State of Art of the Radiotherapy of Esophageal Cancer

Prof dr Chiricuta I Christian

AMETHYST - Otopeni

Tumor Board RADIOTHERAPY CENTER BUCHAREST - AMETHYST

TUMOR BOARD

Divisions, terminology, and relationships of the esophagus. UES, upper esophageal sphincter; LES, lower esophageal sphincter. (Courtesy Dr. Dorothea Liebermann-Meffert; modified.)

ESOPHAGEAL CANCER TNM

Plan de radioterapie la un pacient cu o tumora atreimii craniale a esofagului iradiata pe un voluminsufficient si cu o doza insuficienta realizat intr-uncentru cu aparatura de ultima generatie si conformrecomandarile societatii americane de oncologie.

Exemplul cel mai elocvent cum intr-un centru de radioterapie cuaparatura de virf se foloseste o tehnica de iradiere din epocacobaltului si anume tehnica box (4 cimpuri). Aceasta tehnica faceimposibila aplicarea dozei necesare pentru a obtine un controltumoral. Din cei 66 Gy necesari au fost aplicati numai 50 Gy in 25fractiuni. Maduva spinarii a obtinut deja 37 Gy din 40 posibili. Oreiradiere cu doza necesare unui control tumoral adica cel putin 66Gy la 2 luni de la finalizarea primei radioterapii este imposibila.

Acesti medici activi azi in multe centre “au cazut nepregatiti intr-oepoca “moderna” si nu pot face fata cerintelor. Cine raspunde desoarta pacientului mai sus prezentat: un protocol nefericit al uneisocietati recunoscute (NCCN), un medic ce vine din era cobalt-uluisi acum are pe mina un accelerator de ultima generatie. Underamine constiinta medicului ? De ce nu trimite acest pacient la uncentru ce ofera tratamentul necesar?

Exodul de medici cu specialitatea radioterapie si oncologie este orealitate cu consecinte dramatice asupra asigurarii unui supportadecvat pacientului oncologic. In anul 2007 a fost raportat unnumar de 100 de medici de radioterapie in reteaua de stat, azisunt numai 50-60 in toata tara la stat si privat. Necesitatileradioterapiei la o populatie de 18 -20 de milioane ar fi 80 deacceleratoare liniare ce trebuie sa fie inzestrate cu cite 3 medicide specialitate per fiecare accelerator. Deci 240 pina la 300 demedici de specialitate sunt necesari considerind si pe cei ce ies lapensie in urmatorii ani.

This analysis demonstrates a marked downstaging and a significant survival benefit with combined neoadjuvant radiochemotherapy as compared to primary resection.

Die Rolle der PET-Untersuchung

beim Esophagus Karzinom

ISRO

Target Volume DefinitionBased on Involvement of Regional Lymphatics in Dependence of the Localisation of

the Primary Tumor

Kiricuta 1992 based on data from Akiyama 1988

Incidence of involvement of the lower neck nodes of the mediastinal and upper abdominal lymphatics for the extrathoracal and the intrathorcal esophageal cancer

Esophageal Carcinoma

TNM Regional Nodes

Cervical esophagus:

- scalene, internal jugular, upper cervical

- periesophageal

- supraclavicular

- cervical

Intrathoracic esophagus (upper, middle, lower):

- tracheobronchial

- superior mediastinal

- peritracheal

- carinal

- hilar (pulmonary

- periesophageal

- perigastric

- paracardial

- mediastinal

Recommendation for Lymphadenectomy

6 or more LN

ISRO

Lymph Node Staging MapEsophageal Cancer - Standardized Node Locations

Niegweg et al. Annals of Surgery 1999

ESOPHAGEAL CANCER TNM

ESOPHAGEAL CANCER

ESOPHAGEAL CANCER

55

65

75

85

Jun 9

7

Mrz

98

Apr

98

Mai

98

Sep

98

Okt 98

Dez

98

Dez

98

Dez

98

Dez

98

Jan 9

9

Jan 9

9

Jan 9

9

Feb

99

Gewichtsentwicklung bei Pat. mit Oropharynx Ca u. Zweittumor

des Ösophagus

Gew

icht

ges

und

Tumorresektion I.

Strahlentherapie mit

66,6Gy

Tumorresektion II

KG

Ösophagus-Ca

PEG-Anlage

Strahlentherapie mit

70Gy

Orale

Trinknahrung

Sondennahrung mit

3320-3528 kcal.

Ösophaguskarzinom im mittleren Drittel, mit ausgeprägtem extraluminären Wachstum ins Mediastinum (T4 NX M0) ED 11/98

Gleiches Karzinom nach Radiotherapie mit 70 Gy von 12/98 - 1/99

(distaler Anteil des Ösophagus)

nach 70 Gy RT

nach 60 Gy RT

vor RTvor RT

nach 60 Gy RT

vor RTEsophagus

Karzinom

82 Jahre alte

Patientin

Vor RT

Nach 60 Gy RT

Vor RT

Nach 70 Gy RT

Esophagus Karzinom

82 Jahre alte Patientin

vor CHT

vor CHT

vor CHTTumorbettnach

CHT + RT

Tumor

LK Meta Supraclav.

Tumor

Esophagus Tumordes oberen intrathorakalem Drittel

Esophagus Tumormit

Dosisverteilung

Vor CHT

PETvorCHT

ESOPHAGEAL CANCER

ESOPHAGEAL CANCER

ESOPHAGEAL CANCER

ESOPHAGEAL CANCER

ISRO

Anatomy of the Esophagus:The lymphatic drainage Zones of Resano

Haagensen 1972

PREOP RT + CHT, RTOG 94 – 05Minski et al. JCO 2002

Therefore, 50.4 Gy at 1.8 Gy per fraction 5 days per week is currently considered standardfor patients with esophageal cancer treated with concurrent chemoradiation therapy.56–58,66

Preop RT + CHT

ESOPHAGEAL CANCER VMAT RADIOTHERAPY

dupa iradiereFistula?

dupa iradiereFistula?

