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Ryu DG, Yu F, Liu H, Lee SS, Lee SL. Clinical Outcomes and Prognosis of Esophageal Squamous Cell Carcinoma Presenting with Obstruction. J Gastrointest Cancer 2024; 56:35. [PMID: 39702624 DOI: 10.1007/s12029-024-01159-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2024] [Indexed: 12/21/2024]
Abstract
BACKGROUND The prognosis of esophageal squamous cell carcinoma (ESCC) with obstruction is unclear. This study aimed to analyze clinical outcomes and prognosis of patients with ESCC and obstruction. METHODS Patients with advanced ESCC were included and divided into obstructive and non-obstructive groups. Clinical outcomes and survival according to treatment were compared between these groups. RESULTS Among 353 patients with advanced ESCC, obstruction was present in 105 (29.7%). ESCC with obstruction was more common in the upper thoracic location (23.8% vs. 14.5%, p = 0.036) and had a higher stage (7.6% vs. 32.7%, p < 0.001 in stage 2; 41.0% vs. 24.2%, p = 0.002 in stage 4) than those without obstruction. The median survival time of patients with obstruction was significantly shorter than that of patients without obstruction (7.6 months vs. 20.2 months, p < 0.001). Patients with obstruction had a significantly lower survival rate regardless of treatment. When surgery was performed first on patients with obstruction, the R0 resection rate was significantly lower (33.3% vs. 88.5%, p < 0.001). For patients with obstruction in resectable stages, surgery after neoadjuvant chemoradiotherapy resulted in the best survival (HR: 0.48; 95% CI: 0.15 - 1.49; p = 0.201). When only chemoradiotherapy was performed in resectable stages, clinically complete response rate was significantly lower (35.3% vs. 64.9%, p = 0.035) in the obstructive group. CONCLUSION ESCC with obstruction was at a more advanced stage and had a poor prognosis regardless of treatment. Surgery first or chemoradiotherapy alone is not recommended for these patients. Neoadjuvant chemoradiotherapy prior to surgical resection is recommended for those with ESCC and obstruction at resectable stages.
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Affiliation(s)
- Dae Gon Ryu
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Fengxue Yu
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hongqun Liu
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Samuel S Lee
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Sangjune Laurence Lee
- Division of Radiation Oncology, University of Calgary, Tom Baker Cancer Centre, 1331 29 Street NW, Calgary, AB, T2N 4N2, Canada.
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Schulz D, Koob I, Pickhard A, Schmid RM, Abdelhafez M. Risk factors for total laryngectomy associated proximal esophageal stricture formation in head and neck cancer patients. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:193-198. [PMID: 37758037 DOI: 10.1055/a-2150-2689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
BACKGROUND Development of esophageal strictures is common after the total laryngectomy of head and neck cancer patients. While endoscopic techniques like dilatation by balloon or Salvary bougies are well established, risk factors and pathophysiology for development of refractory strictures are less well understood. OBJECTIVE To evaluate risk factors associated with occurrence and recurrence of total-laryngectomy-associated esophageal strictures in head and neck cancer patients. METHODS We analyzed retrospectively a cohort of 170 head and neck squamous cell carcinoma patients, who underwent total laryngectomy between 2007 and 2017. The outcome measure was laryngectomy-associated proximal esophageal stricture needing an endoscopic dilatation by using a balloon or Savary dilators. RESULTS Of the 170 patients in the cohort, 32 (18.8%) developed strictures. Mean time between surgery and first endoscopic intervention was 24.4 months. Significant predictive factors were age ≥ 65 (p=0.017), nodal status N> 1 (p=0.003), continued alcohol abuse after surgery (p=0.005) and diabetes mellitus (p=0.005). In a subgroup, 17 of 32 patients developed refractory strictures and needed more than three dilatations to relieve dysphagia. Postoperative mean (p=0.016) and maximum (p=0.015) C-reactive protein (CRP) were predictive for refractory strictures. CONCLUSION Symptomatic strictures occurred in 18.8% of the cases. Age, nodal status N>1, continued alcohol abuse and diabetes mellitus were predictive factors. For refractory stenosis (>3 dilatations needed) mean and maximum postoperative CRP were predictive. This may indicate that systemic inflammatory response post-surgery is involved in the stricture formation process.
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Affiliation(s)
- Dominik Schulz
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Isabelle Koob
- Department of Head and Neck Surgery, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Anja Pickhard
- Department of Head and Neck Surgery, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Roland M Schmid
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Mohamed Abdelhafez
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
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Effects of Microbeam Irradiation on Rodent Esophageal Smooth Muscle Contraction. Cells 2022; 12:cells12010176. [PMID: 36611969 PMCID: PMC9818134 DOI: 10.3390/cells12010176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/14/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND High-dose-rate radiotherapy has shown promising results with respect to normal tissue preservation. We developed an ex vivo model to study the physiological effects of experimental radiotherapy in the rodent esophageal smooth muscle. METHODS We assessed the physiological parameters of the esophageal function in ex vivo preparations of the proximal, middle, and distal segments in the organ bath. High-dose-rate synchrotron irradiation was conducted using both the microbeam irradiation (MBI) technique with peak doses greater than 200 Gy and broadbeam irradiation (BBI) with doses ranging between 3.5-4 Gy. RESULTS Neither MBI nor BBI affected the function of the contractile apparatus. While peak latency and maximal force change were not affected in the BBI group, and no changes were seen in the proximal esophagus segments after MBI, a significant increase in peak latency and a decrease in maximal force change was observed in the middle and distal esophageal segments. CONCLUSION No severe changes in physiological parameters of esophageal contraction were determined after high-dose-rate radiotherapy in our model, but our results indicate a delayed esophageal function. From the clinical perspective, the observed increase in peak latency and decreased maximal force change may indicate delayed esophageal transit.
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An D, Cao Q, Su N, Li W, Li Z, Liu Y, Zhang Y, Li B. Response Prediction to Concurrent Chemoradiotherapy in Esophageal Squamous Cell Carcinoma Using Delta-Radiomics Based on Sequential Whole-Tumor ADC Map. Front Oncol 2022; 12:787489. [PMID: 35392222 PMCID: PMC8982070 DOI: 10.3389/fonc.2022.787489] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/21/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose The purpose of this study was to investigate the association between the radiomics features (RFs) extracted from a whole-tumor ADC map during the early treatment course and response to concurrent chemoradiotherapy (cCRT) in patients with esophageal squamous cell carcinoma (ESCC). Methods Patients with ESCC who received concurrent chemoradiotherapy were enrolled in two hospitals. Whole-tumor ADC values and RFs were extracted from sequential ADC maps before treatment, after the 5th radiation, and after the 10th radiation, and the changes of ADC values and RFs were calculated as the relative difference between different time points. RFs were selected and further imported to a support vector machine classifier for building a radiomics signature. Radiomics signatures were obtained from both RFs extracted from pretreatment images and three sets of delta-RFs. Prediction models for different responders based on clinical characteristics and radiomics signatures were built up with logistic regression. Results Patients (n=76) from hospital 1 were randomly assigned to training (n=53) and internal testing set (n=23) in a ratio of 7 to 3. In addition, to further test the performance of the model, data from another institute (n=17) were assigned to the external testing set. Neither ADC values nor delta-ADC values were correlated with treatment response in the three sets. It showed a predictive effect to treatment response that the AUC values of the radiomics signature built from delta-RFs over the first 2 weeks were 0.824, 0.744, and 0.742 in the training, the internal testing, and the external testing set, respectively. Compared with the evaluated response, the performance of response prediction in the internal testing set was acceptable (p = 0.048). Conclusions The ADC map-based delta-RFs during the early course of treatment were effective to predict the response to cCRT in patients with ESCC.
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Affiliation(s)
- Dianzheng An
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong University, Jinan, China
| | - Qiang Cao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Na Su
- Department of Radiology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Wanhu Li
- Department of Radiology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Zhe Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Yanxiao Liu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Yuxing Zhang
- Department of Imaging, Anyang Tumor Hospital, The Fourth Affiliated Hospital of Henan University of Science and Technology, Anyang, China
| | - Baosheng Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
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Debi U, Sharma M, Singh L, Sinha A. Barium esophagogram in various esophageal diseases: A pictorial essay. Indian J Radiol Imaging 2021; 29:141-154. [PMID: 31367085 PMCID: PMC6639862 DOI: 10.4103/ijri.ijri_465_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Recent years have seen a decline in number of barium procedures due to wider availability of cross sectional imaging modalities. Though use of barium esophagography/barium swallow has decreased in day to day clinical practice, it still remains a valuable test for structural and functional evaluation of esophagus. It can be performed as single or double contrast examination or as a multiphasic examination comprising upright double contrast views followed by prone single contrast views. This pictorial essay demonstrates imaging features of various esophageal diseases on barium esophagogram.
