Radiation Therapy-Related Toxicity: Esophagus

  • Voichita Bar Ad
  • Maria Werner-Wasik
Part of the Medical Radiology book series (MEDRAD)


Radiation-induced esophagitis is a dose-limiting toxicity of lung cancer treatment. The majority of patients receiving concurrent chemotherapy and thoracic irradiation experience acute esophagitis. Acute esophagitis may be disabling and necessitate hospitalization, placement of a feeding tube in the stomach, or initiation of parenteral nutrition. Moreover, interruption of the course of radiation therapy may be required in order to permit healing of the esophageal injury. Such treatment breaks have been demonstrated to decrease survival of patients with unresectable lung cancer. Proper prevention, diagnosis, and treatment of esophagitis are therefore essential, as it may have a direct influence on tumor control and survival.


Intensity Modulate Radiation Therapy Stereotactic Body Radiation Therapy Radiation Therapy Oncology Group Thoracic Radiotherapy Esophageal Injury 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Lethal dose


National Cancer Institute’s Common Terminology Criteria for Adverse Events


Radiation Therapy Oncology Group


Continuous hyperfractionated accelerated radiation therapy


European Organization for Research and Treatment of Cancer


Three-dimensional conformal radiation therapy


Dose–volume histograms


Quantitative analysis of normal tissue effects in the clinic


Computed tomography


Maximal tolerated dose


Volume receiving more than x Gy


Stereotactic body radiation therapy


Time-to-event continual reassessment method


Dose-limiting toxicities


Tolerance dose


Intensity modulated radiation therapy


Normal tissue complication probability


Cobalt-gray equivalent


Concurrent chemotherapy



No conflict of interest to declare.


