Radiation Oncology/Supportive care/Esophagitis

Esophageal Toxicity Management Toxicity and Dosimetry Please see the Esophagus Toxicity section for information about toxicity grading and dosimetric considerations Treatment Overview Symptomatic relief Topical anesthetics (e.g. viscous lidocaine) NSAID analgesics Narcotic analgesics Ca++ blocker if spasm a component Proton pump inhibitor if GERD a component Nutritional support IV fluids G-tube feeding TPN Sucralfate may be helpful, but clinical trials inconclusive Prevention Sucralfate NCCTG (1993-1994) -- Sucralfate suspension vs placebo Randomized. 97/100 patients undergoing mediastinal RT. Arm 1) Sucralfate suspension 1g/30 ml QID during and for 2 weeks after RT vs. Arm 2) placebo 1997 PMID 9060568 -- "Placebo-controlled trial of sucralfate for inhibiting radiation-induced esophagitis." (McGinnis WL, J Clin Oncol. 1997 Mar;15(3):1239-43.) Outcome: No difference in RTOG esophagitis score or self-reported questionnaire scores Toxicity: GI toxicity sucralfate 58% vs. placebo 14% (SS); medication stopped 40% vs. 4% (SS) Conclusion: No benefit for oral sucralfate solutions, with significant side effects Amifostine Greece Multicenter (1997-1999) -- amifostine vs control Randomized. 97 patients with advanced lung CA, undergoing definitive RT 55-60 Gy. No concurrent chemotherapy. Arm 1) amifostine 340 mg/m2 QD 15 min prior to RT vs. Arm 2) control 2001 PMID 11704311 -- "Randomized phase III trial of radiation treatment +/- amifostine in patients with advanced-stage lung cancer." (Antonadou D, Int J Radiat Oncol Biol Phys. 2001 Nov 15;51(4):915-22.) Pneumonitis: Grade 2+ amifostine 9% vs. control 43% (SS); Grade 2+ lung damage 16% vs. 49% (SS); 6-month rate of fibrosis 28% vs. 53% (SS) Esophagitis: Grade 2+ amifostine 4% vs. 42% (SS) Outcome: 2-month PR/CR amifostine 75% vs. control 76% (NS) Conclusion: Amifostine reduces pneumonitis, lung fibrosis, and esophagitis without compromising efficacy Glutamine Barcelona; 2007 (Spain) PMID 17531398 -- "Prevention of radiochemotherapy-induced esophagitis with glutamine: results of a pilot study." (Algara M, Int J Radiat Oncol Biol Phys. 2007 Oct 1;69(2):342-9. Epub 2007 May 24.) Prospective. 75 patients with lung CA. Prophylactic glutamine powder 10g TID. RT 65-70 Gy Outcome: no esophagitis in 49% of concurrent chemo-RT and 73% of sequential chemo-RT patients Dosimetry: Grade 2+ esophagitis if V50 <=30% risk 22% vs. V50 >30% risk 71% (SS) Conclusion: Oral glutamine may have role in prevention of esophageal complications