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Affiliation(s)
- Uma Debi
- Department of Radiodiagnosis and Imaging, PGIMER Chandigarh, India
| | - Madhurima Sharma
- Department of Radiodiagnosis and Imaging, PGIMER Chandigarh, India
| | - Lokesh Singh
- Department of Radiodiagnosis and Imaging, PGIMER Chandigarh, India
| | - Anindita Sinha
- Department of Radiodiagnosis and Imaging, PGIMER Chandigarh, India
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Vitton V, Andrianjafy C, Luciano L, Gonzalez JM, Padovani L. Radio-induced esophageal motility disorders: An unrecognized diagnosis. Cancer Radiother 2021; 25:249-253. [PMID: 33454192 DOI: 10.1016/j.canrad.2020.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Esophageal motility disorders (EMD) after cervical or thoracic radiation therapy (RT) may represent a late impairment and appear under-diagnosed. This study aimed to assess the prevalence of EMD, diagnosed by high-resolution esophageal manometry (HREM) after cervical or thoracic RT. In this retrospective, single-centre study, all patients whom received cervical or thoracic RT and underwent HREM were eligible. MATERIAL AND METHODS Oncologic data were collected: site of neoplasia, type of cancer, oncologic management (surgery and chemotherapy). EMD were classified according to the new Chicago Classification. RESULTS Twenty patients (14 females), of mean age 62.33±11.14 years were included. Breast cancer was the most represented indication for RT (40%). Other cancers were lung tumor, head and neck tumors and Hogdkin's lymphoma. Dysphagia was the most frequent symptom justifying HREM (70%). Patients received a mean of 51±19.27 Gy, 70% of them (14/20) had radiation therapy concomitantly with chemotherapy. The delay between last radiation therapy session and HERM was 10.68±12.42 years. Twelve (60%) patients had an abnormal pattern at on HERM. Among them, 3 patients (15%) presented with a major motility disorder. The most frequent motility disorder was ineffective esophageal motility in 8 (40%) patients, 1 (5%) patient presented with type II achalasia. CONCLUSION EMD should be suspected in patients with a history of cervical or thoracic RT in case of upper GI symptoms with normal endoscopy. In these particular patients, a manometric diagnosis that can explain their symptoms is of particular importance to limit anxiety linked to unexplained troubles.
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Affiliation(s)
- V Vitton
- Service de gastrœntérologie, hôpital Nord, Assistance publique-Hôpitaux de Marseille, Aix-Marseille université, Chemin des Bourrelys, Marseille , France
| | - C Andrianjafy
- Service de gastrœntérologie, hôpital Nord, Assistance publique-Hôpitaux de Marseille, Aix-Marseille université, Chemin des Bourrelys, Marseille , France
| | - L Luciano
- Gastroenterology unit, French military hospital Laveran, Marseille, France.
| | - J-M Gonzalez
- Service de gastrœntérologie, hôpital Nord, Assistance publique-Hôpitaux de Marseille, Aix-Marseille université, Chemin des Bourrelys, Marseille , France
| | - L Padovani
- Service de radiothérapie, hôpital Nord, Assistance publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin des Bourrelys, Marseille , France
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Kamat R, Gupta P, Reddy YR, Kochhar S, Nagi B, Kochhar R. Corrosive injuries of the upper gastrointestinal tract: A pictorial review of the imaging features. Indian J Radiol Imaging 2019; 29:6-13. [PMID: 31000935 PMCID: PMC6467036 DOI: 10.4103/ijri.ijri_349_18] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Corrosive ingestion is a common form of poisoning. Corrosive agents cause severe damage to the gastrointestinal (GI) tract. The most severe forms of injury can lead to mortality; however, the major concern with this type of injury is life-long morbidity. Upper GI endoscopy is the test of choice for assessing severity in the acute phase of the disease. The long-term management is based on the site, length, number, location, and tightness of the stricture. This information is best provided by the barium contrast studies. In this pictorial review, a spectrum of findings in patients with corrosive injuries of the esophagus and stomach is illustrated. The role of various imaging modalities including barium studies, endoscopic ultrasound, computed tomography, and magnetic resonance imaging is discussed.
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Affiliation(s)
- Rohan Kamat
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Imaging and Research (PGIMER), Chandigarh, India
| | - Pankaj Gupta
- Department of Gastroenterology, Postgraduate Institute of Medical Imaging and Research (PGIMER), Chandigarh, India
| | - Yalaka Rami Reddy
- Department of Gastroenterology, Postgraduate Institute of Medical Imaging and Research (PGIMER), Chandigarh, India
| | - Suman Kochhar
- Department of Radiodiagnosis and Imaging, GMCH, Chandigarh, India
| | - Birinder Nagi
- Department of Gastroenterology, Postgraduate Institute of Medical Imaging and Research (PGIMER), Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Imaging and Research (PGIMER), Chandigarh, India
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Agarwal V, Logie N, Morris CG, Bradley JA, Rotondo RL, Bradfield SM, Indelicato DJ. Esophagitis associated with multimodality management of pediatric Ewing sarcoma of thorax. Pediatr Blood Cancer 2018; 65:e27006. [PMID: 29431250 DOI: 10.1002/pbc.27006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 01/05/2018] [Accepted: 01/18/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Ewing sarcoma of the thoracic spine and chest wall is frequently treated with concurrent chemotherapy and radiation therapy (RT). Treatment-related acute esophagitis can lead to hospitalization and treatment delays. The aim of this study was to analyze the incidence, risk factors, and management of esophagitis in pediatric patients with Ewing sarcoma of the thoracic region. METHODS We conducted a single-institution retrospective review of patients treated over a 10-year period. Medical records were reviewed for patient and treatment characteristics associated with Common Terminology Criteria for Adverse Events grade 2 or higher esophagitis. RT plans were also reviewed and various esophageal dose metrics were analyzed. RESULTS Twelve of 37 patients (32%) developed acute esophagitis. Neutropenia was associated with an increased risk of esophagitis (60% vs. 14%; P < 0.01). RT significantly contributed to its incidence when maximum esophageal dose was >47 Gy (69% vs. 5%; P < 0.0001) and esophageal D5cm3 was >15 Gy (67% vs. 9%; P < 0.001). All 12 patients with esophagitis were managed with oral opioid analgesics. Nine patients with persistent symptoms received subsequent fluconazole for empiric fungal treatment and each had a decreased need for opioid analgesics within 2-5 days. CONCLUSION Approximately one-third of patients with Ewing sarcoma of the thoracic region will develop acute esophagitis. An esophageal D5cm3 dose < 15 Gy and maximal esophageal dose < 47 Gy may keep the rate of acute esophagitis under 5%. However, the association with neutropenia and consistent response to antifungal therapy suggest chemotherapy-associated toxicity and an infectious component as part of the process.
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Affiliation(s)
- Vibhuti Agarwal
- Division of Hematology/Oncology, Nemours Children's Specialty Care, Jacksonville, Florida
| | - Natalie Logie
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Scott M Bradfield
- Division of Hematology/Oncology, Nemours Children's Specialty Care, Jacksonville, Florida
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
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Geng L, Wu R, Hu H, Zhao Y, Fan L, Zhao Z, Liao D, Li M, Xiang M, Ma Y, Du X. Clinical application of oral meglumine diatrizoate esophagogram in screening esophageal fistula during radiotherapy for esophageal cancer. Medicine (Baltimore) 2018; 97:e0668. [PMID: 29718892 PMCID: PMC6393137 DOI: 10.1097/md.0000000000010668] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Esophageal fistula is a serious and common complication of radiotherapy for esophageal cancer. Therefore, early diagnosis and treatment is necessary. Because of side effect of barium esophagography, it cannot be used to screening esophageal fistula during radiotherapy. Meglumine diatrizoate is an ionic contrast agent, its adverse reactions were rarely seen when it was used in the body cavity. The purpose of this trial is identified the sensitivity and specificity of oral meglumine diatrizoate in an esophagogram for screening esophageal fistula during radiotherapy. METHODS/DESIGN This trial was a prospective, multicenter, diagnostic clinical trial. A total of 105 patients with esophageal cancer will swallowed meglumine diatrizoate and underwent a radiographic examination weekly during radiotherapy, medical personnel observed the esophageal lesions to determine whether an esophageal fistula formed. If an esophageal fistula was observed, esophagofiberoscopy and/or computer tomography was used to further confirm the diagnosis. And the sensitivity and specificity of meglumine diatrizoate should be calculated for screening esophageal fistula during radiotherapy. DISCUSSION To our knowledge, this study protocol is the first to identify the sensitivity and specificity of oral meglumine diatrizoate in an esophagogram for screening esophageal fistula during radiotherapy. If oral meglumine diatrizoate can be used to screening esophageal fistula, more patients will benefit from early detection and treatment.
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Affiliation(s)
- Lidan Geng
- Department of Oncology, Mianyang Central Hospital, Mianyang
- Department of Oncology, Affiliated Hospital of North Sichuan Medical College, Nan Chong
| | - Rong Wu
- Department of Oncology, Mianyang Central Hospital, Mianyang
| | - He Hu
- Department of Oncology, Yan Ting County Cancer Hospital, Yan Ting
| | | | - Lingli Fan
- Department of Oncology, Mianyang Central Hospital, Mianyang
| | - Zhenhua Zhao
- Department of Oncology, Mianyang Central Hospital, Mianyang
| | - Dongbiao Liao
- Department of Oncology, Mianyang Central Hospital, Mianyang
| | | | - Miao Xiang
- Department of Oncology, Mianyang Central Hospital, Mianyang
| | - Ying Ma
- Department of Scientific Research and Education, Mianyang Central Hospital, Mianyang, People's Republic of China
| | - Xiaobo Du
- Department of Oncology, Mianyang Central Hospital, Mianyang
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Rovirosa A, Marsiglia H, Lartigau E, Zimmermann P, Chirat E, Delapierre M, Briot E, Gerbaulet A. Endoluminal High-Dose-Rate Brachytherapy with a Palliative aim in Esophageal Cancer: Preliminary Results at the Institut Gustave Roussy. TUMORI JOURNAL 2018; 81:359-63. [PMID: 8804454 DOI: 10.1177/030089169508100511] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Ten patients with advanced esophageal carcinoma were treated with endoluminal high-dose-rate brachytherapy at the Institut Gustave Roussy. Eight of them had recurrences after external beam radiotherapy. They were treated with a high-dose rate iridium-192 source. Five patients received 6 sessions of 4 Gy, 4 patients 3 sessions of 4 Gy, and 1 patient received 3 sessions of 8 Gy. The interval time between each session was 1 week. Seventy percent of patients improved their dysphagia, with 80% endoscopic tumor response. The Karnofsky index was improved in most of the patients. The mean survival was 4 months, and dysphagiafree survival was 2.5 months. Two patients had treatment toxicity but only a transitory WHO G1 esophagitis. Endoesophageal high-dose-rate curietherapy seems an effective technique in palliative treatments. We found low toxicity and an excellent tolerance to treatment in previously irradiated patients. The efficacy of the treatment is highly dependent on a precise tumor volume evaluation.
