SMART-boost technique in future. 461
Combined external beam and low dose rate intracavitary radiotherapy for carcinoma of the esophagus IV. Ramanarasiah Tulas[, V. Nagarajan, M. Nagarajan, P. Gnanaprakasam, S. Rajeswari G.Kuppuswamy Naidu Memorial Hospital, VN Cancer Centre, Coimbatore, India Esophageal cancer accounts for about 7% of all cancers registered at VN Cancer Centre, G.Kuppuswamy Naidu Memorial Hospital, Coimbatore. Inspite of the advances made in the fields of Surgery, Radiation therapy and Chemotherapy, the outlook for this disease continues to be grim. Moreover, optimal Surgical or Radiation techniques are not well defined. This paper is a review of 157 cases treated between Feb 1989 and Dec 1998 with External Radiation therapy and Low dose rate Brachytherapy. The one year disease free survival was about 40%. The longest disease free survival was 4 years. These results are compared with results of Surgical treatment methods in literature. As the disease has a grim out come with any modality of treatment, organ preserving and less invasive treatment methods may be better to palliate the patient and provide better quality of life. 462
A randomized study of preoperative concentrated irradiation combined with surgery in esophageal carcinoma G. Ma, D. Zhou, X. Gao, Y. Ping, L. Zuo, J.-Wan The 4th Hospita of Hebei Medical University, Radiation Oncology, Shijiazhuang, China Introduction: Esophageal carcinoma, with high incidence rate in China, has poor prognosis and rapid clinical progression. The most doctors applied preoperative conventional irradiation 30-40Gy/3-4weeks, with an interval of 2-4 weeks, and then made the radical operations. In our study, preoperative concentrated irradiation 25Gy/5F/5-7days and surgery within 2 weeks were done. This report appreciates the effect and applying value of preoperative concentrated irradiation from clinic, pathology, DNA content and p53 protein expression. Methods: From Oct.1994 to Oct.1995, a prospective randomized clinical trial was carried, out in 62 patients with esophageal carcinoma in the thoracic middle third segment. The tumor lengths were from 4cm to 7cm in xray films. 31 cases were given preoperative irradiation 25Gy/5F/5-7days and surgery within 2 weeks after radiation, while the other 31 cases were given surgery alone. Tumor lengths, DNA contents and p53 protein expressions by Flow Cytometry(FCM) were measured in pre-and post irradiation. Normal esophagus and operative carcinoma were also observed as controls. Results: 1. Tumor lengths(M-SD) in surgery alone were 5.23-0.97cm preoperatively and 5.00-0.88cm postoperatively, respectively (P>0.20). In composite treatment group, they were 5.25-0.97cm in pre -irradiation, 4.33-1.30cm in post-irradiation and 3.87-1.07cm in post operation, respectively (P<0.01). 2. The values (M-SD) of DNA index were 1. 31-0.24 in spree-irradiation and 1.16-0.21 in post-irradiation, respectively (P<0.001). S-phase fractions (SPF) were 16.18-5.68% in pre-irradiation and 11.985.19% in post-irradiation, respectively(P<0.005). 3. The values (M-SD) of fluorescence indexes were 1.69-0.32 in pre-irradiation and 1.t8-0.17 in post-irradiation, respectively (P<0.001). Conclusions: 1. Preoperative concentrated irradiation could be able to reduce tumor bulk.. 2. The high values of DI, SPF and FI are closely correlated with high proliferate activity and high-grade malignancy. Preoperative concentrated irradiation could be able to reduce DNA content, S-phase fractions and p53 protein expression in esophageal carcinoma, and would be able to reduce proliferate activity. 3. The pre-operative concentrated irradiation combined with surgery in the treatment of esophageal carcinoma had a good curative effect in short term. As for long-term survival rate, all patients need to be followed up further. 463
The results of combined external irradiation and low-dose rate intralurninal brachytherapy for esophageal cancer, M. Someva 1, A. Saito2, H. Nagakura 1, A. Oouchi 1, K. Sakata 1, M. Hareyama 1 1Sapporo Madical University, School of Medicine, Department of Radiology, Sapporo, Japan 2National Hakodate Hospital, Department of Radiology, Hakodate, Japan Purpose: We examined the results of combined external irradiation and low-dose rate intraluminal brachytherapy for esophageal cancer.
