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