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Affiliation(s)
- A Rovirosa
- Servicio De Oncología Radoterápica, Hospital Clinic I Universitari, Barcelona, Spain
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Shields H, Li J, Pelletier S, Wang H, Freedman R, Mamon H, Ng A, Freedman A, Come S, Avigan D, Huberman M, Recht A. Persistence of dysphagia and odynophagia after mediastinal radiation and chemotherapy in patients with lung cancer or lymphoma. Dis Esophagus 2017; 30:1-8. [PMID: 27247116 DOI: 10.1111/dote.12498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal symptoms are common during radiation and chemotherapy. It is unclear how often these symptoms persist after therapy. We retrospectively reviewed medical records of 320 adults treated for nonmetastatic breast cancer (84), lung cancer (109), or Hodgkin and non-Hodgkin lymphoma (127) who were disease-free at 10-14 months after therapy. Treatment included chemotherapy with or without nonmediastinal radiation therapy (150 patients), chemotherapy plus sequential mediastinal radiation therapy (MRT) (48 patients), chemotherapy plus concurrent MRT (61 patients), or non-MRT only (61 patients). Proton pump inhibitor use was documented. All treatment groups had similar prevalence of the esophageal symptom of heartburn before therapy. Rates were higher during treatment in those who received MRT with or without chemotherapy, but declined by 10-14 months after treatment. However, low baseline rates of dysphagia (4%) and odynophagia (2%) increased significantly after combined chemotherapy and MRT to 72% for dysphagia and 62% for odynophagia (P < 0.01) during treatment and stayed significantly elevated over baseline with 27% of the patients having dysphagia and 11% having odynophagia at 10-14 months after treatment. The use of proton pump inhibitors by patients who had MRT with chemotherapy was significantly increased during and after treatment (P = 0.002). Dysphagia, odynophagia and the use of proton pump inhibitors were significantly more common both during and after treatment than before treatment in patients who received both chemotherapy and mediastinal radiation. Our data highlight the important challenge for clinicians of managing patients with lung cancer and lymphoma who have persistent esophageal problems, particularly dysphagia and odynophagia, at approximately 1 year after treatment.
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Affiliation(s)
- Helen Shields
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Justin Li
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Helen Wang
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rachel Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Harvey Mamon
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA, USA
| | - Andrea Ng
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA, USA
| | - Arnold Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Steven Come
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - David Avigan
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mark Huberman
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Abram Recht
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Adams KN, Shah RN, Buckmire RA. Stricture location predicts swallowing outcomes following endoscopic rendezvous procedures. Laryngoscope 2016; 127:1388-1391. [DOI: 10.1002/lary.26330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2016] [Indexed: 12/28/2022]
Affiliation(s)
- Katherine N. Adams
- University of North Carolina Medical School; University of North Carolina Hospitals; Chapel Hill North Carolina U.S.A
| | - Rupali N. Shah
- Department of Otolaryngology-Head and Neck Surgery; University of North Carolina Hospitals; Chapel Hill North Carolina U.S.A
| | - Robert A. Buckmire
- Department of Otolaryngology-Head and Neck Surgery; University of North Carolina Hospitals; Chapel Hill North Carolina U.S.A
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Benveniste MF, Gomez D, Carter BW, Betancourt Cuellar SL, De Groot PM, Marom EM. Radiation Effects in the Mediastinum and Surroundings: Imaging Findings and Complications. Semin Ultrasound CT MR 2015; 37:268-80. [PMID: 27261350 DOI: 10.1053/j.sult.2015.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Radiotherapy is one of the cornerstones for treatment of patients with cancer. Although advances in radiotherapy technology have considerably improved radiation delivery, potential adverse effects are still common. Postradiation changes to the mediastinum can include different structures such as the heart, great vessels, and esophagus. The purpose of the article was to illustrate the expected variety of changes to the mediastinum and adjacent lung resulting from external beam radiotherapy and radiotherapy-induced complications to the mediastinum and to discuss different radiotherapy delivery techniques.
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Affiliation(s)
- Marcelo F Benveniste
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Daniel Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brett W Carter
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Patricia M De Groot
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Edith M Marom
- Department of Diagnostic Radiology, The Chaim Sheba Medical Center, Tel Hashomer, Israel
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15
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Agarwalla A, Small AJ, Mendelson AH, Scott FI, Kochman ML. Risk of recurrent or refractory strictures and outcome of endoscopic dilation for radiation-induced esophageal strictures. Surg Endosc 2014; 29:1903-12. [PMID: 25277484 DOI: 10.1007/s00464-014-3883-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 09/04/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Radiation therapy for head, neck, and esophageal cancer can result in esophageal strictures that may be difficult to manage. Radiation-induced esophageal strictures often require repeat dilation to obtain relief of dysphagia. This study aimed to determine the long-term clinical success and rates of recurrent and refractory stenosis in patients with radiation-induced strictures undergoing dilation. METHODS Retrospective cohort study of patients with radiation-induced strictures who underwent endoscopic dilation by a single provider from October 2007-October 2012. Outcomes measured included long-term clinical efficacy, interval between sessions, number of dilations, and proportion of radiation strictures that were recurrent or refractory. Risk factors for refractory strictures were assessed. RESULTS 63 patients underwent 303 dilations. All presented with a stricture >30 days after last radiation session. Clinical success to target diameter was achieved in 52 patients (83%). A mean of 3.3 (±2.6) dilations over a median period of 4 weeks was needed to achieve initial patency. Recurrence occurred in 17 (33%) at a median of 22 weeks. Twenty-seven strictures (43%) were refractory to dilation therapy. Fluoroscopy during dilation (OR 22.88; 95% CI 3.19-164.07), severe esophageal stenosis (lumen <9 mm) (OR 10.51; 95% CI 1.94-56.88), and proximal location with prior malignancy extrinsic to the lumen (OR 6.96; 95% CI 1.33-36.29) were independent predictors of refractory strictures in multivariate analysis. CONCLUSIONS (1) Radiation-induced strictures have a delayed onset (>30 days) from time of radiation injury. (2) Endoscopic dilation can achieve medium-term luminal remediation but the strictures have a high long-term recurrence rate of up to 33%. (3) Remediation of radiation strictures following laryngectomy can be achieved but require frequent dilations. (4) Clinical and procedural predictors may identify patients at high risk of refractory strictures. (5) The optimal strategy in highly selected refractory patients is not clear.
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Affiliation(s)
- Anant Agarwalla
- Department of Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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16
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Cho YC, Kim JH, Park JH, Shin JH, Ko HK, Song HY. Fluoroscopically guided balloon dilation for benign bronchial stricture occurring after radiotherapy in patients with lung cancer. Cardiovasc Intervent Radiol 2014; 37:750-755. [PMID: 24196264 DOI: 10.1007/s00270-013-0735-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 08/11/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate the safety and clinical effectiveness of fluoroscopically guided balloon dilation in patients with benign bronchial stricture occurring after radiotherapy (RT). METHODS From March 2002 to January 2013, ten patients with benign bronchial stricture occurring after RT underwent fluoroscopically guided balloon dilation as their initial treatment. Technical success, primary and secondary clinical success, improvement in respiratory status, and complications were evaluated. The symptomatic improvement period was calculated. RESULTS A total of 15 balloon dilation sessions were performed in ten patients, with a range of 1-4 sessions per patient (mean 1.5 sessions). Technical success was achieved in 100 %. Six of the ten patients exhibited no symptom recurrence and required no further treatment until the end of follow-up (range 4-105 months). Four patients (40 %) experienced recurrent symptom, and two of four patients underwent repeat balloon dilations. The remaining two patients underwent cutting balloon dilation and temporary stent placement, respectively, and they exhibited symptom improvement after adjuvant treatment until the end of our study. Finally, primary clinical success was achieved in six of ten patients (60 %) and secondary clinical success was achieved in eight of ten patients (80 %). The mean symptom improvement period was 61.9 ± 16 months (95 % confidence interval 30.6-93.3). CONCLUSION Fluoroscopically guided balloon dilation seems to be safe and clinically effective for the treatment of RT-induced benign bronchial stricture. Temporary stent placement or cutting balloon dilation could be considered in patients with benign bronchial strictures resistant to fluoroscopically guided balloon dilation.
