Oblique portals for the primary and ant portal for nodesFour filed box technique (compensator to be used)Anterior wedge pair fieldsIMRTCT planning: IV contrast for mediastinal, abdominal and coeliac vessels
Change photoHow anterior field marked on post side
Photo theekkaro, scan a cervical region ba swallow if possible
5-FU, 5-fluorouracil; ECOG, Eastern Cooperative Oncology Group; GEJ, gastroesophageal junction; OS, overall survival; PD, progressive disease; PS, performance score; R, randomization. Data from the phase III ToGA trial clearly put trastuzumab on the map for patients with HER2-overexpressing gastric and GE junction cancer. To accrue a sufficient number of patients with HER2-positive gastric cancers, 3800 patients were screened for HER2 expression, and eventually 22% of these patients (n = 810) were found to be HER2 positive according to the study protocol. Of the 810 patients who were considered eligible for the study, 584 were ultimately randomized to receive either 5-fluorouracil or capecitabine plus cisplatin with or without trastuzumab. The dose of capecitabine used was 1000 mg/m2 twice daily, about the standard dose, administered for 2 weeks on and 1 week off. Most investigators used capecitabine and not the infusional 5-fluorouracil variation. The primary endpoint of this trial was overall survival.
AUTHOR NO OF PTS DOSE 2 YRS
Pearson 208 50Gy/4Wks NA 17%
Beatty et al 344 >40Gy to
n et al
Okawa et al 96 NR 9%(I-20%,II-
263 11%(yrs) 7%
RTOG 85-01 TRIAL(RT ALONE V/S CMT)
Wk 5 Wk 11
CDDP 75mg/m2 Day 1 and 5-FU 1gm/m2 C.I. day 1- 4
RESULTS OF RTOG 85-01 TRIAL
Gr IV Gr V Local
54% 44% 20% 3% 43% 22% 12.5 mo,
83% 25% 3% 0 64% 38% 8.9 mo,
P-value Sig Sig Sig Sig Sig Sig
All patients who received RT alone were dead of disease by 3 years.
Established chemoradiation as the conventional nonsurgical treatment
for esophageal cancer
Herskovic A et al. NEJM 1992;326:1593-1598
CONCURRENT CT+RT- META ANALYSIS OF 11RCT
Cochrane Database of Systematic Reviews
RESULTS OF METANALYSIS
Concomitant RTCT provided significant reduction in
mortality with a HR of 0.73.
The absolute survival benefit for RTCT at 1yr and 2 yr
was 9%and 4% respectively.
There was an absolute reduction of local recurrence
rate of 12%
INTENSIFICATION OF RADIATION DOSE
(BY BRACHYTHERAPY BOOST)
The cumulative incidence of fistula was 18%/year
and the crude incidence was 14%.
Esophageal fistulas were treatment-related rather
than tumor-related of the six treatment-related
fistulas, three were fatal .
Occurred in the region of the brachytherapy.
Five of the six patients developing fistulas received
15 Gy brachytherapy dose. (median-3.9 months)
The other patient received just one fraction of 5 Gy
and developed a fistula within 0.5 months.
Wk 5 Wk 13
CDDP 75mg/m2 Day 1 and 5-FU 1gm/m2 C.I. day 1- 4
High dose RT
Wk 1 Wk 5 Wk 11 Wk 15
Minsky BD et al. JCO 2002;20:1167-1174
No significant difference in
MS-18 v/s 13 months
2 yr survival—40% v/s 31%
No significant difference in time to first
failure(52% v/s 56%)
(local /regional failure or locoregional
persistance of cancer)
This trial demonstrated that for patients who receive concurrent chemotherapy
with radiation, higher doses of radiation therapy do not offer a
local/regional control or survival advantage.
PRE OP.CT+RT+S VS S
PATH CR LOCOREG
Urba et al 8.2 5fu+cddp+Vbl+R
r et al
Three-year survival (odds ratio 0.66,
95% confidence interval 0.47
to 0.92; P 0.016).