Methods: Since 1979 to 1998, previously untreated 100 patients (82 males and 18 females) were treated with externat irradiation combined with 137Cs intraluminal brachytherapy in National Hakodate Hospital. The age of patients ranged from 48 to 88 with an average of 69.9 years. Ninety two patients were histologically confirmed (squamous cell carcinoma:90, adenocarcinoma:l, adenosquamous carcinoma:l) and the others were not. The distribution of patients according to the classification of the Japanese Society for Esophageal Disease was as follows; sites (Ce:4, Ut:16, Mt:58, Lt:21, Ae:l), the esophagographic and esophagoscopic findings (superficial type:23, advanced type:77), and tumor lengths (less than 5cm:46, more than 5.1cm:54). No patients had distant metastases. The dose of external irradiation was 50-65Gy/25-32 fractions and brachytherapy of 1024Gy/2-3 fractions at mucosal surface of esophagus was added. Results: Five-year actuarial survival rate of all cases was 12.2 % and 5year cause specific survival was 27.8 %. Five-year cause specific survival of the superficial type was 62.6 %, and that of the advanced type was 16.9 %. The difference was statistically significant (P<0.01). Seventy of 100 cases had complete response, 2-year and 5-year local relapse-free survival in CR cases were 52.5 % and 33.9 %, respectively. In 87 cases whose follow-up period were more than 2 years, the cases whose tumor length is less than 5cm and dose of brachytherapy is more than 20Gy had better local contorl rate compared to other groups. No correlation between the dose of external irradiation and local control rate was observed. One died of radiation pneumonitis. However, severe late complication such as esophageal ulcer or perforation were not seen. Conclusions: There were significant differences of cause specific survival rates between the superficial type and the advanced type of esophageal cancer. The addition of 20-24Gy with brachytherapy after external irradiation appeared to improve local control of better local control of esophageal cancer. 464
Late esophagealtoxicity with combination of external beam radiation, intraluminal brachytherapy and 5-fluorouracil infusion in carcinoma esophagus v. Sharma J.P. Agarwal, K.A. Dinshaw, R.M. Nehru, K.M. Mohandas, R. Deshpande, S. Bhattanwar Department of Radiotherapy, Tata Memorial Hospital, Parel, MumbaL India Purpose: to determine the late toxicity and optimization of dose of intraluminal radiation. Methods: one hundred patients with potentially curable carcinoma of esophagus were treated with external beam radiation to a dose of 50 Gy/28 frs./5.5 weeks followed by intraluminal brachytherapy (ILBT) with 5fluorouracil infusion from 1990 to 1993. The external radiation dose was 50 Gy/28 frs./5.5 weeks and the Intraluminal Brachytherapy dose was 20 Gy and 15 Gy for Group 1 and Group 2 of 50 patients each. Results: the treatment related complications were strictures 24% versus 8% (p=0.029), ulceration 30% versus 28% (p=0.8) and tracheoesophageal fistulae 12% each among group 1 and group 2 respectively. The overall survival for group 1 and group 2 was 8% and 23% at 5 years (p=0.02). Conclusions: the results of addition of 5-fluorouracil with brachytherapy are encouraging. However, the development of life threatening complications is a major concern and extreme caution is urged to select patients for combination of Intraluminal Brachytherapy and 5-Fluorouracil infusion treatment. 465
The role of HDR intraluminal brachytherapy in the curative treatment of carcinoma esophagus. N. Patni1, V. Sharma2 K.A. Dinshaw2 1Bhagwan Mahaveer Cancer Hospital & Research Centre, Radiation Oncology, Jaipur, India 2Tata Memorial Hospital, Radiation Oncology, Mumbai, India Purpose: To evaluate the rote of HDR ILRT in improving swallowing and quality of life, survival and treatment related morbidity. Methods: HDR ILRT was performed in 36 patients of carcinoma esophagus from 1995 to 1997 at Tata Memorial Hospital. Patients' characterstics 26 male, 10 female, mean age 63.8 years, lesion less than 10 cms. with no extra esophageal or locoregional spread. Patients were treated with curative intent with 5040 cGy/28 fractions/5.5 weeks followed by HDR ILRT 12Gy/2 fractions/once weekly. Results: The useful swallowing was improved from 50% in pretreatment to 92% in 6 weeks post treatment patients, maintained in 43% for one year after treatment. Mean and median survival was 12.6 months and 9 months respectively. 21% developed complications like strictures and tracheeesophageal fistulae. 50% patients had treatment failures of which 28% were