The multimodality therapy of advanced inoperable esophageal carcinoma. A retrospective analysis]

BACKGROUND: The records of 161 patients with inoperable esophageal carcinoma were reviewed to determine the influence of concurrent radiochemotherapy and brachytherapy on overall survival. PATIENTS AND METHODS: From 1984 to 1999 161 patients suffering from advanced esophageal carcinoma Stage II to IV were treated with radiotherapy alone (131) or radiochemotherapy (30). In 48 patients additional brachytherapy was given. Median follow-up was 8 months (1 to 64 months), the median external beam doses was 51 Gy (18 to 66.6 Gy) and the median brachytherapy dose was 10 Gy (4 to 25 Gy). Chemotherapy consisted of cisplatin and 5-fluorouracil. RESULTS: Median survival for all patients was 10 months, 3-year survival rate 13% and the 5-year survival 5.2%. In univariate analysis the best results were achieved by concurrent radiochemotherapy with a median overall survival of 13 months, a 4-year survival of 18% (p = 0.0368), the combination of external radiotherapy and additional brachytherapy with a median overall survival of 14 months, a 4-year survival of 12.2% (p = 0.0008). After combination of concurrent radiochemotherapy and brachytherapy the 2-year survival rate is 58%. Multivariate analysis revealed simultaneous radiochemotherapy, external beam dose and additional brachytherapy as prognostic factors. Combination of concurrent radiochemotherapy and brachytherapy was possible without significant increase of local toxicity. CONCLUSIONS: Our retrospective analysis demonstrates that concurrent radiochemotherapy and additional brachytherapy are effective treatment schedules without significant increase of toxicity and may improve overall survival of patients with inoperable carcinoma of the esophagus. According to the results of this retrospective study, it would be appropriate to conduct a randomized trial to evaluate the benefit of combination of concurrent radiochemotherapy and brachytherapy.     

Pulmonary complications of cytosine-arabinoside therapy: radiographic findings

Sixty-four patients underwent 66 remission induction courses with intermediate-dose cytosine-arabinoside (Ara-C) for treatment of acute myelogenous leukemia, acute lymphoblastic leukemia, or high-grade malignant non-Hodgkin's lymphoma. The Ara-C was administered in combination with amsacrine with or without VP16-213 and prednisone. After complete remission was achieved, 27 patients received 38 consolidation courses consisting of high-dose Ara-C either alone or in combination with amsacrine with or without VP16-213 and prednisone. Seven (11%) of 66 induction courses and eight (21%) of 38 consolidation courses were complicated by respiratory failure that was considered a pulmonary reaction to Ara-C therapy. The initial findings on chest radiographs in the 15 cases included a diffuse interstitial pattern (two), a mixed interstitial-alveolar pattern (eight), an alveolar pattern (three), and a normal pattern (two). In 11 cases, the abnormalities were diffuse throughout both lungs with a preference for the lower lobes in five. The changes were localized in two cases. A small pleural effusion was observed in two patients. In the majority of cases, the initial radiographic changes progressed to a predominantly alveolar pattern. Thirteen patients recovered clinically within 2-9 days, and two patients died of pulmonary complications. Radiologic recovery took 7-21 days. Rapid regression of alveolar consolidations within 3-7 days was the first sign of radiologic improvement. The interstitial pattern gradually regressed. We conclude that the spectrum of radiologic abnormalities in cases of pulmonary reaction to Ara-C therapy includes diffuse interstitial, mixed interstitial-alveolar, or alveolar pulmonary changes.     

Radiation therapy for gastric wall metastasis from esophageal carcinoma

An 86-year-old man with dysphagia underwent gastrointestinal fiberscopy (GIF) and was found to have a circumferential type 3 advanced carcinoma in the upper thoracic esophagus and a type 2 tumor in the posterior wall of the gastric body. Microscopic examination of biopsy specimens of both tumors demonstrated moderately differentiated squamous cell carcinoma. He was diagnosed as having stage IVb (T3N0M1b) esophageal carcinoma with gastric wall metastasis. A total of 60 Gy in 30 fractions of three-dimensional conformal radiation therapy (3D-CRT) was first administered to the esophageal carcinoma, next to the gastric wall metastasis. Concurrent chemotherapy was not given because of the patient’s refusal. No subjective morbidity was observed during the treatment. In the GIF study immediately after 3D-CRT, both esophageal and gastric wall tumors had attained a complete response. The dysphagia dissolved as the esophageal tumor shrunk. The patient has been doing well for 17 months after the start of 3D-CRT. No local recurrence was observed in either the esophagus or the stomach during follow-up GIF. Considering the dismal prognosis of esophageal carcinoma patients with intramural metastasis to the stomach, a watchful follow-up is needed.     