Rate of complete resection (odds
ratio 0.53, 95% confidence
0.33 to 0.84; P 0.007).
Compared with surgery alone, neoadjuvant
chemoradiation and surgery
Improved 3-year survival
Reduced local-regional cancer recurrence.
Higher rate of complete (R0) resection.
Pathological complete response in 21% patients
Survival benefit was most pronounced when CT+RT
were given concurrently instead of sequentially
Provides strong evidence for a survival benefit of neoadjuvant
chemoradiotherapy or chemotherapy over surgery alone in patients with
oesophageal carcinoma. clear advantage of
neoadjuvant chemoradiotherapy over neoadjuvant chemotherapy has not
In patients with locally advanced thoracic esophageal
cancers, especially epidermoid, who respond to
chemoradiation, there is no benefit for the addition of
surgery after chemoradiation compared with the
continuation of additional chemoradiation.
chemoradiation alone entailed fewer early deaths and a
shorter hospital stay
More locoregional relapses.
Because clinical prognostic factors donot help in
choosing between both strategies, further studies
comparing surgery and chemoradiation should search
for newpredictive factors and evaluate new tools to
detect early responders.
PET scan was reported to discriminate responders from
nonresponders as early as 14 days after starting
chemoradiation and should be re-evaluated in future
The study suggests that there is no difference in clinical toxicity profiles or
survival outcomes with either definitive chemoradiotherapy or chemoradiation
followed by surgery in management of locally advanced esophageal cancer.
Future studies are necessary to investigate dose
escalation of chemoradiotherapy, thereby reducing
the risk of treatment failures in patients treated
The design and delivery of radiation therapy for
esophageal cancer requires a knowledge of the –
Natural history of the disease
Patterns of failure
Use of proper equipment
Implementation of methods to decrease treatment-
Close collaboration with the physics and technology
staff are essential.
As radiation oncology is both an art and a science.
TECHNIQUES OF RADIATION THERAPY
External beam radiotherapy
Important considerations for RT
Nearby vital structures: spinal cord. lungs, heart
Movement in target tissue and vital structures: lungs,
Variable density of tissues: lungs
Extent of the disease should be known based on imaging
During simulation, the patient is positioned, straightened, and
immobilized on the simulation table.
Arms are generally placed overhead.
Palpable neck disease should be marked with a radio-
Administration of oral contrast to delineate the esophagus is
Some authors recommend placing the patient in the prone
position for treatment to displace the esophagus away from
the spinal cord
Off cord Boost: After 40-44Gy
3 field technique -- one direct anterior and two lateral/ posterior oblique
- Homogeneous dose distribution
- Tumor better covered
- Critical organs are out of the field
‘T’ shaped AP-PA field:
Upper cervical esophagus lesion
- Treated from laryngopharynx to carina
- Supraclavicular and upper mediastinal LN s irradiated electively
AP-PA fields with lung shielding
Superior: Thyroid notch
Lateral : Junction of medial 2/3rd and lateral 1/3rd clavicle
Lower: Adequate margins from lesion (include upper mediastinal LNs)
Shielding: 5 HVL lead shield from 1cm below the
Lung correction factor
-Co60 - dose decreased by 4%/cm
- For 4 MV - 3% /cm
- 10 MV -2 %/cm of lung
APPROPRIATE TARGET VOLUME AND
NEED OF ELECTIVE NODAL
IRRADIATION IN CONFORMAL
•In patients treated with 3D-CRT for esophageal SCC, the omission of elective
nodal irradiation was not associated with a significant amount of failure in
lymph node regions not included in the planning target volume.
•Local failure and distant metastases remained the predominant problems.
•A longitudinal margin of 3 cm from the GTV to the CTV1 is probably enough
BASIS OF OMITTING ENI
Recurrence was with in GTV
1. Recurrene pattern(in-field)
Predominant failure pattern in with esophageal SCC was local
in-field or distant failures. Regional nodal recurrence (out-of-
field) was infrequent (8%) in the absence of elective node
2. Biological behavior of the disease
Esophageal cancer is characterized by a high rate of nodal
involvement and its spread pattern is not always predictable.
