HDR Brachytherapy boost after definitive CRT in esophageal cancer

[probiotic]

Hi guys
Anyone has any experience with HDR brachytherapy boost to escalate dose in definitive chemoradiotherapy for esophageal cancer?


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[Palex80]

Yes, I've done it before in a few cases.

Usually 2 x 5 Gy prescribed to 5mm depth. I only did it for T2N0 disease, which was inoperable due to comorbidities/age. RCTx was 54/1.8.

In my opinion you don't need to do it. There are some german and asian data pointing out to enhanced control, all retrospective. You can however nowadays easily push the dose higher than 50.4-54 Gy with EBRT. Just boost to 60-66Gy and you probably have more or less the same effect.

 

[seper]

Old, classic data from US shows that it is not worth it. The only patient I've seen that had it died from post-procedure aspiration.

 

[Chartreuse Wombat]

Bad idea in my opinion. We have a randomized study of dose-escalation that was negative and a Phase I/II study that found excess toxicity with HDR.

https://www.ncbi.nlm.nih.gov/pubmed/11870157

https://www.ncbi.nlm.nih.gov/pubmed/9112458

 

[evilbooyaa]

I guess the question becomes - why boost with HDR? you can do IMRT boost much safer, IMO, without having to worry about exact location of catheter and whether it's along the correct side of the wall.

Regardless of a boost their main risk is for distant failure.

 

[medgator]

People used to boost with HDR implant for H&N CA before the era of IMRT. I think esophagus is in the same boat. In the IMRT area, I don't see a point to brachhy for either disease site outside of an isolated/symptomatic recurrence after treatment.

 

[Palex80]

Bad idea in my opinion. We have a randomized study of dose-escalation that was negative and a Phase I/II study that found excess toxicity with HDR.

https://www.ncbi.nlm.nih.gov/pubmed/11870157

https://www.ncbi.nlm.nih.gov/pubmed/9112458

The Minsky trial has several flaws. It was underpowered, patients died in the dose escalation arm even before reaching the escalated dose, etc...
I am aware that in the US people seldom go over 50.4 Gy for definitive RCT in esophageal cancer but in Europe doses are rather higher. Mostly in the area of 60 Gy.

 

[probiotic]

Bad idea in my opinion. We have a randomized study of dose-escalation that was negative and a Phase I/II study that found excess toxicity with HDR.

https://www.ncbi.nlm.nih.gov/pubmed/11870157

https://www.ncbi.nlm.nih.gov/pubmed/9112458

Excessive toxicity in the Gasper trial is attributed to several issues including higher doses (3*5 Gy) in comparison to ABS recomendation (2*5Gy) and using concurrent chemotherapy with the brachytherapy session. Also high grade toxicity was limited to patients in which a 6mm diameter applicator was used that leads to a very high mocusal dose.


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[medgator]

The Minsky trial has several flaws. It was underpowered, patients died in the dose escalation arm even before reaching the escalated dose, etc...
I am aware that in the US people seldom go over 50.4 Gy for definitive RCT in esophageal cancer but in Europe doses are rather higher. Mostly in the area of 60 Gy.

I think people in the US actually do go over 50.4 despite the guidelines understanding the flaws in the minsky trial you pointed out. I've done it before when someone can't go to surgery and I've had some durable long term responses.