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28 Cards in this Set

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What does this image show?
CT showed circumferential thickening at the GE-junction (shown by arrow) consistent with the site of tumor.
Draw the treatment field for a JE jxt esophageal CA on AP DRR.
Digitally reconstructed radiograph for a typical lower esophageal lesion-AP view. gross tumor volume, red; celiac trunk, blue; right kidney, green; left kidney, blue (Courtesy of Rhonda May, CMD and Shiva Das, Ph.D.)
What should be included in the workup of patients with suspected esophageal cancers?
H&P, labs (LFT, AP, Cr), EGD with biopsy. If cancer, then EUS+FNA for nodal sampling for T&N staging, CXR, bronchoscopy (for upper & mid thoracic lesions to r/o tracheoesophgeal fistula), PET/CT. Laparoscopic staging is done in some institutions, with reports of upstaging and spares the morbidity of more aggressive treatment in 10-15% of cases.
What is new about the newly revised 7th Edition of the TNM staging for esophageal cancer?
New system distinguishes the number of nodal metastasis, subclassifies T4 disease, expands Tis definition, and removes M1a/b designation.

Tis=high grade dysplasia and CIS
T1a=involves lamina propria or muscularis mucosae
T1b=involves submucosa
T2=invades muscularis propria
T3=invades adventitia (note: no serosal layer)
T4a=pleural, pericardial, or diaphragm involvement
T4b=other organs (aorta, vertebral body, trachea)

Nx: regional nodes cannot be assessed
N0: No regional node metastasis
N1: 1-2 regional lymph nodes metastasis, including nodes previously labeled as M1a*
N2: 3-6 regional lymph nodes metastasis, including nodes previously labeled as M1a*
N3: >=7 regional lymph nodes metastasis, including nodes previously labeled as M1a*

