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Presented By:
Dr. Vandana
Dept. of Radiation Oncology
CSMMU, Lucknow
Clinical Anatomy
Hollow muscular tube 25 cm in
length which spans from the
cricopharyngeus at the cricoid
cartilage to gastroesophageal
junction (Extends from C7-T10).
Has 4 constrictions
At
starting(cricophyrangeal
junction)
crossed by aortic arch(9inch)
crossed by left bronchus(11inch)
Pierces the diaphragm(15inch)
Histologically 4 layers:
mucosa, submucosa, muscular &
fibrous layer.
Contd
Four regions of the
esophagus:
Lymphatic Drainage
Epidemiology
Most common in China, Iran, South Africa, India and the former
Soviet Union.
Contd
Worldwide SCC responsible for most of the cases.
Genetic abnormalities:
p53 mutation, loss of 3p and 9q alleli, amp. Cyclin D1 &
amp. EGFR
Barretts esophagus is a
Pattern of spread
T1 14 to 21%
T2 38 to 60%
Pathological Classification
95%
Clinical Features
It is commonly associated with the
symptoms of dysphagia, wt. loss,
pain, anorexia, and vomiting
Symptoms often start 3 to 4
months before diagnosis
Dysphagia - in more than 90% pt.
Odynophagia - in 50% of pt.
Wt. loss more than 5 % of total
body wt. in 40 70% pt.
associated with worst prognosis.
Contd
Complications:
Cachexia, Malnutrition, dehydration, anaemia,.
Aspiration pneumonia.
Distant metastasis.
Invasion of near by structures: e.g.
Recurrent laryngeal nerve Hoarseness of voice
Trachea Stridor & TOF cough, choking &
cyanosis
Perforation into the pleural cavity Empyema
back pain in celiac axis node involvement
a:
Includes
nodes
previously labeled as
M1a
b : M1a designation
is no longer recognized
in the 7th edn. of the
AJCC system
Staging : Adenocarcinoma
Group
Tis (HGD)
1, X
IA
T1
1-2, X
IB
T1
T2
IIA
T2
IIB
T3
1-2, X
3
N1
T1-2
N2
T3
N1
T4a
N0
IIIB
T3
N2
IIIC
T4a
N1-2
T4b
Any
Any
N3
Any
Any
IV
Grade
N0
T1-2
IIIA
M0
Any
M1
Diagnostic Workup
Detailed history & Physical examination: Dysphagia,
Confirmation of diagnosis:
EGD: allow direct visualization and biopsy, measure proximal & distal distance of
tumor from incisor, presence of Barretts esophagus.
Early, superficial
cancer
Circumferential ulceration
esophageal cancer
Malignant stricture
of esophagus
Staging:
CT chest and abdomen: Essential for staging because it can identify extension
beyond the esophageal wall, enlarged lymph nodes and visceral metastases.
Endoscopic Ultrasonography
EUS:
PET Scan
Figure Distant lymph node metastases of esophageal cancer detected by integrated CT PET. A, Integrated CT
PET demonstrates para-aortic lymph node metastases showing increased FDG uptake (arrowheads). B,
Corresponding CT image shows lymph nodes (arrowheads) measuring 5 to 8 mm in diameter. Based on size
criteria, these lymph nodes may be considered benign on CT scan
Barium swallow:
can delineate proximal and distal margins as well as TEF
Helpful for correlation with simulation film.
Apple core
appearance
Treatment
Site of disease
Extent of disease involvement
Co-morbid conditions
Patient preference.
Surgery
Prerequisite for surgery
disease should be 5 cm beyond cricophyrangeus.
Surgery indications
Lower 1/3 rd oesophageal ds involving GE junction.
Tumor size <5 cm .
palliative surgery
Types of Surgery
Chemotherapy
No data proving that chemotherapy alone provides
improved survival or palliation. Partial response, not longterm remission, is the rule
Indication
Radiotherapy
Curative
Radical RT
Pre-Op RT
Post Op RT
Concurrent chemo-radiation
Palliative
EBRT
Brachytherapy
EBRT Techniques
Patient Positioning:
CERVICAL ESOPHAGUS: Supine with arms by the side
IMMOBILISATION :
Perspex cast
SUPERIOR BORDER: At C 7
INFERIOR BORDER : At T 4 ( carina )
2 cm lateral margins.
