstract Introduction: 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 regi- men 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 brachy- therapy is also emerging as a promising option in nodal recurrences. Introduction Carcinoma oesophagus is the seventh most common cancer worldwide with more than 50,000 new cases in 2018. 1 Also, it is the sixth most common cause of cancer-related deaths. Two major histological subtypes are oesophageal adenocarcinoma and oesophageal squamous cell carci- noma. Environmental and genetic factors play a major role in the causation of oesophageal cancer. Squamous cell histology is the predominant subtype in China, while adenocarcinoma is more common in North America and Europe. 2 Treatment of carcinoma oesophagus requires a multimodality approach which includes sur- gery, radiotherapy (RT) and chemotherapy. RT is an important treatment modality in carci- noma oesophagus in various settings. It is used as external beam radiotherapy (EBRT) or brachytherapy or both. Despite the inherent radio sensitivity of oesophageal tumours, curative doses are difficult to achieve because of close proximity of the target to vital organs. By exploiting the inverse-square law resulting in rapid dose fall-off, brachytherapy becomes an effective means of delivering high dose to tumour while delivering much lower doses to sur- rounding organs at risk (OARs) such as the lung, heart and spinal cord. High-dose rate (HDR) technique allows treatment to be delivered in 5 to 10 minutes by an afterloading catheter intro- duced through the nose into the primary tumour site under fluoroscopic guidance. It requires expertise to perform oesophageal brachytherapy. Fear of perforation of the oeso- phageal wall during dilation and the requirement of special infrastructure make it a less used modality for treatment in oesophageal cancers. Considering the good results obtained by bra- chytherapy in sites such as cervix, breast, rectum, head and neck, it has been tried in oesophageal carcinoma in different settings, such as curative, palliative and adjuvant. More sophisticated technology has allowed us to tailor the treatment as per requirement. Different modes of brachytherapy used in carcinoma oesophagus are intraluminal, seed brachytherapy and intraoperative. Both seed and intraoperative brachytherapy are lesser used modes of brachytherapy and has not been reviewed. There has been recent advancement in applicators which addresses the shortcoming of previous applicators. This paper comprehensively https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1460396920001120 Downloaded from https://www.cambridge.org/core. IP address: 122.177.126.196, on 19 Jan 2021 at 15:57:38, subject to the Cambridge Core terms of use, available at