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Affiliation(s)
- Young Chul Cho
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea,
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17
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Fares S, Irfan FB. Thoracic Emergencies in Immunocompromised Patients. Emerg Med Clin North Am 2012; 30:565-89, x. [DOI: 10.1016/j.emc.2011.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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18
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Bera G, Pointreau Y, Denis F, Orain I, Dupuis O, Créhange G. Dose de tolérance à l’irradiation des tissus sains : l’œsophage. Cancer Radiother 2010; 14:327-35. [DOI: 10.1016/j.canrad.2010.02.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 02/02/2010] [Indexed: 12/26/2022]
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Park JJ, Lee YC, Kim BK, Kim JH, Park JC, Kim YJ, Lee SK, Song SY, Chung JB. Long-term clinical outcomes of self-expanding metal stents for treatment of malignant gastroesophageal junction obstructions and prognostic factors for stent patency: effects of anticancer treatments. Dig Liver Dis 2010; 42:436-40. [PMID: 19767253 DOI: 10.1016/j.dld.2009.07.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Revised: 07/23/2009] [Accepted: 07/28/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND Self-expanding metal stent has emerged as an effective treatment option for malignant gastroesophageal junction obstruction. However, data on the clinicopathologic factors associated with stent patency are still lacking. AIM To investigate the long-term clinical outcomes and prognostic factors, including treatment modalities, affecting stent patency in patients with malignant gastroesophageal junction obstruction given self-expanding metal stent insertions. METHODS A total 89 patients who underwent self-expanding metal stent insertion for malignant gastroesophageal junction obstruction were enrolled. We analysed technical and clinical success rates, complications, and prognostic factors affecting stent patency. RESULTS Self-expanding metal stent insertion was successful in all patients and clinical improvement was achieved in 93.3%. Stent malfunction occurred in 32.9% of patients. The median overall survival time and stent patency time were 143 (95% CI: 99-187) and 190 days (95% CI: 108-272), respectively. In multivariate analysis, radiation therapy after stent placement significantly prolonged stent patency (OR: 0.221; 95% CI: 0.055-0.884; p=0.033). A higher migration rate was observed in those patients given chemotherapy after covered self-expanding metal stent placement (no anticancer treatment: 10.0%, chemotherapy: 42.9%, chemoradiation therapy: 9.1%, p=0.042). CONCLUSIONS Self-expanding metal stent is a feasible and effective treatment for malignant gastroesophageal junction obstruction. Radiation therapy after stent placement significantly prolongs overall stent patency and chemotherapy increases the migration rate of covered stents.
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Affiliation(s)
- Jae Jun Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
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Dabak H, Karlidag T, Akpolat N, Keles E, Alpay HC, Serin M, Kaygusuz I, Yalcin S, Isik O. The effects of methylprednisolone and halofuginone on preventing esophageal and hypopharyngeal fibrosis in delivered radiotherapy. Eur Arch Otorhinolaryngol 2010; 267:1429-35. [PMID: 20364346 DOI: 10.1007/s00405-010-1242-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2010] [Accepted: 03/22/2010] [Indexed: 12/20/2022]
Abstract
In this study, we assessed the effects of halofuginone and methylprednisolone on hypopharyngeal and esophageal stricture that can develop following radiation to the head and neck of rats. Rats were divided into four groups randomly and 18 Gy radiation was given to the head and neck regions of all rats except the control group. Group 1 (Control Group): No radiation or drugs were administered. Group 2 (Radiation Group): only radiation was applied without any drugs. Group 3 (Halofuginone Group): halofuginone 100 microg/kg per day was given intraperitoneally. Group 4 (Methylprednisolone Group): methylprednisolone 1 mg/kg per day was administered intramuscularly. In all groups, 90 days after application of radiation, sections of the proximal esophagus and hypopharynx were examined for fibrosis, fibroblast proliferation, vascularization, epithelial atypia, necrosis, polymorphonuclear leukocytes, mononuclear cells, and stenosis index by light microscope and the hydroxyproline levels were assessed biochemically. Fibrosis, epithelial atypia and hydroxyproline levels were found to be significantly higher in the radiation group compared to the control group (P < 0.05). We did not observe fibrosis in either the halofuginone or the control groups. Fibrosis was also significantly lower in the methylprednisolone group than the radiation group (P < 0.05). The differences of the stenosis index scores between the groups were not statistically significant (P < 0.05). Vascularization was similar in all groups. We think that especially halofuginone is a drug that can be used safely to prevent fibrosis due to radiotherapy, but further studies are needed.
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Affiliation(s)
- Hakan Dabak
- Department of Otorhinolaryngology, Medical Faculty, Firat University, 23119, Elazig, Turkey
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Wu X, Levine MS, Hernandez J, Kogan JR. Wide-mouthed sacculation of the esophagus: a cause of dysphagia after radiation therapy. Dysphagia 2010; 25:341-4. [PMID: 20204413 DOI: 10.1007/s00455-010-9274-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 01/13/2010] [Indexed: 11/28/2022]
Abstract
We describe a patient who presented with dysphagia after radiation therapy for Hodgkin's lymphoma secondary to wide-mouthed sacculation of the upper esophagus on barium esophagography, most likely resulting from localized radiation necrosis of the muscular layer of the esophageal wall. Despite its rarity, radiologists should be aware of this finding as a potential cause of dysphagia after radiation therapy to the neck or chest. Unlike radiation strictures, radiation-induced sacculation of the esophagus probably can be managed conservatively without need for endoscopic dilatation procedures.
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Affiliation(s)
- Xin Wu
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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22
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Vu KN, Day TA, Gillespie MB, Martin-Harris B, Sinha D, Stuart RK, Sharma AK. Proximal esophageal stenosis in head and neck cancer patients after total laryngectomy and radiation. ORL J Otorhinolaryngol Relat Spec 2008; 70:229-35. [PMID: 18467817 DOI: 10.1159/000130870] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Accepted: 03/15/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND There has been an increasing focus on late functional effects of head and neck cancer (HNC) treatment. This study was undertaken to evaluate the incidence of late proximal esophageal stricture in patients undergoing total laryngectomy (TL) and radiation therapy (RT). MATERIAL AND METHODS An institutional retrospective review of HNC patients treated between 1995 and 2003 with TL and RT was undertaken. Thirty-three patients with stage II-IV disease were included; 25 patients had TL and postoperative RT (group 1), while 8 patients had definitive RT with salvage laryngectomy (group 2). RESULTS The median follow-up was 28 months. At the last follow-up, 25 patients (76%) were alive and disease free. Four had died and 3 developed distant metastasis. Dysphagia or stenosis developed in 40% in group 1 and 75% in group 2 patients. The median time to dysphagia was 5.5 months for all patients. CONCLUSIONS The incidence of esophageal stenosis was 33% for all patients. Contributing factors for esophageal stenosis after TL and RT include continued alcohol and tobacco use, the dose-volume relationship of the RT and normal tissue damage from the tumor and the treatment.
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Affiliation(s)
- Kim N Vu
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC 29425, USA
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23
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Lawson JD, Otto K, Grist W, Johnstone PA. Frequency of esophageal stenosis after simultaneous modulated accelerated radiation therapy and chemotherapy for head and neck cancer. Am J Otolaryngol 2008; 29:13-9. [PMID: 18061826 DOI: 10.1016/j.amjoto.2006.12.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2006] [Accepted: 12/13/2006] [Indexed: 10/22/2022]
Abstract
BACKGROUND Chronic esophageal toxicity after radiotherapy alone for cancer of the head and neck (HNCa) is rare: 2.6% for strictures and 0.8% for stenosis after a 60-Gy dose. With combined modality therapy, stricture rates of 22% to 37% have been reported. We report the frequency of esophageal toxicity after simultaneous modulated accelerated radiation therapy (SMART) with chemotherapy for HNCa. METHODS The records of the otolaryngology/head and neck surgery department of Emory University, Atlanta, GA, were screened for patients undergoing combined modality therapy using SMART for HNCa. Radiation Oncology records were reviewed for target and critical normal structure dosimetry, with detailed analysis of esophageal and supraglottic laryngeal dosimetry. Hospital and clinic records were reviewed for evidence of esophageal toxicity. RESULTS From January 2003 to August 2005, 99 patients underwent definitive therapy for squamous cell HNCa using SMART and chemotherapy. Follow-up was documented in all cases. Median dose to sites of gross primary or nodal disease was 70.29 Gy, at 2.13 Gy per fraction. Median dose to the ipsilateral neck was 63.03 Gy at 1.91 Gy per fraction. Median dose to the contralateral neck in 97 patients treated was 57.75 Gy at 1.75 Gy per fraction. Thirteen (13%) patients developed esophageal strictures. Five (5%) patients had complete esophageal stenosis. Four (14%) of the 29 patients with either a hypopharyngeal primary or a N2c nodal disease developed complete stenosis. A statistically larger esophageal volume of esophagus reactivity > or = 60 Gy (V(60)) was found in patients who developed stenosis/stricture when compared with a randomly selected population of N2a/b patients who did not develop those toxicities. Esophageal stenosis/stricture was also numerically more common in patients receiving taxane-based chemotherapy, developing in 23%, as opposed to 9% in patients treated with platinum-based chemotherapy. CONCLUSION The risk of esophageal stenosis may increase with SMART and chemotherapy for HNCa. Potential mechanisms to reduce this include (a) contouring the esophagus as a dose-limiting structure; (b) early flexible examination posttreatment, with early intervention with dilation; (c) improved therapy for mucositis.