Inainte de iradiereFara fistula

ESOPHAGEAL CANCER VMAT RADIOTHERAPY

dupa iradiereFistula?

Inainte de iradiereFara fistula

ESOPHAGEAL CANCER VMAT RADIOTHERAPY

Inainte de iradieredupa iradiereFistula?

dupa iradiereFistula?

ESOPHAGEAL CANCER VMAT RADIOTHERAPY

Ultima iradiere (la 50 Gy)

Prima iradiere (la 0 Gy)dupa iradiere

Fistula?

ESOPHAGEAL CANCER VMAT RADIOTHERAPY

CANCER AL ESOFAGULUI PROXIMAL EXTRATORACAL CU EXTENSIE PACIENT IN VIRSTA DE 79 ANI

54 ani

8/2014

81 ani

AMETHYST TEAM

AMETHYST RADIOTHERAPY CLINIC

24 MASTER - STUDENTS

This patient is a 72-year-oldmale who presented withanemia.Esophagogastroduodenoscopy(“EGD”) revealed esophagealtumor extending from 29.0cmto 38.0cm. Endoesophagealultrasound staged this as T3 N0M0 carcinoma. CT scanrevealed abnormality involvingthe distal esophagus. The planwas for radiation therapycombined with chemotherapyand then definitive surgery.

A radiation-planning wholebody FDG PET/CT scan wasordered prior to onset oftreatment. This revealedintense increased uptake ofFDG in the distal esophagusand also two abnormal nodesin the anterior mediastinumsuperior to the primary mass.This was a surprise finding andvaluable in changing theradiation treatment volume soas to include these nodes.Both tumor staging andradiation treatment volumewere changed as a result ofthe PET/CT.

Whole body FDG-PET/CT MIP view (A), transaxial (B1) andsagittal (B2) fused images in a 64-year-old man withoesophageal carcinoma (thin arrows) and vertebralinvolvement (thick arrows), which rendered himinoperable.

Preoperative Radiochemotherapy in Gastric Cancer: Another Ongoing Shift From Adjuvant to Neoadjuvant?

JCO 2005, 3870-3871

Abdelkarim S. AllalRadiation Oncology Service, Geneva University Hospital,

Geneva, Switzerland

Fletcher1973

Perez& Brady1996

MacDonald2001

palliation AdjuvantRT+CT

Neoadjuvant

Siewert

CHEMORADIOTHERAPY AFTER SURGERY COMPARED WITH SURGERY ALONE FOR ADENOCARCINOMA OF THE STOMACH OR GASTROESOPHAGEAL JUNCTIONJ. S. MACDONALD et al. N Engl J Med, 2001; 345 (10): 725-730

Postoperative chemoradiotherapy should be considered for all patients at high risk for recurrence of adenocarcinoma of the stomach or gastroesophageal

junction who have undergone curative resection.

Greutate la inceput RT+CHT 65 kg, la sfirsit RT+CHT 65kg

66 ani

DG

ESOPHAGEAL CANCER TNM

ESOPHAGEAL CANCER TNM

PREOP RT + CHT, RTOG 94 – 05Minski et al. JCO 2002

Therefore, 50.4 Gy at 1.8 Gy per fraction 5 days per week is currently considered standardfor patients with esophageal cancer treated with concurrent chemoradiation therapy.56–58,66

ESOPHAGEAL CANCER

ESOPHAGEAL CANCER

Computed tomography (CT) scan and positron emission tomography (PET) images of a 71-year-old man who presented with abdominal discomfort. A, Chest CT scan showing abnormalesophageal thickening extending from the midesophagus to the distal esophagus.Esophagogastroduodenoscopy showed involvement with a moderately well differentiatedesophageal adenocarcinoma extending from 25 to 35 cm of the esophagus. B and C, PET scan(B) and combined PET-CT scans (C) show abnormal uptake in that area. D, Coronal PET imagesshow extent of the cancer. (Courtesy of Dr. Bohdan Bybel, Department of Radiology, ClevelandClinic.)

ESOPHAGEAL CANCER

Endoscopic ultrasonography (EUS). A, EUS can assess enlarged lymph nodessurrounding the esophageal cancer. Using certain criteria and combining them withfine-needle aspiration of suspicious lymph nodes (B), the accuracy can reach almost95%. This is highly dependent on operator experience.

ESOPHAGEAL CANCER

ESOPHAGEAL CANCER

ESOPHAGEAL CANCER

ESOPHAGEAL CANCER

ESOPHAGEAL CANCER

Adenocarcinoma

Squamous cell carcinoma

50

55

60

65

70

75

80

85

90

95

100

105

110

Bevor Ther. Begin RT End RT

Ge

wic

ht

in k

g

Pat.v.S. Pat.La. Pat.Jö. Pat.Kr.

Pat.Re. Pat. Ge. Pat. Wa. Pat. Fa.

Gewichts-Follow Up von Patienten mit Hochdosisstrahlentherapie bei

HNO-Tumoren

unter Immunonutrition

ESOPHAGEAL CANCER

SCC Adeno Ca

Radiation was delivered in daily fractions of 1.8 Gy (days 1–5, 8–12, 15–19, and 22–26) to a total dose of 36 Gy using a multiple field technique. Surgical resection was carried out 4–5weeks following completion of chemoradiation

28/03/14

Results

P=0.0098

163