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A new technique for endocavitary irradiation of the esophagus
0360.3016189 $3.00 + .I0 Copyright 0 I989 Pergamon Press plc
??Technical Innovations and Notes
A NEW TECHNIQUE G.
B.
PIZZI,
FOR ENDOCAVITARY
IRRADIATION
OF THE ESOPHAGUS
M.D.,* A. BEORCHIA,M.D.,* M. E. CEREGHINI,M.D.,* G. CONTENTO,PHYS.D.,~ S. FONGIONE, M.D.,* R. GUGLIELMI, M.D.* AND G. MANDOLITI, M.D.* Ospedale Civile, Udine
Recently, high-dose rate intracavitary irradiation has been used as a boost therapy or a palliative therapy in the treatment of the esophageal carcinoma. The new intraesophageal device is based on a modified Sengstaken-Blackemore tube. On the surface of the esophageal balloon of the S-B tube Cyponil tubes are fixed as iridium containers. The device is placed at the level of the neoplastic lesion. Treatment tolerance is good. Brachytherapy,
Esophageal carcinoma.
INTRODUCTION
are fixed on its surface. Then they are covered with a second security esophageal balloon. The patient is given antiemetic and spasmolitic drugs, before the loaded tube is inserted in the usual manner (Fig. 2). During the treatment, the patient is fed through the S-Btube.
The prognosis for a patient with esophageal carcinoma, treated by external radiation alone, is poor because of both distant metastasis and local recurrence. So as to minimize local failures, recently, intracavitary irradiation of the esophagus has been use used as boost therapy (1, 3, 5) or as palliative therapy (7). The high-dose rate intracavitary irradiation is the most used method for an adequate dose can be given with short and repeated exposures. With this method, late complications such as fistulas (6) esophageal structure (2), and esophageal ulceration (4), cannot be avoided. To reduce late complications a low-dose rate method is more suitable. This paper describes a new intraesophageal device allowing low-dose rate treatments to be easily performed and well tolerated. METHODS
AND
Dosimetry The six surface of the central odose that
,
MATERIALS
An adequate device is needed to use the low-dose rate of the Iridium wires. For this reason a Sengstaken-Blackemore tube has been modified. First of all an unmodified S-B tube is inserted and anchored by gastric balloon. The dental arc is reported on the surface of the tube. Once the tube is extracted the esophageal balloon is accurately placed as distant from dental arc as indicated by the esophagoscopy (Fig. 1). The esophageal balloon is inflated to obtain a cylindric form with a diameter of 2.5 cm. According to this 6 tubes of Cyponil as Iridium containers
Fig. 1. The original Sengstaken-Blackemore
33 100 Udine,
tube (inside) and
the modified one.
Acknowledgements-The authors want to thank Mr. Vittorino Mariotti for his technical cooperation. The authors also thank Ms. Danila Ariavig for typing this manuscript. Accepted for publication 27 July 1988.
* Istituto di Radioterapia. t Servizio di Fisica Sanitaria. Reprint requests to: Gianbeppi Pizzi M.D., Istituto di Radioterapia, Ospedale Civile, U.S.L. 7, Udinese, P. le S. Maria della Misericordia,
radioactive sorces are placed on the cylindrical the tube so that the radioactive lines intersect plane to form a regular hexagon. The first isincludes the cylinder coaxial to the tube with
UD, Italia.
261
262
I. J. Radiation Oncology 0 Biology 0 Physics
January 1989, Volume 16, Number I
0
1
2
80
40
30
Fig. 3. Dosimetry. central plane.
Fig. 2. Radiography showing the ‘921ridium wires positioned modified Sengstaken-Blackemore tube.
a margin of at least 5 mm is assumed (Fig. 3). RESULTS
AND
as reference
by
isodose
DISCUSSION
Four patients were treated with this technique. The treatment was always well tolerated and no early com-
Isodose curves disposition
3 20
on the transverse
plications were observed. A control biopsy, performed three months after the treatment was completed, did not show any sign of relapse. To treat an esophageal carcinoma it is essential to irradiate a large part of the esophagus even if the neoplastic lesion is apparently limited, and to irradiate the regions of probable lymphatic spread. Our technique might follow external radiotherapy to deliver a booster dose of irradiation in the more involved area. This method cannot be used when external beam irradiation fails to reduce the constricting esophageal lesions.
REFERENCES George, F. W., III. Radiation management in esophageal cancer; with a review of intraesophageal radioactive iridium treatment in 24 patients. Am. J. Surg. 139:795-804; 1980. Hishikawa, Y.; Kamikanya, N.; Tanaka, S.; Miura, T. Esophageal structure following high-dose rate intracavitary irradiation for esophageal cancer. Radiology 159(3):7 15716; 1986. Hishikawa, Y.; Kamikanya, N.; Tanaka, S.; Miura, T. Radiotherapy and esophageal carcinoma: role of high-dose rate intracavitary irradiation. Radiother. Oncol. 9: 13-20; 1987. Hishikawa, Y.; Tanaka, S.; Miura, T. Esophageal ulceration
induced by intracavitary irradiation for esophageal carcinoma. Am. J. Roentgenol. 143:269-273; 1984. 5. Hishikawa, Y.; Tanaka, S.; Miura, T. Early esophageal carcinoma treated with intracavitary irradiation. Radiology 156(2):519-522; 1985. 6. Hishikawa, Y.; Tanaka, S.; Miura, T. Esophageal fistula associated with intracavitary irradiation for esophageal carcinoma. Radiology 159(2):549-55 1; 1986. 7. Rowland, C. G.; Pagliaro, K. M. Intracavitary irradiation in palliation of carcinoma of oesophagus and card&. Lancet 8462 ii:981-982; 1985.
