Radiation-induced oesophagitis is a consequence of radiotherapy toxicity of the oesophagus resulting in acute and/or chronic complications:
- acute oesophagitis: usually 2 to 4 weeks after commencing radiotherapy 1 to within ≤3 months after completion of the radiotherapy 3
- chronic oesophagitis: >3 months after completion of the radiotherapy 3
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Epidemiology
Patients receiving external-beam radiation therapy to treat bronchogenic carcinoma, mediastinal lymphomas, or tumours involving the thoracic spine are at risk 1. The method of radiation delivery (e.g. conventional radiotherapy vs. 3D-CRT), the total radiation dose, and the concurrent administration of chemotherapy are variants that may increase the risk for radiation-induced oesophagitis 2. Simultaneous treatment with doxorubicin hydrochloride greatly accentuates oesophageal inflammation 4.
Clinical presentation
- acute: dysphasia, odynophagia, and chest pain 1,2
- chronic: pending
Pathology
The radiation is known to cause cell death via pro-inflammatory cytokines triggered by direct DNA damage. The oesophageal mucosa has a high cell turnover and, therefore, is extremely vulnerable to radiation 3. The acute toxicity will manifest as mucosal inflammation, which may complicate with further ulceration or superimposed infection 2. If the inflammation overtakes the capacity of repair of the mucosa, oesophageal fibrosis will progressively develop and manifest later with strictures.
Radiographic features
Fluoroscopy
Given the superficial involvement in acute radiation-induced oesophagitis, most of the cases will show a normal oesophagogram. When there is a severe acute oesophagitis, fluoroscopy findings may include 1:
- abnormal peristalsis 2
- serrated contour due to wall oedema
- granular appearance without discrete ulcers
- mucosal ulceration: multiple, small, and within the radiation portal
- sloughing of the mucosa
- focal luminal narrowing: due to spasm and oedema
- perforation or fistulation: rare
In the late phase, a radiation-induced stricture may be demonstrated, characterised by a long stenotic segment of smooth contours correlating with the radiation portal 2.
CT
Both acute or chronic phases may show a focal oesophageal wall thickening along the irradiated oesophagus 2.
Nuclear medicine
PET-CT
In the acute phase, FDG PET-CT will demonstrate an extensive linear uptake within the irradiated oesophagus 2, reflecting inflammation.
Treatment and prognosis
Most of the acute radiation-induced oesophagitis tends to be self-limiting in most cases and managed clinically without further investigations 1.
Severe cases of acute oesophagitis can potentially complicate with perforation or fistulation, but these are rare findings nowadays.
Differential diagnosis
In the acute phase, consider:
- infective oesophagitis, particularly considering that those patients are immunocompromised
-
reflux oesophagitis
- usually also demonstrates hiatal hernia or gastrooesophageal reflux