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24
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Seo YS, Park JJ, Kim BG, Kim JH, Kim JH, Kim CH, Kim JY, Byun KS, Bak YT. Segmental amputation of esophagus with bronchial-wall rupture during removal of a stent for benign esophageal stricture. Gastrointest Endosc 2006; 64:141-3. [PMID: 16813827 DOI: 10.1016/j.gie.2006.02.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2006] [Accepted: 02/06/2006] [Indexed: 12/31/2022]
Affiliation(s)
- Yeon Seok Seo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Guro Hospital, Gurodong-gil 97, Guro-go, Seoul 152-703, Korea
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25
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Choi GB, Shin JH, Song HY, Lee YS, Cho YK, Bae JI, Kim JH, Jeong YH, Park MH. Fluoroscopically guided balloon dilation for patients with esophageal stricture after radiation treatment. J Vasc Interv Radiol 2006; 16:1705-10. [PMID: 16371539 DOI: 10.1097/01.rvi.0000179813.93992.9e] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To evaluate the safety and clinical effectiveness of fluoroscopically guided balloon dilation in patients with esophageal stricture after radiation therapy (RT). MATERIALS AND METHODS From April 1993 through December 2004, fluoroscopically guided balloon dilation was performed in 15 patients with esophageal strictures secondary to previous RT. Technical success, clinical success, recurrence of dysphagia, primary and secondary patency rates, and complications related to the procedure were retrospectively evaluated. RESULTS Twenty-five balloon dilations were performed in 15 patients, with a mean of 1.7 dilations per patient (range, 1-5). Technical success was achieved in all procedures. One patient was immediately lost to follow-up and another underwent elective esophageal surgery 13 days after the procedure. Of the remaining 13 patients, clinical success was achieved 11 (85%). Two of 13 patients exhibited recurrence of dysphagia before 1 month after balloon dilation. Among the 11 patients in whom clinical success was achieved, seven exhibited maintained initial improvement of dysphagia until their last follow-up (mean, 174 days) and four exhibited recurrence of dysphagia after the first balloon dilation. Dysphagia recurred 2-128 days (mean, 67.2 d) after the first balloon dilation in six of the 13 patients (46%), who underwent further balloon dilation and/or stent placement. The primary and secondary patency rates at 1, 3, and 6 months were 86%, 68%, and 47% and 100%, 92%, and 62%, respectively. There were no major complications. Type 1 and 2 esophageal ruptures occurred after 12 dilations in nine patients; they were treated conservatively. CONCLUSION Fluoroscopically guided balloon dilation for esophageal stricture after RT can be safe and effective. However, the high rate of recurrent dysphagia requires repeated dilations.
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Affiliation(s)
- Gi Bok Choi
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea
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Gillespie MB, Day TA, Sharma AK, Brodsky MB, Martin-Harris B. Role of mitomycin in upper digestive tract stricture. Head Neck 2006; 29:12-7. [PMID: 17022087 DOI: 10.1002/hed.20476] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Mitomycin C is an anti-fibroblast chemotherapeutic agent that has demonstrated promise in the treatment of head and neck cancer-related cervical stenosis. The present study investigates whether the application of mitomycin C at the time of dilation is both safe and effective in the treatment of head and neck cancer-related upper digestive tract stricture. METHODS Twelve patients with progressive dysphagia and video-fluoroscopic evidence of upper digestive tract stricture after head and neck cancer treatment were dilated by Maloney or Savory dilators followed by the application of mitomycin C (0.2 mg/0.4 mL saline) to the stenotic segment for 5 minutes. Outcome measures included complication rate, improvement in baseline dietary consistency, and improvement in swallowing-related quality of life as measured by the M. D. Anderson Dysphagia Inventory. RESULTS All patients experienced improvement in their baseline dietary consistency (p = .002) and M. D. Anderson Dysphagia Inventory composite score (p = .001) after a mean follow-up time of 19 months. No complications from mitomycin use were observed. CONCLUSION Mitomycin application appears to be a safe and potentially effective treatment for head and neck cancer-related upper digestive tract stricture. Given the small sample size and limited follow-up time, a randomized, controlled trial is needed to determine whether mitomycin application offers additional benefit over standard dilation therapy.
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Affiliation(s)
- M Boyd Gillespie
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.
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Kim HC, Shin JH, Song HY, Park SI, Ko GY, Youn HK, Sung KB. Fluoroscopically Guided Balloon Dilation for Benign Anastomotic Stricture after Ivor-Lewis Esophagectomy: Experience in 62 Patients. J Vasc Interv Radiol 2005; 16:1699-704. [PMID: 16371538 DOI: 10.1097/01.rvi.0000185417.89885.2e] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To evaluate the safety and clinical effectiveness of fluoroscopically guided balloon dilation in 62 patients with benign anastomotic stricture after Ivor-Lewis esophagectomy. MATERIALS AND METHODS Between January 1996 and June 2004, fluoroscopically guided balloon dilation was undertaken in 62 patients with benign anastomotic stricture after Ivor-Lewis esophagectomy. Radiologic images and medical records including complications were retrospectively reviewed. The maximum diameters of the balloon catheters used were 18-20 mm. Clinical success was defined by the absence of recurrent dysphagia after balloon dilation until the most recent follow-up. The Fisher exact test was used to assess the relationship of symptomatic recurrence and the balloon size, width of the stricture, and radiation therapy. RESULTS There were 115 sessions of balloon dilation in 62 patients (mean, 1.85 sessions per patient). Clinical success was achieved in 59 patients (95%) by means of a single dilation (n = 29) or by multiple dilations (n = 30). One patient with severe stenosis was successfully treated with temporary placement of a covered retrievable stent. Major complications such as esophageal perforation or massive bleeding did not occur. Four patients with mucosal tear (n = 3) or aspiration pneumonia (n = 1) were conservatively treated. Patients with severe stricture had more symptomatic recurrences than those with moderate stricture. CONCLUSION Fluoroscopically guided balloon dilation is a safe and successful treatment modality for benign anastomotic stricture after Ivor-Lewis esophagectomy.
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Affiliation(s)
- Hyo-Cheol Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap-2dong, Songpa-gu, Seoul 138-736, Korea
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Abstract
The barium esophagram is a valuable diagnostic test for evaluating structural and functional abnormalities of the esophagus. The study is usually performed as a multiphasic examination that includes upright double-contrast views with a high-density barium suspension, prone single-contrast views with a low-density barium suspension, and, not infrequently, mucosal-relief views with either density of barium suspension. The double-contrast phase optimizes the ability to detect inflammatory or neoplastic diseases, whereas the single-contrast phase optimizes the ability to detect hiatal hernias and lower esophageal rings or strictures. Fluoroscopic examination of the esophagus is also important for assessing motility disorders such as achalasia and diffuse esophageal spasm. This article is a review of gastroesophageal reflux disease, other types of esophagitis, benign and malignant esophageal tumors, varices, lower esophageal rings, diverticula, and esophageal motility disorders, all of which can be diagnosed with the aid of esophagography.
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Affiliation(s)
- Marc S Levine
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
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Petro M, Wein RO, Minocha A. Treatment of a radiation-induced esophageal web with retrograde esophagoscopy and puncture. Am J Otolaryngol 2005; 26:353-5. [PMID: 16137538 DOI: 10.1016/j.amjoto.2005.02.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/19/2004] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To present a technique for the treatment of complete esophageal stenosis in the post-radiation patient that may be applied to selected patients with obstructing stenoses. STUDY DESIGN A case report of the treatment of a post-radiation esophageal web. METHODS A review of the patient's history of treatment and a discussion of reported treatment options. RESULTS A complete obstruction of the cervical esophagus was diagnosed in a patient after chemoradiation for a hypopharyngeal carcinoma. Retrograde esophagoscopy through the patient's percutaneous endoscopic gastrostomy tube site aided visualization and perforation of the obstructing tissue. Subsequent dilation has allowed the patient to resume oral intake of a regular diet without restrictions. CONCLUSION Combined direct laryngoscopy with retrograde esophagoscopy represents a viable alternative to more extensive approaches for recannulization of selected obstructing esophageal stenoses.
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Affiliation(s)
- Melanie Petro
- Department of Otolaryngology and Communicative Sciences, University of Mississippi Medical Center, Jackson, MS, USA
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Türkölmez S, Atasever T, Akmansu M. Effects of radiation therapy on oesophageal transit in patients with inner quadrant breast tumour. Nucl Med Commun 2005; 26:721-6. [PMID: 16000991 DOI: 10.1097/01.mnm.0000171785.03403.6f] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate quantitatively the effect of low doses of radiation therapy on the oesophageal transit in patients with inner quadrant breast carcinoma. METHODS Eighteen female patients with locally advanced inner quadrant breast tumour were included in this study. A total dose of 5000 cGy in 25 fractions of 200 cGy was applied from four different treatment portals to all patients. Oesophageal motility was evaluated before and immediately after radiotherapy using oesophageal scintigraphy. The oesophageal transit times (ETTs) for the upper one-third, the lower two-thirds portion and the whole oesophagus were calculated. RESULTS The upper one-third portion of the oesophagus received a mean dose of 600 cGy and the lower two-thirds portion received a mean dose of 1530 cGy as a result of 5000 cGy dose application. All of the patients developed grade 1 oesophageal toxicity. Post-radiation therapy ETT values were significantly higher compared to pre-radiation therapy ETT values (P<0.001). Before irradiation, ETT values for the upper one-third, distal two-thirds of the oesophagus and the whole oesophagus were 4.77+/-1.08, 11.22+/-2.85 and 11.61+/-2.97 s, respectively. After irradiation, ETT values for the upper one-third, distal two-thirds of the oesophagus and the whole oesophagus were 6.92+/-2.15, 23.30+/-5.65 and 23.74+/-5.70 s, respectively. CONCLUSIONS Oesophageal transit seems to be affected by radiation even without a clinically significant oesophageal symptom and oesophageal scintigraphy allows sensitive, non-invasive and quantifiable assessment of the oesophageal transit time.