SC nodes irradiated electively.
SC nodes will be underdosed if oblique portals are used to
treat primary; can be boosted by a separate field if
required.
Radiotherapy
for CA
esophagus
EBRT - DOSES
Energy
6 10 MV linac or Co60
Chemoradiation:
50.4 Gy in 28 # at 1.8 Gy per #
Boost to 60 66 Gy for residual disease
Radical RT:
45 Gy / 25 # / 1.8 Gy per #
boost with 2 cm margin to total dose of
60Gy
Dose limitations
Spinal cord Dmax:45 Gy at 1.8 Gy/fx
Lung: Limit 70% of both lungs <20 Gy
Heart: Limit 50% of ventricles <25 Gy
Brachytherapy (Intraluminal)
As a boost after EBRT or as a palliative measure
Local control of 25% - 35 in palliative setting
In curative setting, addition of brachytherapy does not
improve results compared to Chemoradiation.
Limit dose to critical structure
Dose escalation to primary
Relief bleeding, pain and improves swallowing status in
palliative setting.
Contraindications:
T E fistula
Cervical esophagous location
Stenosis which cannot be bypassed
Contd
APPLICATORS
Trials RT alone
No randomized trials of RT Vs Sx
5 yr survival with conventional RT : < 10%
Tumors < 5 cm , 5 yr survival : 20%
Stage wise 5 yr survival:
Stage
Stage
Stage
Stage
I 20%
II 10%
III 3 %
IV 0%
Contd
For cervical esophagus, cure rates were similar with Radical
RT or Sx alone.
RT or Sx alone DOES NOT alter the natural history of the
disease.
RTOG 8501: RT Vs Chemo RT
Better LRC and improved OS with ChemoRT
Trials PreOP RT
Principle:
resectability, likelihood of tumor dissemination during
Sx , radioresponsiveness due to unaltered blood supply
5 randomised trials ,shows no apparent clinical benefit to
use of preop rt alone except,
Only one trial ( Huang et al ) showed survival advantage
of 46% Vs 25% with 40 Gy RT
Recent meta analysis Oesophageal Cancer Collaborative
Group study showed no clear survival advantage.
Trials PostOP RT
Advantages:
Treat areas at risk for recurrences while
minimizing dose to OAR.
Patients with node negative , completely
resected T1 / T2 tumors can be excluded.
Disadvantage:
Tolerance of stomach
interpositioning.
or
bowel
used
for
Contd
2 randomised trials:
Peniere et al :
Fok et al :
Trials Chemoradiation
ChemoRT
Vs RT Alone
61 pts chemoRT 50 Gy RT +
5 FU + CDDP on 1 , 5 , 8 & 11 weeks
Median survival : 8.9 Vs 12.5 months
5 yr survival : 0% Vs 30 %
Distant mets @ 5 yrs: 40% Vs 12 %
Acute toxicity : 25% Vs 44 %
Contd
RT dose escalation in Chemo RT
Contd
PRE OP CHEMO RT Vs Sx ALONE
44 Randomised trials
2 studies showed in local recurrence
Urba et al 19 % Vs 42 %
Bosset et al ( EORTC ) 28% Vs 40%
Pre-operative Chemotherapy
The role of preoperative
chemotherapy alone is
controversial, according
to
mixed
results
from
clinical trials.
Stage
Stage IIII and IVA
resectable
medically-fit
Recommended treatment
definitive chemo-RT (preferred for cervical esophagus)
Definitive chemo-RT
Stage IV palliative
Current approach
Conclusion
Dysphagia and weight loss are the two most common presentations in
patients with esophageal cancer.
Thank You
Patient undergoing
have worse quality
surgery
of life.
Surgery following
combined CRT appears to
improve local control, its
impact on ultimate survival
remains controversial.