*M1a (differ by site): upper thoracic=cervical LN mets; mid thoracic=not applicable; lower thoracic/GE jcn=celiac LN mets. (Note: M1a designation is no longer recognized on the 7th edition.)
M1: distant metastasis (retroperitoneal, paraaortic LN, lung, liver, bone, etc).
How do transhiatal and transthoracic esophagectomy procedures compare in terms of dissection extent and location of the disease?
In general: Transhiatal approach maybe less morbid, but have less exposure to allow wider tumor clearance or more thorough LN dissection compared to transthoracic approach. Anastomatic leak for transhiatal approach is easier to manage than the transthoracic approach (cervical vs intrathoracic leaks).
Transhiatal esophagectomy: pros: Good for distal tumors with possible en-bloc resection, laparotomy and cervical approach (no thoractomy) w/ cervical anastomosis, less morbid with less pain and avoids fatal intrathoracic anastomotic leak. Cons: poor visualization of upper/mid thoracic tumors, LN dissection limited to blunt dissection, more anastomotic leaks, more recurrent laryngeal nerve palsy.
Transthoracic esophagectomy: Ivor-Lewis (right thoractomy) is the most common and preferred route and best for exposure for all levels of esophagus, whereas left thoractomy provides access to only distal esophagus. Ivor Lewis (rt thoractomy and laparotomy) provides direct visualization and exposure with better radial margin and more thorough LN dissection. Cons: intrathoracic leak can lead to fatal mediastinitis.
Does the number of nodes removed from esophagectomy predict for better outcome?
Yes, data suggests that the number of nodes removed is an independent predictor of survival. In one large study, the optimal number is 23 (Peyre CG et al., Ann Surg 2008)
What are the typical pCR rates after chemoradiation for esophageal cancer?
pCR rate range from 22-40% in the randomized trials using cisplatin/5FU (on average 25-30%).
What are some supportive measures that should be considered for patients being treated for esophageal ca?
Avoid interruptions for manageable acute toxicities. Prophylactic anti-emetics and use antacid/antidiarrheals prn. Nutritional assessment and consider the need for feeding tube.
What is the data to support using definitve chemo/rt vs rt alone for locally advanced esophageal ca?
RTOG 85-01 randomised pts to RT alone vs RT +cis/5FU. The 5 yr OS with 27% vs 0% for RT alone.
Is there a benefit to escalating the RT dose beyond 50.4 when using chemo/rt for esophageal ca? What study supports this?
The Intergroup 0123 by Minsky is a phase III study that randomized pts to 50.5 Gy vs 64.8 Gy with cis/5FU. No difference in LC. excessive deaths in high dose arm. No benefit to higher dose even with deaths excluded.
If a patient has esophagectomy with gastric pull-up, does post-op RT need to cover the anatamosis?
Describe the standard chemo/rt regimen for esophageal ca as done in RTOG 85-01. What is 5 yr OS?
Definitve Chemo/RT
Standard therapy is from RTOG 85-01
5-FU: 1000 mg/m2 by CI, weeks 1 and 4
CDDP: 70 mg/m2, weeks 1 and 4
RT: 50.4 Gy (this is the standard!)
5-yr OS: 27%
T3N1 esophageal ca is stage group III. What is estimated 5 yr OS?
5-yr OS by stage--pretty dismal for anything beyond a T1N0 lesion
I – 60%
II – 30%
III – 20%
IV - <5%
The largest study to date to look at the effects of preoperative chemoradiotherapy in advanced esophageal cancer has found that a combination regimen of chemotherapy and radiation before resection is superior to surgery alone--describe this study and its results.
phase III multicenter CROSS trial, involving 364 patients in the Netherlands with resectable esophageal adenocarcinoma or squamous cell carcinoma, the median survival of patients who received chemoradiation (CRT) and surgery was 49 months, compared to 26 months for those who received surgery alone. With a median follow-up of 32 months, 70 patients had died in the CRT group vs 97 in the surgery-alone group, and 3-year overall survival was superior in the CRT arm. The CRT regimen used in the CROSS trial-paclitaxel with carboplatin and 41.4 Gy radiotherapy-was well tolerated, CRT with surgery improved outcomes most for patients with squamous cell carcinoma (HR = 0.34), who comprised 23% of patients treated in both arms of the trial.
An esophageal ca invades the lamina propria. What is the stage adn treatment. What is the lymph node risk?
T1a-lamina propria: very low risk of distant mets <3%
Endoscopic mucosal resection w/o surgery is adequate
An esophageal ca invades the submucosa. What is the stage and standard of care.
T1b--standard of care is esophagectomy. For non-surgical candidate, 50.4 Gy with 2 drug chmo
What types of toxicities are experienced during radiotherapy and what measures should be taken to help minimize these toxicities?
Acute: esophagitis, skin irritation, fatigue, weight loss;
Late: dysphagia, stricture, pneumonitis, laryngeal edema, cardiac injury, renal insufficiency, liver injury.
Relief with topic anaesthesia, narcotics, H2 blockers, feeding tube, and limiting dose to critical structures.
What is standard chemotherapy for concurrent chemo-rt for esophageal ca?
Cis 75mg/m2 q 3 weeks x 4
5FU: 1000 mg/m2 CVI q 4 wks
Postop rec for a T2, N0 SCC of esophagus?
Observe – no RT
What is the role of adjuvant chemo +/- RT after surgery for esophageal ca?
No proven role for either. Neither improves survival. RT improves local control but with a toxicity cost. It is not standard to offer adjuvant therapy.
Rationale for neoadjuvant chemo/rt for esophageal ca
meta-analysis shows survival benefit over surgery alone with a 13% 2 year survival benefit for chemo/rt and a 7% benefit with chemo alone. Largest benefit seen in adenocarcinoma
Is surgery really needed after neoadjuvant chemo/rt for esophageal ca?
Not proven for SCC. Stahl even shows higher mortality with surgery. For adenoca-based on Stahl 2007, neoadjuvant chemo/rt improves 3 yr OS 28/5 to 48%.
What do you expect the pCR rate to be for locally advanced adenocca of the esophagus after neoadjuvant chemo vs chemo/rt
per Stahl 2007, neoadjuvant chemo/rt yields 16% pCR vs only 2% with neoadjuvant chemo alone
What dosimetric factor is most signficant predictor of post-operative morbidity for esophageal ca (in patients that got neoadjuvant chemo/rt)
VS5 volume of lung that got 5 Gy or less; goal is at least 3000cc get less than 5 Gy
Describe the prescription for an esophageal ca
GTV plus 1 cm radially and 3-4 cm sup inf. (modified based on anatomic boundaries) use 4D ct to get ITV. Add 5 mm to get PTV
NCCN notes a location at which esophageal ca is not resectable, even if the patient is physiologically able to undergo surgery; describe.
Esophageal resection should be considered for all physiologically fit patients with resectable esophageal cancer
(> 5 cm from cricopharyngeus)
Cervical or cervicothoracic esophageal carcinomas < 5 cm from the cricopharyngeus should be treated with definitive
What is local control and survival when using definitive chemo/rt for locally advanced esophageal ca?
Base on knowledge of RTOG 8501: Survival at 5 yrs is 26% (vs 0 in RT alone arm). LF is 45 % (vs 68% in RT alone)
Describe the technique for treating Supraclavs in a cervical esophagus primary.
RTOG 0436 says:
For cervical primaries (defined as tumors above the carina), the
>> bilateral supraclavicular nodes
>> need to be included. The preferable method is a 3-field technique (2
>> anterior obliques and a
>> posterior field). In most cases, this is not possible; therefore, it
>> is acceptable to initially treat
>> AP/PA to approximately 39.6 Gy, then switch to obliques to exclude the
>> spinal cord. The
>> supraclavicular field, which is excluded from the obliques, can be
>> supplemented with electrons to
>> bring the total dose up to 50.4 Gy (calculated 3 cm below the skin
>> surface). For mid-esophageal
>> primaries (at or below the carina), the paraesophageal nodes need to
>> be included, not the
>> supraclavicular or celiac. For distal/gastroesophageal primaries, the
>> field should include the
>> celiac nodes.