Abstract The majority of patients with carcino- ma of the oesophagus present with advanced disease and difficulty in swallowing as their main symptom. These patients receive intraluminal radiation therapy for quick relief of dysphagia as one of the main palliative options. Presently lesion length is esti- mated depending on the filling defect seen on Hexabrix swallow, which is measured against the number of ver- tebrae the lesion spans (each vertebra is taken to measure 2.5 cm). We have devised a modification of the tech- nique for the intraluminal procedure, with patients having a localisation film with Hexabrix at the simulator using a magnification graticule, with the grid projecting at 1 cm intervals at the isocentre. Ten consecutive patients underwent the procedure and the lesion length was calculated using the modified as well as the earlier tech- nique. The mean and median differ- ences in lengths calculated were 1.72 cm and 1.5 cm respectively (range 1.25 - 2.50 cm). The length of the lesion was longer when the number of vertebrae was used for an estimation of the length. With the modified tech- nique it was possible to decrease treat- ment length and the number of nor- mal oesophageal mucosa in the treat- ment volume, thereby reducing the chance of treatment-related complica- tions such as strictures and ulceration. Introduction The majority of patients with car- cinoma of the oesophagus present with advanced stage disease and poor prognosis, with difficulty in swallow- ing as the major presenting symp- tom.1 Intraluminal radiation therapy is useful for controlling the endolumi- nal disease and this treatment modal- ity leads to rapid improvement in swallowing. Various authors have published on the use of low and high dose rate intraluminal brachytherapy alone or in combination with external beam radiation therapy for the pallia- tion of advanced oesophageal can- cer.2-5 Ideally, the palliative treatment should not aggravate the patient’s symptoms by causing treatment- related toxicity or complications. The purpose of the modified technique is: (i) accurate assessment of the length of the lesion on Hexabrix swallow; and (ii) to decrease the fluoroscopy time during the procedure, thereby reducing staff exposure to radiation. Methods and materials Ten consecutive patients due for intraluminal radiation therapy for carcinoma of the oesophagus under- went the modified technique of simu- lation with Hexabrix using the magni- fication graticule with the grid pro- jecting at 1 cm interval at the isocentre prior to the procedure (Fig. 1). The length of the lesion and the centre of ORIGINAL ARTICLE 31 SA JOURNAL OF RADIOLOGY • May 2004 Vertebral height as the measure of lesion length in carcinoma of the oesophagus — is it accurate? V Sharma MD, PhD B Donde MB BCh, MMed Rad (t) M Mohiuddin MB BS, MMed Rad (Onc) B S Rabin MB BCh, MMed Rad (t) U Majeed MB BS, FFRad (Onc) D Chetty MB ChB C Nyongensa MB BS A Msemo MB BS Department of Radiation Oncology, Johannesburg Hospital and University of the Witwatersrand D van der Merwe PhD Department of Medical Physics, Johannesburg Hospital and University of the Witwatersrand R Glynn-Thomas MB BCh, DMRD (RCP, RCS) Department of Radiology, Johannesburg Hospital and University of the Witwatersrand ORIGINAL ARTICLE 32 SA JOURNAL OF RADIOLOGY • May 2004 field for treatment were localised and marked. The localised centre was tat- tooed and a lead wire placed at the centre. This procedure facilitated the positioning of the high dose rate (HDR) treatment catheter and assess- ment of the treatment length. Patients received premedication with pethi- dine and Buscopan 30 minutes before the procedure. The pharynx was anaesthetised with a topical spray using xylocaine 4%. The brachythera- py tube was inserted under fluoro- scopic guidance6 and fixed in position using a face mask. In the present procedure, insertion of the catheter is done under fluoro- scopic guidance after giving Hexabrix to demarcate the proximal end of the lesion. Most of the time, the distal end of the lesion cannot be delineated without giving Hexabrix 3 - 4 times with repeated fluoroscopy. The length of the lesion is therefore estimated by correlating with the number of verte- brae from the Hexabrix swallow per- formed in the radiology department (each vertebra is taken to measure 2.5 cm). 