Also, skip node metastases are frequently observed. Thus the
biological behavior of this disease makes it difficult to define in
advance the extent of coverage of elective nodal irradiation.
If distant lymph node areas were irradiated prophylactically,
patients would then experience more severe radiation
complications and have a poorer treatment tolerance.
In CRT for esophageal SqCC, ENI was effective for preventing regional nodal
failure. TheUPPER THORACIC esophageal carcinomas had significantly more local
recurrences than the middle or lower thoracic sites.
No global consensus on whether or not
ENI should be performed.
POST-OPERATIVE MANAGEMENT IN
CASES OF UPFRONT SURGERY
TRASTUZUMAB + CHEMOTHERAPY IN
ADVANCED HER2+ GASTRIC CANCER: TOGA
Rationale: a subpopulation of gastric cancers overexpress HER2
(n = 584)
(N = 3803)
Stratified by ECOG PS,
advanced vs metastatic, gastric vs GEJ,
measurable disease, capecitabine vs 5-FU
(n = 810; 22% of
5-FU or Capecitabine* +
Cisplatin 80 mg/m2 q3w x 6 +
Trastuzumab 6 mg/kg q3w until PD
(8 mg/kg loading dose)
(n = 294)
5-FU or Capecitabine* +
Cisplatin 80 mg/m2 q3w x 6
(n = 290)
Bang YJ, et al. Lancet. 2010;376:687-697.
(n = 294)
(n = 290)
HR (95% CI) P Value
13.8 11.1 0.74 (0.60-
6.7 5.5 0.71 (0.59-
Established transtuzumab and chemotherapy is a new standard of
care for Her-2 neu expressing advanced gastric and EGJ
Significant OS benefit
Safety profile were similar
Fractionated BT is the best modality of palliation in comparison to all other
modalities.for advanced esophageal cancers. It offers best palliation both in
terms of survival(6.2) as well as symptom free duration
40% pts were free of dysphagia for one yr.
16Gy/2# or 18 Gy/3#
Dysphagia improved more rapidly after stent placement than
after brachytherapy, but longterm relief of dysphagia was better
Stent placement had more complications than brachytherapy
which was mainly due to an increased incidence of late
No difference for median survival (p=0·23).
Quality-of-life scores were in favour of brachytherapy compared
with stent placement.
Total medical costs were also much the same for stent
placement (€8215) and brachytherapy (€8135).
Due to better long-term relief of dysphagia with fewer
complications brachytherapy is recommended as the primary
treatment for palliation of dysphagia from oesophageal cancer.
• After placing the patient in left lateral position, a fibre-optic endoscope is
• The esophagus will be evaluated for extent of residual tumor, presence of
ulcer and stricture.
• If suitable for brachytherapy, a stainless steel guide wire will be passed
through the biopsy channel of the endoscope and passed beyond the
• Depending upon the site of lesion, the length of selectron boogie will be
adjusted by altering position of the mouth piece, so that lower end of the
boogie is 2cm beyond the lower limit of initial lesion.
• The boogie will be threaded over the guide wire, which is then withdrawn
1 cm from the mid-source / mid-dwell position without
- Assess radiation tolerability before starting radiation
- Plenty of fluids, frequent sips of cool liquids
- Disprin and local anesthetic gargles
- Avoid hot spicy, dry food
- Ryles tube insertion: Grade 3-4 dysphagia/ <1500kcal/day
Respiratory physiotherapy: to improve pulmonary function
During radiation, check patient status at least once a week
Antiemetics, Antacids, soothening agents be prescribed when needed
Treatment interruptions or dose reductions for manageable acute
toxicities should be avoided.
- Uses photosensitiser (Hematoporphyrin) and red (WL=630nm) LASER
- Resultant free radicals destroy DNA of rapidly dividing cells.
Early esophageal cancer
Persistant or recurrent esophageal cancer post RT, CCT, Sx
Local swelling and inflammation
Photosensitivity: shield skin and eyes for 4 hours