Impact of radical dose escalation by endoluminal brachytherapy and induction chemotherapy in the definitive treatment of locally advanced esophageal cancer - A retrospective study

Background: The loco-regional recurrence rate remains the main concern in the treatment of esophageal cancer. However, there are controversial data regarding the benefit of dose escalation in the treatment of esophageal cancer. The study examines the implications of dose escalation with endoluminal brachytherapy after induction chemotherapy and definitive chemoradiation in cases of carcinoma esophagus. Material and Methods: Total 31 biopsy-proven patients with inoperable, locally advanced esophageal cancer of stage IIA-IIIB were enrolled from January 2006 till December 2018. All patients underwent two cycles of three weekly induction chemotherapy followed by definitive external beam radiotherapy of 45-50.4 Gray (Gy) at 1.8 Gy per fraction along with chemotherapy, followed by intraluminal brachytherapy boost of two fractions with 5 Gy each. Overall survival (OS) was censored at death or the last follow-up. Results: Of 31 patients, 26 (83.97%) received concurrent chemotherapy and 30 (96.77%) completed radiation therapy. At the end of 3 months, 10 (32.2%), 13 (41.9%), 5 (16.1%), and 3 (9.6%) had complete response, partial response, stable disease, and progression of the disease, respectively. Distal failure was seen in five (16.1%) cases. The median OS was 28 months. OS at 2 years and 5 years was 20 (64.5%) and 9 (28.3%), respectively. At the end of 3 months, 17 (54.8%) of patients had no dysphagia, four (12.9%) of patients had improvement of more than 2 points in dysphagia score, five (16.1%) of patients had no change in the score and five (16.1%) of the patients had worsening of the dysphagia score by 1 point. Median dysphagia-free survival was 10.7 months, eight (25.8%) developed dysphagia after the dysphagia-free interval and two (6.4%) had worsening of dysphagia after treatment. There were no reported grade III or grade IV acute toxicities. Conclusion: The protocol has shown an acceptable survival and dysphagia-free interval. The study suggests intraluminal brachytherapy with induction chemotherapy and definitive chemoradiation is a feasible option in locally advanced esophageal cancer.