Radiation-Induced Esophagitis: A Common, Debilitating Clinical Challenge in Thoracic Radiotherapy

Radiation-induced esophageal swelling (esophagitis) and painful swallowing (odynophagia) are common and debilitating treatment toxicities for patients undergoing radiotherapy for lung, breast, or head and neck cancers or lymphoma, and represent a significant clinical and research challenge. Recent advances in radiographic quantification of esophagitis grade and the identification of candidate predictive biomarkers and multivariate risk-stratification models might lead to more timely detection and management of esophageal radiotoxicities. But the optimal dosimetric strategy for preventing radiation esophagitis has yet to be identified. Several clinical trials are under way to test potential treatments.

Acute radiotherapy-induced esophagitis (ARIE) is the most frequent local complication of thoracic radiotherapy; it is debilitating and can cause treatment disruptions and treatment discontinuation, affecting both patients’ quality of life and prognosis.^1-4Radiotherapy-induced mucosal inflammation, epithelial ulceration, and spikes in inflammatory cytokines are suspected pathophysiological culprits.³

Higher radiation dose and combined chemoradiation are both associated with the risk of developing esophagitis and painful swallowing (odynophagia).^1-3Some patients develop late esophageal stricture, with similar symptoms — but these cases are more frequently irreversible.³

In general, ARIE occurs within 3 months after completion of radiotherapy; however, typically onset occurs 2 weeks after treatment begins and lasts until 4 weeks after treatment concludes, with progressively worsening odynophagia, nausea, dysphagia, and, if ineffectively managed, anorexia.^1,3Late radiation esophagitis occurs more than 3 months after radiotherapy ends, with an average time from treatment to symptom onset of 6 months.³

Radiation esophagitis ranges from asymptomatic or mild fibrosis and slight difficulty with swallowing solid food to severe ulceration, fibrosis, perforation, necrosis, and even fistula.^2,3Severity is graded on a scale of 1 to 5: grade 1 represents clinically or radiographically detected and asymptomatic; grade 2 and 3, symptomatic with altered eating habits; grade 4, life-threatening requiring invasive intervention; and 5, patient death.³