  1. Ahn S, Kahn D, Zhou S et al (2005) Dosimetric and clinical predictors for radiation-induced esophageal injury. Int J Radiat Oncol Biol Phys 61:335–347PubMedCrossRefGoogle Scholar
  2. Antonadou D, Coliarakis N, Synodinou M et al (2001) Randomized phase II trial of radiation treatment plus/minus amifostine in patients with advanced-stage lung cancer. Int J Radiat Oncol Biol Phys 51:915–922PubMedCrossRefGoogle Scholar
  3. Ball D, Bishop J, Smith J et al (1995) A phase III study of accelerated radiotherapy with and without carboplatin in non-small cell lung cancer: an interim toxicity analysis of the first 100 patients. Int J Radiat Oncol Biol Phys 31:267–272PubMedCrossRefGoogle Scholar
  4. Belderbos J, Heemsbergen W, Hoogeman M, Pengel K, Rossi M, Lebesque J (2005) Acute esophageal toxicity in non-small cell lung cancer patients after high dose conformal radiotherapy. Radiother Oncol 75:157–164PubMedCrossRefGoogle Scholar
  5. Boal DK, Newburger PE, Teele RL (1979) Esophagitis induced by combined radiation and adriamycin. Am J Radiol 132:567–570Google Scholar
  6. Bradley J, Graham MV, Winter K et al (2005) Toxicity and outcome results of RTOG 9311: a phase I-II dose escalation study using three-dimensional conformal radiation therapy in patients with inoperable non-small-cell lung carcinoma. Int J Radiat Oncol Biol Phys 61:318–328PubMedCrossRefGoogle Scholar
  7. Byhardt RW, Scott C, Sause WT et al (1998) Response, toxicity, failure patterns, and survival in five RTOG trials of sequential and/or concurrent chemotherapy and radiotherapy for locally advanced non-small cell carcinoma of the lung. Int J Radiat Oncol Biol Phys 42:469–478PubMedCrossRefGoogle Scholar
  8. Chang JY, Komaki R, Bucci MK et al (2009) Failure patterns and toxicity of concurrent proton therapy and chemotherapy for stage III non-small cell lung cancer. Int J Radiat Oncol Biol Phys 75(3):S446CrossRefGoogle Scholar
  9. Chen Y, Pandya KJ, Feins R et al (2008) Toxicity profile and pharmacokinetic study of a phase I low-dose schedule-dependent radiosensitizing paclitaxel chemoradiation regimen for inoperable non-small cell lung cancer. Int J Radiat Oncol Biol Phys 71:407–413PubMedCrossRefGoogle Scholar
  10. Choi GB, Shin JH, Song HY et al (2005) Fluoroscopically guided balloon dilation for patients with esophageal stricture after radiation treatment. J Vasc Interv Radiol 16(12):1705–1710PubMedCrossRefGoogle Scholar
  11. Choy H, Safran H (1995) Preliminary analysis of a phase II study of weekly paclitaxel and concurrent radiation therapy for locally advanced non-small cell lung cancer. Semin Oncol 4(Suppl 9):55–57Google Scholar
  12. Choy H, LaPorte K, Knill-Selby E, Mohr P, Shy Y (1999) Esophagitis in combined modality therapy for locally advanced non-small cell lung cancer. Sem Rad Oncol 9:90–96Google Scholar
  13. Cox JD, Pajak TF, Asbell S et al (1993) Interruptions of high-dose radiation therapy decrease long-term survival of favorable patients with unresectable non-small cell carcinoma of the lung: analysis of 1244 cases from 3 RTOG trials. Int J Radiat Oncol Biol Phys 27:493–498PubMedCrossRefGoogle Scholar
  14. Dieleman EMT, Senan S, Vincent A et al (2007) Four-dimentional computed tomographic analysis of esophageal mobility during normal respiration. Int J Radiat Oncol Biol Phys 67:775–780PubMedCrossRefGoogle Scholar
  15. Dubray B, Livartowski A, Beuzeboc P, Pouillart P, Cosset JM (1995) Combined chemoradiation for locally advanced non-small cell lung cancer. J Infus Chemother 5:195–196PubMedGoogle Scholar
  16. Emami B (1996) Three-dimensional conformal radiation therapy in bronchogenic carcinoma. Semin Radiat Oncol 6:92–97PubMedCrossRefGoogle Scholar
  17. Gandara DR, Chansky K, Albain KS et al (2003) Consolidation docetaxel after concurrent chemoradiotherapy in stage IIIb non-small cell lung cancer: phase II southwest oncology group study S9504. J Clin Oncol 21(10):2004–2010PubMedCrossRefGoogle Scholar
  18. Goldstein HM, Rogers LF, Fletcher GH, Dodd GD (1975) Radiological manifestations of radiation-induced injury to the normal upper gastrointestinal tract. Radiology 117:135–140PubMedGoogle Scholar
  19. Grills IS, Yan D, Martinez AA, Vicini FA, Wong JW, Kestin LL (2003) Potential for reduced toxicity and dose escalation in the treatment of inoperable non-small-cell lung cancer: a comparison of intensity-modulated radiation therapy (IMRT), 3D conformal radiation, and elective nodal irradiation. Int J Radiat Oncol Biol Phys 57(3):875–890PubMedCrossRefGoogle Scholar
  20. Kahn D, Zhou S, Ahn SJ et al (2005) “Anatomically-correct” dosimetric parameters may be better predictors for esophageal toxicity than are traditional CT-based metrics. Int J Radiat Oncol Biol Phys 62(3):645–651PubMedCrossRefGoogle Scholar
  21. Kim TH, Cho KH, Pyo HR et al (2005) Dose-volumetric parameters of acute esophageal toxicity in patients with lung cancer treated with three-dimensional conformal radiotherapy. Int J Radiat Oncol Biol Phys 64(4):995–1002CrossRefGoogle Scholar