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Affiliation(s)
- Seyda Türkölmez
- Department of Nuclear Medicine, Ankara Training and Research Hospital, Gazi University School of Medicine Ankara, Turkey.
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31
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Qiao WB, Zhao YH, Zhao YB, Wang RZ. Clinical and dosimetric factors of radiation-induced esophageal injury: Radiation-induced esophageal toxicity. World J Gastroenterol 2005; 11:2626-9. [PMID: 15849822 PMCID: PMC4305754 DOI: 10.3748/wjg.v11.i17.2626] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the clinical and dosimetric predictive factors for radiation-induced esophageal injury in patients with non-small-cell lung cancer (NSCLC) during three-dimensional conformal radiotherapy (3D-CRT).
METHODS: We retrospectively analyzed 208 consecutive patients (146 men and 62 women) with NSCLC treated with 3D-CRT. The median age of the patients was 64 years (range 35-87 years). The clinical and treatment parameters including gender, age, performance status, sequential chemotherapy, concurrent chemotherapy, presence of carinal or subcarinal lymph nodes, pretreatment weight loss, mean dose to the entire esophagus, maximal point dose to the esophagus, and percentage of volume of esophagus receiving >55 Gy were studied. Clinical and dosimetric factors for radiation-induced acute and late grade 3-5 esophageal injury were analyzed according to Radiation Therapy Oncology Group (RTOG) criteria.
RESULTS: Twenty-five (12%) of the two hundred and eight patients developed acute or late grade 3-5 esophageal injury. Among them, nine patients had both acute and late grade 3-5 esophageal injury, two died of late esophageal perforation. Concurrent chemotherapy and maximal point dose to the esophagus ≥60 Gy were significantly associated with the risk of grade 3-5 esophageal injury. Fifty-four (26%) of the two hundred and eight patients received concurrent chemotherapy. Among them, 25 (46%) developed grade 3-5 esophageal injury (P = 0.0001<0.01). However, no grade 3-5 esophageal injury occurred in patients who received a maximal point dose to the esophagus <60 Gy (P = 0.0001<0.01).
CONCLUSION: Concurrent chemotherapy and the maximal esophageal point dose ≥60 Gy are significantly associated with the risk of grade 3-5 esophageal injury in patients with NSCLC treated with 3D-CRT.
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Affiliation(s)
- Wen-Bo Qiao
- Department of Radiotherapy Oncology, Tumor Hospital of Harbin Medical University, Harbin 150040, Heilongjiang Province, China.
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Mavroidis P, Lind BK, Theodorou K, Laurell G, Fernberg JO, Lefkopoulos D, Kappas C, Brahme A. Statistical methods for clinical verification of dose–response parameters related to esophageal stricture and AVM obliteration from radiotherapy. Phys Med Biol 2004; 49:3797-816. [PMID: 15446806 DOI: 10.1088/0031-9155/49/16/023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The purpose of this work is to provide some statistical methods for evaluating the predictive strength of radiobiological models and the validity of dose-response parameters for tumour control and normal tissue complications. This is accomplished by associating the expected complication rates, which are calculated using different models, with the clinical follow-up records. These methods are applied to 77 patients who received radiation treatment for head and neck cancer and 85 patients who were treated for arteriovenous malformation (AVM). The three-dimensional dose distribution delivered to esophagus and AVM nidus and the clinical follow-up results were available for each patient. Dose-response parameters derived by a maximum likelihood fitting were used as a reference to evaluate their compatibility with the examined treatment methodologies. The impact of the parameter uncertainties on the dose-response curves is demonstrated. The clinical utilization of the radiobiological parameters is illustrated. The radiobiological models (relative seriality and linear Poisson) and the reference parameters are validated to prove their suitability in reproducing the treatment outcome pattern of the patient material studied (through the probability of finding a worse fit, area under the ROC curve and chi2 test). The analysis was carried out for the upper 5 cm of the esophagus (proximal esophagus) where all the strictures are formed, and the total volume of AVM. The estimated confidence intervals of the dose-response curves appear to have a significant supporting role on their clinical implementation and use.
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Affiliation(s)
- Panayiotis Mavroidis
- Department of Medical Radiation Physics, Karolinska Institutet and Stockholm University, Sweden.
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Lew RJ, Shah JN, Chalian A, Weber RS, Williams NN, Kochman ML. Technique of endoscopic retrograde puncture and dilatation of total esophageal stenosis in patients with radiation-induced strictures. Head Neck 2004; 26:179-83. [PMID: 14762887 DOI: 10.1002/hed.10365] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Complete esophageal stenosis can occur after external beam radiation therapy for malignancies. Treatment for this complication has traditionally involved surgery. METHODS A new technique to reestablish luminal patency is described. This minimally invasive technique involves retrograde endoscopy by means of gastrostomy tube tract and puncture of the stenotic occlusion followed by stricture dilatation. The procedure is performed under combined endoscopic and laryngoscopic guidance. RESULTS Five consecutive patients who had complete esophageal stenoses develop after radiation therapy for malignant disease underwent retrograde endoscopy by way of gastrostomy tube tracts. Stenoses were punctured under endoscopic and laryngoscopic guidance with guide wires. Strictures were dilated with wire-guided balloons or polyvinyl dilators. Luminal patency was established in all patients using this technique without procedural complications. CONCLUSIONS Endoscopic retrograde puncture and dilatation of total esophageal stenoses is safe, effective, and useful to reestablish luminal patency for radiation-induced strictures. This technique should be attempted before more invasive treatments.
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Affiliation(s)
- Ronald J Lew
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Division of Gastroenterology, 3400 Spruce Street, 3 Ravdin Building, Philadelphia, Pennsylvania 19104, USA
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Mavroidis P, Laurell G, Kraepelien T, Fernberg JO, Lind BK, Brahme A. Determination and clinical verification of dose-response parameters for esophageal stricture from head and neck radiotherapy. Acta Oncol 2004; 42:865-81. [PMID: 14968948 DOI: 10.1080/02841860310012833] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The purpose of this work is to determine the parameters and evaluate the predictive strength of the relative seriality model. This is accomplished by associating the calculated complication rates with the clinical follow-up records. The study is based on 82 patients who received radiation treatment for head and neck cancer. For each patient the 3D dose distribution delivered to the esophagus and the clinical treatment outcome were available. Clinical symptoms and radiological findings were used to assess the manifestation of radiation-induced esophageal strictures. These data were introduced into a maximum likelihood fitting to calculate the best estimates of the parameters used by the relative seriality model (D50 = 68.4 Gy, gamma = 6.55, s = 0.22). The uncertainties of these parameters were also calculated and their individual influence on the dose-response curve was demonstrated. The best estimate of the parameters was applied to 58 patients of the study material and their esophageal stricture induction probabilities were calculated to illustrate the clinical utilization of the calculated parameters. The calculation of the biological effective dose (BED) appeared to be significantly sensitive to the applied fractionation correction for complex treatment plans. The relative seriality model was proved suitable in reproducing the treatment outcome pattern of the patient material studied (probability of finding a worse fit = 61.0%, the area under the ROC curve = 0.84 and chi2 test = 0.95). The analysis was carried out for the upper 5 cm of the esophagus (proximal esophagus) where all the strictures are formed. Radiation-induced strictures were found to have a strong volume dependence (low relative seriality). The uncertainties of the parameters appear to have a significant supporting role on the estimated dose-response curve.
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Affiliation(s)
- Panayiotis Mavroidis
- Department of Medical Radiation Physics, Karolinska Institutet, Stockholm University, Sweden.
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35
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Werner-Wasik M, Yu X, Marks LB, Schultheiss TE. Normal-tissue toxicities of thoracic radiation therapy: esophagus, lung, and spinal cord as organs at risk. Hematol Oncol Clin North Am 2004; 18:131-60, x-xi. [PMID: 15005286 DOI: 10.1016/s0889-8588(03)00150-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The evolution of therapeutic approaches for lung cancer illustrates the trend for treatment intensification, with hopes that dose-intense chemotherapy regimens, higher radiation therapy (RT) doses, or novel fractionation schemes will result in prolongation of survival. Current chemotherapy- and RT-intense regimens may not be intensified further without addressing dose-limiting toxicities such as esophagitis. It is important to understand factors pre-disposing to esophagitis so that strategies to minimize its severity can be investigated. Pulmonary complications such as pneumonitis and fibrosis from RT (with or without chemotherapy) are dose and volume dependent. Methods to better identify the target tissues and improved RT-delivery systems may facilitate increasing target doses or reducing doses to adjacent normal tissues. Biologic predictors may allow clinicians in the future to individualize RT treatment based on a patient's toxicity risk profile. Radiation myelopathy is still the most feared radiation complication of lung cancer treatment. The authors address the known parameters that influence the incidence of thoracic radiation myelopathy and the putative factors that could be considered when a clinician may be required to push the spinal cord dose in favor of tumor control.
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Affiliation(s)
- Maria Werner-Wasik
- Department of Radiation Oncology, Kimmel Cancer Center of Jefferson Medical College, 111 South 11th Street, Philadelphia, PA 19107, USA.