Frequency of severe complications after radiation therapy for cervical carcinoma.

An analysis of a material of 265 patients treated by radiation therapy for cervical carcinoma was performed with respect to severe complications. The complication rate in patients free of recurrence was 1.9 per cent and in those with recurrence 23 per cent, which indicates that severe complications are often caused by recurrence of the tumour.     

中晚期原发性肝癌合并症的介入治疗研究

目的探讨中晚期原发性肝癌合并症的综合介入治疗方法。方法将经病理、影像学诊断及AFP值证实的原发性肝癌符合筛选条件的患者共62例,按住院号数的单、双数随机分成两组:对照组(单纯TACE组)32例,综合治疗组(TACE 合并症处理组)30例。综合治疗组行TACE术时对肝动静脉瘘、门静脉癌栓及下腔静脉病变等并发症给予综合处理。结果TACE组治疗32例患者,1、2和3年生存率分别为68%、50%和19%,中位生存期1.5年;综合治疗组30例患者1、2和3年生存率分别为87%、75%和48%,中位生存期2.0年。综合治疗组的生存率及生存期均显著高于对照组(P<0.05)。与对照组相比综合治疗组疗效与死亡风险率差异有统计学意义(P<0.05)。结论原发性肝癌合并症的控制可增加TACE的疗效,显著提高原发性肝癌患者生存率,延长生存期。     

Foreign esophageal body impaction: multimodality imaging diagnosis

We report a case of a portion of bran bread impacted in the cervical esophagus in an 88-year-old woman. A complete radiologic study including ultrasonography, computed tomography, and barium swallow was performed. These techniques confirmed and localized the foreign body, which was endoscopically removed. A complete radiologic assessment can guarantee the usefulness of esophagoscopy to avoid significant morbidity from unnecessary procedures in a patient in poor clinical condition. Ultrasonography and computed tomography are attractive and profitable options in these cases.     

Renal transplant evaluation: multimodality imaging of post-transplant complications

With advancements in surgical techniques and immuno-suppression, renal transplantation is established as the most effective treatment option in patients with end-stage renal disease. Early detection of renal allograft complications is important for long-term graft survival. Late clinical presentation often causes diagnostic delays till the time allograft failure is advanced and irreversible. Imaging plays a key role in routine surveillance and in management of acute or chronic transplant dysfunction. Multimodality imaging approach is important with ultrasound-Doppler as the first-line imaging study in immediate, early and late post-transplant periods. Additional imaging studies are often required depending on clinical settings and initial ultrasound. Renal functional MRI is a rapidly growing field that has huge potential for early diagnosis of transplant dysfunction. Multiparametric MRI may be integrated in clinical practice as a noninvasive and comprehensive “one-stop” modality for early diagnosis and longitudinal monitoring of renal allograft dysfunctions, which is essential for guiding appropriate interventions to delay or prevent irreversible renal damage. With rapidly increasing numbers of renal transplantation along with improved patient survival, it is necessary for radiologists in all practice settings to be familiar with the normal appearances and imaging spectrum of anatomical and functional complications in a transplant kidney. Radiologist”s role as an integral part of multidisciplinary transplantation team continues to grow with increasing numbers of successful renal transplantation programs across the globe.     

Laser therapy and insertion of Wallstents for palliative treatment of esophageal carcinoma.

A combination of endoscopic laser therapy (ELT) and insertion of Wallstents is a good alternative therapy for palliation of esophageal carcinoma and was performed in 12 patients. The method allows repeated laser therapy and, if necessary, supplementary insertion of stents to maintain the patients' ability to swallow during their remaining lifespan.     

Surgery for esophageal carcinoma.

