title: Factors influencing the development of ulcers and strictures in carcinoma of the esophagus treated with radiotherapy with or without concurrent chemotherapy.
abstract: OBJECTIVE
  To ascertain factors that could influence the development of ulcers and strictures in the definitive management of squamous cell carcinoma (SCC) of esophagus treated with external beam radiotherapy (EBRT), high-dose-rate (HDR) intralumenal radiotherapy (ILRT) with or without concurrent weekly cisplatin (CDDP @ 35 mg/m2) chemotherapy (CT).
  
  
  METHODS
  Between 1990-2005, 244 patients with inoperable SCC of esophagus were identified from our database and grouped into one of the following: those receiving at least 60 Gy EBRT (Gp E, n=44); EBRT followed by HDR-ILRT (Gp E+I, n=98); at least 50 Gy EBRT with CT (Gp E+C, n=68); EBRT+HDR-ILRT + CT (Gp E+I+C, n=34). Ulcers (discovered on endoscopy) and strictures evident on a barium swallow (which needed dilatations) were scored as treatment induced, if the biopsy was negative. Factors likely to influence their outcome were analyzed.
  
  
  RESULTS
  The groups were matched for all patient and disease characteristics except pretreatment hemoglobin and Karnofsky performance score (KPS), which were lower in Gp E. The incidence of ulcers was 7%, 8%, 6% and 21% (P=0.08) while that of strictures was 14%, 9%, 21% and 41% (P=0.00) for the groups E, E+I, E+C and E+I+C respectively. On univariate analysis, patients with better KPS (P=0.03), treated with narrow applicators (6 mm vs. 10 mm, P=0.00), received CT (P=0.00) or assigned to Gp E+I+C (P =0.00) were more likely to develop strictures, with a trend for development of ulcers in Gp. E+I+C (P=0.08). Logistic regression retained only Gp E+I+C for development of ulcers (OR 10.36, 95% CI 1.2-89.1, P=0.03) and strictures (OR 4.2, 95% CI 1.4-12.6, P=0.00).
  
  
  CONCLUSIONS
  Treatment intensification as in Gp E+I+C results in about a three-fold increase in treatment induced late morbidity which can adversely impact on swallowing function and therefore emphasizes the need for optimisation of HDR-ILRT when used in a CT+RT protocol.
authors.affiliation: Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow-226 014, India.
authors.forename: Rohini
authors.initials: R
authors.lastname: Khurana
authors.forename: Kislay
authors.initials: K
authors.lastname: Dimri
authors.forename: Punita
authors.initials: P
authors.lastname: Lal
authors.forename: Neeraj
authors.initials: N
authors.lastname: Rastogi
authors.forename: K
authors.initials: K
authors.lastname: Joseph
authors.forename: Maria
authors.initials: M
authors.lastname: Das
authors.forename: Shaleen
authors.initials: S
authors.lastname: Kumar
mesh_terms: D000328:Adult; D000368:Aged; D000970:Antineoplastic Agents / Q000009:adverse effects* / Q000627:therapeutic use; D002294:Carcinoma, Squamous Cell / Q000188:drug therapy / Q000532:radiotherapy / Q000628:therapy; D002945:Cisplatin / Q000009:adverse effects / Q000627:therapeutic use; D003131:Combined Modality Therapy; D004935:Esophageal Diseases / Q000175:diagnosis / Q000209:etiology*; D004938:Esophageal Neoplasms / Q000188:drug therapy / Q000532:radiotherapy / Q000628:therapy*; D004940:Esophageal Stenosis / Q000175:diagnosis / Q000209:etiology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011882:Radiotherapy, High-Energy / Q000009:adverse effects*; D014456:Ulcer / Q000175:diagnosis / Q000209:etiology*
chemical_list: D000970:Antineoplastic Agents; D002945:Cisplatin