7,8 Table I shows the estimated length of the lesion using the number of ver- tebrae, the length as measured using a simulation film with grid and the dif- Fig. 1. Simulator film with grid (vertebral length = 2.5 vertebrae = 6.25 cm, grid length = 5 cm). Table 1. Lesion length on Hexabrix swallow Patient number Vertebral height Simulator magnification Difference (cm) grid length (cm ) (cm) 1. 12.00 10.00 2.00 2. 8.00 6.00 2.00 3. 8.50 6.00 2.50 4. 7.50 6.00 1.50 5. 9.50 8.00 1.50 6. 7.50 6.00 1.50 7. 6.50 5.00 1.50 8. 6.25 5.00 1.25 9. 6.50 5.00 1.50 10. 8.00 6.00 2.00 Mean (cm) 8.02 6.30 1.72 Median (cm) 7.75 6.00 1.50 Minimum (cm) 6.25 5.00 1.25 Maximum (cm) 12.00 10.00 2.50 Fig. 2. Basic anatomy of the oesophagus showing four vertebrae = 10 cm. ORIGINAL ARTICLE 33 SA JOURNAL OF RADIOLOGY • May 2004 ference between these two lengths. The lengths according to vertebrae height were 6.25 - 12.0 cm (i.e. 2.5 ver- tebrae to 5 vertebrae), whereas the lengths according to the magnifica- tion graticule with grid were 5 - 10 cm, the difference being 1.25 - 2.50 cm (mean 1.72 cm, median 1.5 cm). Discussion Most patients with carcinoma of the oesophagus present with difficulty in swallowing as their main symptom. The role of intraluminal brachythera- py is to relieve the dysphagia without increasing the side-effects by treating minimal normal oesophageal mucosa. The present procedure of estimation of the length of the lesion by estimating the vertebral length is recommended by Potter and Lim- bergen7 and is depicted by Denittis8 (Fig. 2). The modified technique of doing prior simulation has already been published by us.6 The advantages of the modified technique are: (i) accurate assessment of the length of the lesion; (ii) reduc- tion in treatment length as well as normal mucosa treated, thereby decreasing the morbidity of treatment -related strictures and ulceration; (iii) reduced staff exposure as repeated fluoroscopy is eliminated; and (iv) reduced chance of Hexabrix aspira- tion in patients as the modified tech- nique is performed before sedation and topical anaesthesia. Conclusion Accurate assessment of the lesion length on Hexabrix will reduce nor- mal mucosa irradiation and decrease the toxicity of the treatment. It is rec- ommended that the change in clinical practice done at our centre be evaluat- ed by other groups. References 1. Sur RK, Donde B, Levin CV, Mannell A. Fractionated high dose rate intraluminal brachytherapy in palliation of advanced esophageal cancer. Int J Radiat Oncol Biol Phys 1998; 40: 447-453. 2. Rider WD, Mendoza RD. Some opinions on the treatment of cancer of esophagus. Am J Roentgenol Radium Ther Nucl Med 1969; 105: 514-517. 3. Mannell A, Murray W. Oesophageal cancer in South Africa. A review of 1926 cases. Cancer 1989; 64: 2604-2608. 4. Sharma V, Dinshaw KA, Agarwal JP, et al. Intraluminal brachytherapy for palliation of advanced / recurrent carcinoma of the esopha- gus. J Brachytherapy International 1999; 15: 85-92. 5. Sharma V, Mahantshetty U, Dinshaw KA, Deshpande R, Sharma S. Palliation of advanced /recurrent esophageal cancer with high dose rate brachytherapy. Int J Radiat Oncol Biol Phys 2002; 52: 310-315. 6. Dinshaw KA, Sharma V, Pendse AM, et al. The role of intraluminal radiotherapy and concur- rent 5 Fluorouracil infusion in management of carcinoma esophagus.: A pilot study. J Surg Oncol 1991; 47: 155-160. 7. Potter R, Limbergen EV. Oesophageal cancer. In: Gerbaulet A, Potter R, Mazeron JJ, Meertens H, Limbergen EV, eds. The GEC ESTRO Handbook of Brachytherapy. Leuven, Belgium: ESTRO, 2002: 515-537. 8. Denittis AS. Esophagus. In: Perez CA, Brady LW, Halperin EC, Schmidt-Ullrich RK, eds. Principles and Practice of Radiation Oncology. Philadelphia: Lippincott, Williams and Wilkins, 2004: 1282-1304.