From 1975 through 1988, 257 patients with carcinoma of the thoracic esophagus have been treated in our Department. Operability was 90% (232/257), overall resectability 77% (198/257) and for the operated group 85% (198/232). Hospital mortality was 9.6% but decreased to 3% over the period 1986-1988. There were 65% squamous cell epitheliomas and 35% adenocarcinomas. pTNM staging was as follows: Stage I: 11.6%; Stage II: 23.2%; Stage III: 37.9%; Stage IV: 27.3%. Overall survival was 62.5% at 1 year, 42.4% at 2 year and 30% at 5 year. According to the pTNM staging 5-year survival was 90% for Stage I, 56% for Stage II, 15.3% for Stage III and 0 for Stage IV. There were no statistically significant differences according to tumor localisation, pathologic type, sex, age. Introducing extensive resection and extended lymphadenectomy seems to improve significantly survival in the patients in whom an operation with curative intention was performed, the 1-year survival being 90.8% versus 72%, 2-year survival: 81% versus 46%, and 5-year survival 48.5% versus 41% for respectively radical and non radical resections. Barrett adenocarcinomas have no worse prognosis than other esophageal carcinomas with a 5-year survival of 91.5% if lymphnodes negative, and a 54% overall 5-year survival. Functional results after restoration of continuity with gastric tubulation were judged excellent to very good in 86.5% at 1 year, but infra-aortic anastomoses have a much higher incidence of peptic esophagitis: 53% versus 8% for cervical anastomoses. From this study it can be concluded that in experienced hands surgery today offers the best chances for optimal staging, potential cure, and prolonged high quality palliation.     

立体定向放射治疗结合常规放疗治疗食管癌近期疗效观察

目的：评价立体定向放射技术结合常规放射技术治疗食管癌的近期疗效及不良反应。方法：采用OUR-XGD型全身伽玛射线立体定向放射系统，结合常规放疗（钴60机）治疗20例食管癌，比较治疗前后的食道吞钡片，胃镜，CT片中病灶的大小，临床症状，并观察其不良反应。结果：17例治疗后症状均有不同程度的改善，总有效率为85%，其中CR6例。PR11例。3月内死亡者2例。治疗后病灶无明显变化1例。治疗中5例出现明显恶心，呕吐，胸骨后烧灼样疼痛，5例无明显不适感，10例稍感疲乏无力。结论：立体定向放疗结合常规放疗治疗食管癌有显著的近期疗效，但如何防止远处转移及提高生存率仍很困难。     

胸上段食管癌螺旋断层放疗和容积旋转调强放疗的剂量学比较

目的 比较胸上段食管癌螺旋断层(HT)与容积旋转调强放疗(VMAT)计划的剂量学差异。方法 随机抽样法选取10例胸上段食管癌患者,分别设计HT和VMAT双弧照射调强放疗计划,肿瘤靶区体积(GTV)给予66 Gy/30次,计划靶区体积(PTV)给予50 Gy/30次。根据剂量体积直方图(DVH)评价靶区的D_1%、D_5%、D_95%、D_99%、适形指数(CI)、均匀性指数(HI)和危及器官(OAR)受量,比较治疗时间和机器跳数(MU)的差异。结果 HT组GTV和PTV的D_99%高于VMAT组(t=4.476、3.756,P<0.05);GTV与PTV的D_1%、D_5%、D_95%、HI和CI差异均无统计学意义(P>0.05)。HT组全肺V₁₀、V₁₅、V₂₀和全肺平均剂量(MLD)均显著低于VMAT组(t=-3.369、-4.824、-4.869、-3.657,P<0.05);全肺V₅、V₃₀和脊髓D_max差异均无统计学意义(P >0.05)。HT组治疗时间和MU数均远大于VMAT组(t=13.970、7.982,P<0.05)。结论 HT与VMAT技术均能满足胸上段食管癌放疗剂量要求。HT技术能显著减小双肺受量,而VMAT技术具备明显的效率优势。     

Disappearance of esophageal carcinoma after stenting combined with endoscopic laser therapy

A 92-year-old man with dysphagia secondary to squamous cell carcinoma of the esophagus was palliated repeatedly with endoscopic laser therapy and insertion of esophageal stents. During the treatment period of 32 months, the patient could be fed perorally while ingrowth of tumor, development of new stenoses at the edges of the stents, and breakage of one stent were encountered. A tracheoesophageal fistula developed at the upper edge of the first stent. The patient died from aspiration pneumonia. At autopsy, no cancer cells were found in the esophagus. Combined endoscopic laser treatment and stent therapy may keep a patient free from dysphagia during a long period of time and also may result in the complete disappearance of tumor growth in the esophagus.