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36
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Iyer RB, Silverman PM, Tamm EP, Dunnington JS, DuBrow RA. Diagnosis, staging, and follow-up of esophageal cancer. AJR Am J Roentgenol 2003; 181:785-93. [PMID: 12933482 DOI: 10.2214/ajr.181.3.1810785] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Revathy B Iyer
- Department of Diagnostic Radiology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Unit 57, Houston, TX 77030, USA
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37
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Kashima ML, Eisele DW. Complication of esophageal self-dilation for radiation-induced hypopharyngeal stenosis. Dysphagia 2003; 18:92-5. [PMID: 12825902 DOI: 10.1007/s00455-002-0093-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We present an unusual case of hypopharyngeal stenosis, secondary to radiation therapy for laryngeal squamous cell carcinoma, complicated by repeated inadvertent passage of a Maloney dilator through the larynx into the right mainstem bronchus during self-dilation. A brief review of esophageal/hypopharyngeal stenosis and management alternatives is presented. Self-dilation is presented as a therapeutic method for recurrent stenosis of the hypopharynx and esophagus. Recognition and avoidance of this complication is discussed.
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Affiliation(s)
- Matthew L Kashima
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland 21224, USA
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38
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Luedtke P, Levine MS, Rubesin SE, Weinstein DS, Laufer I. Radiologic diagnosis of benign esophageal strictures: a pattern approach. Radiographics 2003; 23:897-909. [PMID: 12853664 DOI: 10.1148/rg.234025717] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Benign esophageal strictures are a leading cause of dysphagia. Therefore, radiologists have an important role in detecting esophageal strictures and determining their cause. The most common cause of strictures in the distal esophagus is gastroesophageal reflux disease. Reflux-induced ("peptic") strictures may be associated with sacculations, fixed transverse folds, or esophageal intramural pseudodiverticula. In addition, scleroderma, nasogastric intubation, Zollinger-Ellison syndrome, and alkaline reflux esophagitis may be associated with stricture formation in the distal esophagus. Upper and midesophageal strictures may be caused by Barrett esophagus, mediastinal irradiation, ingestion of drugs or caustic substances, congenital esophageal stenosis, skin diseases, or esophageal intramural pseudodiverticulosis. Other unusual causes of esophageal stricture formation include Crohn disease, Candida esophagitis, graft-versus-host disease, eosinophilic esophagitis, Behçet disease, endoscopic sclerotherapy for esophageal varices, and glutaraldehyde contamination at endoscopy. Esophageal strictures are best evaluated with biphasic esophagography that includes both single- and double-contrast spot images. When esophageal strictures are detected at barium examination, the underlying cause can often be determined with a pattern approach that takes into account the clinical history, the appearance and location of the strictures, and the presence of other associated radiographic findings.
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Affiliation(s)
- Pia Luedtke
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA
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39
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Laurell G, Kraepelien T, Mavroidis P, Lind BK, Fernberg JO, Beckman M, Lind MG. Stricture of the proximal esophagus in head and neck carcinoma patients after radiotherapy. Cancer 2003; 97:1693-700. [PMID: 12655526 DOI: 10.1002/cncr.11236] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND It is well recognized that many patients with head and neck carcinoma have problems with food intake and malnutrition. The objective of the current study was to determine the clinical pattern of patients with nonneoplastic stricture of the upper esophagus after radiotherapy for head and neck carcinoma. METHODS A retrospective chart study of 22 patients with stricture of the proximal esophagus diagnosed between 1993 and 1999 at Karolinska Hospital was performed. The dose volume histograms of the first 2 cm and 5 cm, respectively, of the proximal esophagus were calculated. RESULTS Five of the patients (23%) had total obliteration. The first 2 cm of the esophagus received at least 60 grays (Gy) in > 80% of the volume. Radiation injury was not reported to occur at doses < 60 Gy. There was a correlation found between dysphagia during radiotherapy and the development of proximal esophageal stricture. Stricture was diagnosed 1-60 months (median, 6 months) after radiotherapy. In 18 patients, the stricture was treated with single or repeated endoscopic dilation. These treatments allowed a nearly normal diet in 78% of the patients. CONCLUSIONS Stricture of the upper esophagus is one deglutition disorder that is reported to occur after radiotherapy for head and neck carcinoma. In the current study, the authors emphasize the importance of knowing the tolerance of the normal esophagus to irradiation as well as early diagnosis of stricture of the proximal esophagus because this condition may lead to physical and emotional distress.
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Affiliation(s)
- Göran Laurell
- Department of Otolaryngology, Karolinska Hospital, Stockholm, Sweden.
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40
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Abstract
Abnormalities of the esophagus are common, and complications associated with these disorders and diseases can involve the mediastinum, tracheobronchial tree, and lungs. The most common complications include mediastinitis secondary to esophageal perforation or postoperative anastomotic leak, or both; empyema due to fistula formation; and aspiration pneumonia. The authors reviewed the radiologic appearances of those and other common thoracic complications associated with esophageal disorders to facilitate early detection, diagnosis, and management. Computed tomographic (CT) findings of acute mediastinitis secondary to esophageal perforation may include esophageal thickening, extraluminal gas, pleural effusion, single or multiple abscesses, and extraluminal contrast medium. The radiologic manifestations of pneumonia secondary to tracheoesophageal fistula are variable, depending on the spread and severity of the aspiration. The most common radiographic pattern is that of bronchopneumonia with scattered air-space opacities. CT has been regarded as the imaging modality of choice for the evaluation of suspected esophagopleural fistula, because the site of communication between the pleural space and the esophagus can often be seen. An awareness of the radiologic manifestations of these complications is thus required to facilitate early diagnosis.
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Affiliation(s)
- Ana Giménez
- Department of Radiology, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Avda Sant Antoni M. Claret 167, 08025 Barcelona, Spain.
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Franquet T, Giménez A, Rosón N, Torrubia S, Sabaté JM, Pérez C. Aspiration diseases: findings, pitfalls, and differential diagnosis. Radiographics 2000; 20:673-85. [PMID: 10835120 DOI: 10.1148/radiographics.20.3.g00ma01673] [Citation(s) in RCA: 141] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The aspiration of different substances into the airways and lungs may cause a variety of pulmonary complications. These disease entities most commonly involve the posterior segment of the upper lobes and the superior segment of the lower lobes. Esophagography and computed tomography (CT) are especially useful in the evaluation of aspiration disease related to tracheoesophageal or tracheopulmonary fistula. Foreign body aspiration typically occurs in children and manifests as obstructive lobar or segmental overinflation or atelectasis. An extensive, patchy bronchopneumonic pattern may be observed in patients following massive aspiration of gastric acid or water. CT is the modality of choice in establishing the diagnosis of exogenous lipoid pneumonia, which can result from aspiration of hydrocarbons or of mineral oil or a related substance. Aspiration of infectious material manifests as necrotizing consolidation and abscess formation. The relatively low diagnostic accuracy of chest radiography in aspiration diseases can be improved with CT and by being familiar with the clinical settings in which specific complications are likely to occur. Recognition of the varied clinical and radiologic manifestations of these disease entities is imperative for prompt, accurate diagnosis, resulting in decreased morbidity and mortality rates.
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Affiliation(s)
- T Franquet
- Department of Radiology, Hospital de Sant Pau, Universidad Autónoma de Barcelona, Avda San Antonio Maria Claret 168, Barcelona 08125, Spain.
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42
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Mesurolle B, Qanadli SD, Merad M, Mignon F, Baldeyrou P, Tardivon A, Lacombe P, Vanel D. Unusual radiologic findings in the thorax after radiation therapy. Radiographics 2000; 20:67-81. [PMID: 10682772 DOI: 10.1148/radiographics.20.1.g00ja1167] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Radiation therapy is used to treat many intrathoracic and chest wall malignancies. A variety of changes may occur after radiation therapy to the thorax. Radiation therapy produces dramatic effects in the lung. Pulmonary necrosis is an uncommon, severe, late complication of adjuvant postoperative radiation therapy. Bronchiolitis obliterans with organizing pneumonia is a distinct clinicopathologic entity characterized by patchy, migratory, peripheral air-space infiltrates. Radiation therapy can also cause spontaneous pneumothorax, mesothelioma, and lung cancer. In the mediastinum, radiation therapy may cause thymic cysts, calcified lymph nodes, and esophageal injuries. Cardiovascular complications of radiation therapy are often delayed and insidious. Premature coronary artery stenosis occurs after radiation therapy to the mediastinum. Radiation therapy may also give rise to calcifications of the ascending aorta, pericardial disease, valvular injuries, and conduction abnormalities. Women who undergo thoracic irradiation before the age of 30 years have a high risk of developing a second breast cancer. Radiation-induced sarcomas are an infrequent but well-recognized complication of radiation therapy. Other chest wall injuries due to radiation therapy are osteochondroma and rib or clavicle fractures. Knowledge of the imaging features of injuries caused by radiation therapy can prevent misinterpretation as recurrent tumor and may facilitate further treatment.