  22. Komaki R, Lee JS, Milas L et al (2004) Effects of amifostine on acute toxicity from concurrent chemotherapy and radiotherapy for inoperable non-small cell lung cancer: report of a randomized comparative trial. Int J Radiat Oncol Biol Phys 58(5):1369–1377PubMedCrossRefGoogle Scholar
  23. Langer C, Hsu C, Curran W et al (2001) Do elderly patients with locally advanced non-small cell lung cancer benefit from combined modality treatment? A secondary analysis of RTOG 94–10. Int J Radiat Oncol Biol Phys 51(1 Suppl):20–21CrossRefGoogle Scholar
  24. Lepke RA, Libshitz HI (1983) Radiation-induced injury of the esophagus. Radiology 148:375–378PubMedGoogle Scholar
  25. Maguire PD, Sibley GS, Zhou SM et al (1999) Clinical and dosimetric predictors of radiation-induced esophageal toxicity. Int J Radiat Oncol Biol Phys 45(1):97–103PubMedCrossRefGoogle Scholar
  26. McGinnis WL, Loprinzi CL, Buskirk SJ et al (1997) Placebo-controlled trial of sucralfate for inhibiting radiation-induced esophagitis. J Clin Oncol 15:1239–1243PubMedGoogle Scholar
  27. Michalowski A, Hornsey S (1986) Assays of damage to the alimentary canal. Br J Cancer 53(suppl 7):1–6Google Scholar
  28. Movsas B, Scott C, Langer C et al (2005) Randomized trial of amifostine in locally advanced non-small cell lung cancer receiving chemotherapy and hyperfractionated radiation: radiation therapy oncology group trial 98–01. J Clin Oncol 23(10):2145–2154PubMedCrossRefGoogle Scholar
  29. Patel AB, Edelman MJ, Kwork Y, Krasna MJ, Suntharalingam M (2004) Predictors of acute esophagitis in patients with non small-cell lung carcinoma treated with concurrent chemotherapy and hyperfractionated radiotherapy followed by surgery. Int J Radiat Oncol Biol Phys 60:1106–1112PubMedCrossRefGoogle Scholar
  30. Phillips TL, Ross G (1974) Time-dose relationships in the mouse esophagus. Radiology 113:435–440PubMedGoogle Scholar
  31. Rodriguez N, Algara M, Foro P et al (2005) Predictors of acute esophagitis in lung cancer patients treated with concurrent three-dimentional conformal radiotherapy and chemotherapy. Int J Radiat Oncol Biol Phys 73(3):810–817CrossRefGoogle Scholar
  32. Sarna L, Swann S, Langer C et al (2008) Clinically meaningful differences in patient-reported outcomes with amifostine in combination with chemoradiation for locally advanced non-small-cell lung cancer: an analysis of RTOG 98–01. Int J Radiat Oncol Biol Phys 72(5):1378–1384PubMedCrossRefGoogle Scholar
  33. Saunders MI, Dische S, Barrett A, Harvey A, Gibson D, Parmar M (1997) Continuous hyperfractionated accelerated radiotherapy (CHART) versus conventional radiotherapy in non-small cell lung cancer: a randomized multicenter trial. Lancet 350:161–165PubMedCrossRefGoogle Scholar
  34. Spielberger R, Stiff P, Bensinger W et al (2004) Palifermin for oral mucositis after intensive therapy for hematological cancers. N Engl J Med 351(25):2590–2598PubMedCrossRefGoogle Scholar
  35. Stickle RL, Epperly MW, Klein E, Bray J, Greenberger J (1999) Prevention of irradiation-induced esophagitis by plasmid/liposome delivery of the human manganese superoxide dismutase transgene. Radiat Oncol Invest 7:204–217CrossRefGoogle Scholar
  36. Suit H, Goldberg S, Niemierko A et al (2003) Proton beams to replace photon beams in radical dose treatments. Acta Oncol 42(8):800–808PubMedCrossRefGoogle Scholar
  37. Vokes EE, Herndon JE 2nd, Crawford J et al (2002) Randomized phase II study of cisplatin with gemcitabine or paclitaxel or vinorelbine as induction chemotherapy followed by concomitant chemoradiotherapy for stage IIIB non-small-cell lung cancer: cancer and leukemia group B study 9431. J Clin Oncol 20(20):4191–4198PubMedCrossRefGoogle Scholar
  38. Werner-Wasik M, Pequignot E, Leeper D, Hauck W, Curran W (2000) Predictors of severe esophagitis include use of concurrent chemotherapy, but not the length of irradiated esophagus: a multivariate analysis of patients with lung cancer treated with non-operative therapy. Int J Radiat Oncol Biol Phys 48:689–696PubMedCrossRefGoogle Scholar
  39. Werner-Wasik M, Axelrod SA, Friedland DP et al (2002) Phase II trial of twice weekly amifostine in patients with non-small cell lung cancer treated with chemotherapy. Semin Radiat Oncol 12(suppl 1):34–39PubMedCrossRefGoogle Scholar
  40. Werner-Wasik M, Yorke E, Deasy J, Nam J, Marks LB (2010) Radiation dose-volume effects in the esophagus. Int J Radiat Oncol Biol Phys 76(3 Suppl):S86–93PubMedCrossRefGoogle Scholar
  41. Werner-Wasik M, Paulus R, Curran WJ Jr, Byhardt R Acute esophagitis and late lung toxicity in concurrent chemoradiotherapy in patients with locally advanced non-small cell lung cancer: analysis of the radiation therapy oncology group (RTOG) database (in press)Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2011

Authors and Affiliations

  1. 1.Department of Radiation OncologyKimmel Cancer Center of Jefferson Medical College, Thomas Jefferson University HospitalPhiladelphiaUSA

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