25 Oesophageal Cancer

Oesophageal Cancer Brachytherapy

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THE GEC ESTROHANDBOOKOF BRACHYTHERAPY | Part II Clinical Practice Version 1 - 10/06/2019

Fig. 27.3. Staging of oesophagal cancer ( Korean Journal of Thoracic and Cardiovascular Surgery 2015 ) - Tis: high-grade dysplasia - T1a: invasion of lamina propria or muscularis mucosae - T1b: invasion of submucosa - T2: invasion of muscularis propria - T3: invasion of adventitia - T4a: invasion of pleura, pericardium, azygos vein, diaphragm, or peritoneum - T4b: invasion of other surrounding structures/organs as aorta, trachea or a vertebral body

Fig. 27.2. Basic anatomy of the oesophagus with topographic landmarks for the radiological determination of the longitudinal dimensions of the GVT: bony landmark, tracheal bifurcation and aortic notch. The length which is given by oesophagoscopy for the determination of the proximal and distal ends of the length of the GTV is also shown. The black dots indicate potential lymphatic spread.

- N0: no regional lymph node metastases - N1: metastases in 1-2 regional lymph nodes - N2: metastases in 3-6 regional lymph nodes - N3: metastases in 7 or more regional lymph nodes - M0: no distant metastases - M1: distant metastases

6.A. Curative indications in superficial OC (T1a or T1b-SM1) Endoluminal brachytherapy has been used successfully to treat superficial oesophageal cancer in combination with external beam radiotherapy, however, distinguishing clearly between cT1a indications with excellent 5-year outcomes and submucosal tumours cT1b where the results are less favourable [Murakami et al]. This study byMurakami et al. revealed inmultivariate analyses that tumour depth was the only significant predictor for overall survival (p=0.002). Tamaki et al. showed good 5-year outcomes of endoluminal brachytherapy boost in superficial OC in terms of cause-specific survival and locoregional control as well, and could not identify a significant difference between HDR and LDR brachytherapy boost after external beam radiotherapy (50-60 Gy) in terms of efficacy and safety [Tamaki et al.]. The endoscopic classification of the Japan Esophageal Society (JES) based on invasion depth of superficial OC may help to identify the best candidates for endoluminal brachytherapy following non-radical surgery (e.g. superficial submucosal dissection) with excellent cause specific survival rates for SM1 lesions with a submucosal invasion ≤ 200µm [Nagami et al.]. Thus, the indications for endoluminal brachytherapy as a single procedure in superficial OC are T1a N0 M0 and T1b-SM1 N0M0 without risk factors for para-oesophageal lymph node involvement such as G3 and angio-lymphatic invasion. When those risk factors are present in T1a / T1b-SM1 lesions external beam radiotherapy should be added to endoluminal brachytherapy. T1 with significant submucosal invasion (>SM1) and T2 lesions should be considered contraindications for any non-radical surgical procedure.

should be measured in an objective way at baseline and regularly after the therapy (e.g. after 6 weeks, 3 months and 6 months etc.). Standardised means of measuring the respective endpoints should be used. Degree of dysphagia and amount of obstruction is recorded as: 0=no dysphagia, 1=dysphagia to solids, 2=dysphagia to semisolids, 3=dysphagia to liquids, 4=total dysphagia (or aphagia) [Francis et al.]. The performance status (e.g Karnofsky index or WHO score) is documented to evaluate the general condition. The nutritional status (weight, body-mass-index, and nutritional risk score) should be recorded. In order to exclude synchronous malignancies complete examinations of theGI tract and a head&neck examination including panendoscopy are recommended. For patients older than 70 years at diagnosis a Comprehensive Geriatric Assessment (CGE) might be useful. Apart from blood counts, blood coagulation tests, renal tests, liver tests, andCEAno further specific laboratory examinations are necessary. In general, identification of comorbidities and their specific medications is mandatory.

6. INDICATIONS, CONTRA-INDICATIONS

Themain indications for endoluminal brachytherapy in oesophageal cancer are:

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