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Affiliation(s)
- B Mesurolle
- Department of Radiology, Institut Gustave-Roussy, Villejuif, France
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43
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Watanabe S, Nagashima R, Shimazaki Y, Takahashi T, Takeda F, Tamura M, Takahashi T. Esophageal necrosis and bleeding gastric ulcer secondary to ruptured thoracic aortic aneurysm. Gastrointest Endosc 1999; 50:847-9. [PMID: 10570351 DOI: 10.1016/s0016-5107(99)70173-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- S Watanabe
- Second Department of Internal Medicine, Yamagata University School of Medicine, Yamagata, Japan
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44
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Maguire PD, Sibley GS, Zhou SM, Jamieson TA, Light KL, Antoine PA, Herndon JE, Anscher MS, Marks LB. Clinical and dosimetric predictors of radiation-induced esophageal toxicity. Int J Radiat Oncol Biol Phys 1999; 45:97-103. [PMID: 10477012 DOI: 10.1016/s0360-3016(99)00163-7] [Citation(s) in RCA: 132] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate the incidence, severity, and clinical/dosimetric predictors of acute and chronic esophageal toxicities in patients with non-small cell lung cancer (NSCLC) treated with high-dose conformal thoracic radiation. METHODS AND MATERIALS Ninety-one patients with localized NSCLC treated definitively with high-dose conformal radiation therapy (RT) at Duke University Medical Center (DUMC) were reviewed. Patient characteristics were as follows: 53 males and 38 females; median age 64 yr (range 46-82); stage I--16, II--3, IIIa--40, IIIb--30, X--2; dysphagia pre-RT--6 (7%). Treatment parameters included: median corrected dose-78.8 Gy (range 64.2-85.6); BID fractionation-58 (64%); chemotherapy-43 (47%). Acute and late esophageal toxicities were graded by RTOG criteria. Using 3D treatment planning tools, the esophagus was contoured in a uniform fashion, the 3D dose distribution calculated (with lung density correction), and the dose-volume (DVH) and dose-surface histograms (DSH) generated. At each axial level, the percentage of the esophageal circumference at each dose level was calculated. The length of circumferential esophagus and the maximum circumference treated to doses >50 Gy were assessed. Patient and treatment factors were correlated with acute and chronic esophageal dysfunction using univariate and multivariate logistic regression analyses. RESULTS There were no acute or late grade 4 or 5 esophageal toxicities. Ten of 91 patients (11%) developed grade 3 acute toxicity. On univariate analysis of clinical parameters, both dysphagia pre-RT (p = 0.10) and BID fractionation (p = 0.11) tended toward significantly predicting grade 3 acute esophagitis. None of the dosimetric parameters analyzed significantly predicted for grade 3 acute esophagitis. Twelve of 66 assessable patients (18%) developed late esophageal toxicity. Of the clinical parameters analyzed, only dysphagia pre-RT (p = 0.06) tended toward significantly predicting late esophageal toxicity. On univariate analyses, the effects of percent organ volume treated >50 Gy (p = 0.05), percent surface area treated >50 Gy (p = 0.05), length of 100% circumference treated >50 Gy (p = 0.04), and maximum percent of circumference treated >80 Gy (p = 0.01) significantly predicted for late toxicity of all grades. On multivariate analysis, percent organ volume treated >50 Gy (p = 0.02) and maximum percent of circumference treated >80 Gy (p = 0.02) predicted for late toxicity. CONCLUSIONS Late esophageal toxicity following aggressive, high-dose conformal radiotherapy is common but rarely severe. Dosimetric variables addressing the longitudinal and circumferential character of the esophagus have biologic rationale and are predictive of late toxicity. Further studies are needed to assess whether these parameters are better predictors than those derived from traditional DVHs.
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Affiliation(s)
- P D Maguire
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
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45
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Micke O, Schäfer U, Glashörster M, Prott FJ, Willich N. Radiation-induced esophageal carcinoma 30 years after mediastinal irradiation: case report and review of the literature. Jpn J Clin Oncol 1999; 29:164-70. [PMID: 10225701 DOI: 10.1093/jjco/29.3.164] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A 54-year-old man who had been irradiated in 1964 for cervical involvement by Hodgkin's disease was admitted in December 1994 to our clinic with strong complaints of dysphagia. The reason was a moderately differentiated squamous cell carcinoma of the proximal esophagus in the previously irradiated region. The patient had no risk factors (abuse of nicotine or alcohol) for the developement of esophageal carcinoma. A reirradiation was performed, but the disease progressed locally and two weeks after the beginning of the therapy the patient developed two tracheoesophagocutaneous fistulae. The radiation therapy was discontinued and the tumor stenosis was bridged by a tube closing the fistulae. A retrospective dose analysis to evaluate the applied doses will be performed. Furthermore, an overview of 66 cases of the literature with radiation-induced esophageal carcinoma analysed concerning applied dose and latent interval will be given. In conclusion the reported case fits the criteria for radiation-induced malignancies (Chudecki Br J Radiol 1972;45:303-4) known from literature: (1) a history of previous irradiation, (2) a cancer occurring within the irradiated area, (3) gross tissue damage due to an excessive dose of radiation, and (4) a long latent interval between irradiation and development of cancer. Esophageal carcinomas belong to the rare secondary malignancies after the therapeutic use of ionizing radiation. Nevertheless in patients with dysphagia they should be suspected as a differential diagnosis even many years after mediastinal irradiation. The treatment of these tumors is very difficult and is associated with a poor prognosis.
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Affiliation(s)
- O Micke
- Department of Radiotherapy and Radiation Oncology, University of Münster, Germany.
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46
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Abstract
Swallowing disorders affect a large and growing number of people in the United States, particularly the elderly. An appreciation of the anatomy, physiology and pathophysiology of swallowing disorders allows the practitioner to assess these problems and to make arrangements for their treatment. The purpose of this article, therefore, is to give an overview of the diagnosis and treatment of swallowing disorders.
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Affiliation(s)
- E Domenech
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
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47
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Abstract
Radiation-induced late effects of oesophagus are observed after treatment for various cancers. Acute reactions, mainly oesophagitis, are well known and accurately described; late effects share, for most of these, a common consequence: alteration of the main oesophageal function, namely to conduct the food bolus; clinically they are impaired in terms of mobility and stenosis. More rarely, ulcerations and pseudodiverticulae can be observed. Chemotherapy further increases the risk of late effects, especially in case of concomitant chemo-radiotherapy. All numbers and statistical data on oesophagus late effects should be regarded with caution due to recent changes in the therapeutic attitudes (more and more combined chemotherapy-radiotherapy) and some progress in given cancer locations. A common scale like the LENT-SOMA should enable the clinician to better know these late effects on oesophagus which is required to initiate effective prevention measures and adapted treatments.
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Affiliation(s)
- J J Pavy
- Service de radiothérapie, clinique Chénieux, Limoges, France
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48
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Coia LR, Myerson RJ, Tepper JE. Late effects of radiation therapy on the gastrointestinal tract. Int J Radiat Oncol Biol Phys 1995; 31:1213-36. [PMID: 7713784 DOI: 10.1016/0360-3016(94)00419-l] [Citation(s) in RCA: 281] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Late gastrointestinal complications of radiation therapy have been recognized but not extensively studied. In this paper, the late effects of radiation on three gastrointestinal sites, the esophagus, the stomach, and the bowel, are described. Esophageal dysmotility and benign stricture following esophageal irradiation are predominantly a result of damage to the esophageal wall, although mucosal ulcerations also may persist following high-dose radiation. The major late morbidity following gastric irradiation is gastric ulceration caused by mucosal destruction. Late radiation injury to the bowel, which may result in bleeding, frequency, fistula formation, and, particularly in small bowel, obstruction, is caused by damage to the entire thickness of the bowel wall, and predisposing factors have been identified. For each site a description of the pathogenesis, clinical findings, and present management is offered. Simple and reproducible endpoint scales for late toxicity measurement were developed and are presented for each of the three gastrointestinal organs. Factors important in analyzing late complications and future considerations in evaluation and management of radiation-related gastrointestinal injury are discussed.
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Affiliation(s)
- L R Coia
- Fox Chase Cancer Center, Department of Radiation Oncology, Philadelphia, PA 19111, USA
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49
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Soffer EE, Mitros F, Doornbos JF, Friedland J, Launspach J, Summers RW. Morphology and pathology of radiation-induced esophagitis. Double-blind study of naproxen vs placebo for prevention of radiation injury. Dig Dis Sci 1994; 39:655-60. [PMID: 8131705 DOI: 10.1007/bf02088356] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Radiation-induced esophagitis can cause substantial morbidity. Experiments in lab animals have shown that pretreatment with indomethacin protects the esophagus from radiation damage. We conducted a prospective, double-blind, randomized trial of naproxen vs placebo in patients undergoing thoracic radiation therapy for lung cancer. Twenty-eight patients were enrolled, of which 26 completed the study. Sixteen patients were given a short course of radiation (30 Gy/10 fractions/2 weeks), and 10 patients were given a longer course and a larger dose (40-50 Gy/25 fractions/5 weeks). Half of the irradiated patients were treated with naproxen, 375 mg, taken orally twice a day, and half were given an identical placebo. All patients were given ranitidine 300 mg, taken orally once a day. Study drugs were taken throughout the course of radiation. Endoscopy with esophageal biopsies and brushings was performed before and on the last day of treatment. Patients kept a daily diary for symptom scoring. Symptoms such as chest pain, dysphagia, odynophagia, and/or heartburn were reported in 15 patients from both subgroups, resulting in diet restriction to liquids only in eight patients and requiring temporary discontinuation of radiation therapy in one of them. Approximately half the patients in each subgroup developed esophagitis, usually mild and usually limited to the proximal esophagus. Severity of symptoms was not proportional to the severity of esophagitis. Candidiasis was documented in eight patients, but only four had symptoms that were severe in one. We conclude that acute radiation injury to the esophagus is observed in approximately half the patients receiving radiation therapy and can result in substantial morbidity.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- E E Soffer
- Department of Medicine, University of Iowa Hospitals, Iowa City 52242
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Affiliation(s)
- R A DuBrow
- Diagnostic Radiology Department, University of Texas M.D. Anderson Cancer Center, Houston 77030
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