??Technical Innovations and Notes
A NEW TECHNIQUE G.
B.
PIZZI,
FOR ENDOCAVITARY
IRRADIATION
OF THE ESOPHAGUS
M.D.,* A. BEORCHIA,M.D.,* M. E. CEREGHINI,M.D.,* G. CONTENTO,PHYS.D.,~ S. FONGIONE, M.D.,* R. GUGLIELMI, M.D.* AND G. MANDOLITI, M.D.* Ospedale Civile, Udine
Recently, high-dose rate intracavitary irradiation has been used as a boost therapy or a palliative therapy in the treatment of the esophageal carcinoma. The new intraesophageal device is based on a modified Sengstaken-Blackemore tube. On the surface of the esophageal balloon of the S-B tube Cyponil tubes are fixed as iridium containers. The device is placed at the level of the neoplastic lesion. Treatment tolerance is good. Brachytherapy,
Esophageal carcinoma.
INTRODUCTION
are fixed on its surface. Then they are covered with a second security esophageal balloon. The patient is given antiemetic and spasmolitic drugs, before the loaded tube is inserted in the usual manner (Fig. 2). During the treatment, the patient is fed through the S-Btube.
The prognosis for a patient with esophageal carcinoma, treated by external radiation alone, is poor because of both distant metastasis and local recurrence. So as to minimize local failures, recently, intracavitary irradiation of the esophagus has been use used as boost therapy (1, 3, 5) or as palliative therapy (7). The high-dose rate intracavitary irradiation is the most used method for an adequate dose can be given with short and repeated exposures. With this method, late complications such as fistulas (6) esophageal structure (2), and esophageal ulceration (4), cannot be avoided. To reduce late complications a low-dose rate method is more suitable. This paper describes a new intraesophageal device allowing low-dose rate treatments to be easily performed and well tolerated. METHODS
AND
Dosimetry The six surface of the central odose that
,
MATERIALS
An adequate device is needed to use the low-dose rate of the Iridium wires. For this reason a Sengstaken-Blackemore tube has been modified. First of all an unmodified S-B tube is inserted and anchored by gastric balloon. The dental arc is reported on the surface of the tube. Once the tube is extracted the esophageal balloon is accurately placed as distant from dental arc as indicated by the esophagoscopy (Fig. 1). The esophageal balloon is inflated to obtain a cylindric form with a diameter of 2.5 cm. According to this 6 tubes of Cyponil as Iridium containers
Fig. 1. The original Sengstaken-Blackemore
33 100 Udine,
tube (inside) and
the modified one.
Acknowledgements-The authors want to thank Mr. Vittorino Mariotti for his technical cooperation. The authors also thank Ms. Danila Ariavig for typing this manuscript. Accepted for publication 27 July 1988.
* Istituto di Radioterapia. t Servizio di Fisica Sanitaria. Reprint requests to: Gianbeppi Pizzi M.D., Istituto di Radioterapia, Ospedale Civile, U.S.L. 7, Udinese, P. le S. Maria della Misericordia,
radioactive sorces are placed on the cylindrical the tube so that the radioactive lines intersect plane to form a regular hexagon. The first isincludes the cylinder coaxial to the tube with
UD, Italia.
261
262
I. J. Radiation Oncology 0 Biology 0 Physics
January 1989, Volume 16, Number I
0
1
2
80
40
30
Fig. 3. Dosimetry. central plane.
Fig. 2. Radiography showing the ‘921ridium wires positioned modified Sengstaken-Blackemore tube.
a margin of at least 5 mm is assumed (Fig. 3). RESULTS
AND
as reference
by
isodose
DISCUSSION
Four patients were treated with this technique. The treatment was always well tolerated and no early com-
Isodose curves disposition
3 20
on the transverse
plications were observed. A control biopsy, performed three months after the treatment was completed, did not show any sign of relapse. To treat an esophageal carcinoma it is essential to irradiate a large part of the esophagus even if the neoplastic lesion is apparently limited, and to irradiate the regions of probable lymphatic spread. Our technique might follow external radiotherapy to deliver a booster dose of irradiation in the more involved area. This method cannot be used when external beam irradiation fails to reduce the constricting esophageal lesions.
REFERENCES George, F. W., III. Radiation management in esophageal cancer; with a review of intraesophageal radioactive iridium treatment in 24 patients. Am. J. Surg. 139:795-804; 1980. Hishikawa, Y.; Kamikanya, N.; Tanaka, S.; Miura, T. Esophageal structure following high-dose rate intracavitary irradiation for esophageal cancer. Radiology 159(3):7 15716; 1986. Hishikawa, Y.; Kamikanya, N.; Tanaka, S.; Miura, T. Radiotherapy and esophageal carcinoma: role of high-dose rate intracavitary irradiation. Radiother. Oncol. 9: 13-20; 1987. Hishikawa, Y.; Tanaka, S.; Miura, T. Esophageal ulceration
induced by intracavitary irradiation for esophageal carcinoma. Am. J. Roentgenol. 143:269-273; 1984. 5. Hishikawa, Y.; Tanaka, S.; Miura, T. Early esophageal carcinoma treated with intracavitary irradiation. Radiology 156(2):519-522; 1985. 6. Hishikawa, Y.; Tanaka, S.; Miura, T. Esophageal fistula associated with intracavitary irradiation for esophageal carcinoma. Radiology 159(2):549-55 1; 1986. 7. Rowland, C. G.; Pagliaro, K. M. Intracavitary irradiation in palliation of carcinoma of oesophagus and card&. Lancet 8462 ii:981-982; 1985.