RT in Ca Esophagus

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Gist of RT in Esophageal cancer including trials, indications and tecniques.

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RT in Ca Esophagus

  1. 1. RADIATION THERAPY IN CA ESOPHAGUS Dr. T. Sujit A M O ( Radiation Oncology ) Valavadi Narayanaswami Cancer Centre, G.Kuppuswamy Naidu Memorial Hospital, Coimbatore - 641037, Tamilnadu, India April 2007
  2. 2. ROLE OF RT IN CA ESOPHAGUS <ul><li>CURATIVE </li></ul><ul><ul><li>RADICAL RT </li></ul></ul><ul><ul><li>PRE-OP RT </li></ul></ul><ul><ul><li>POST OP RT </li></ul></ul><ul><ul><li>CONCURRENT CHEMORADIATION </li></ul></ul><ul><li>PALLIATIVE </li></ul><ul><li>EBRT </li></ul><ul><li>BRACHYTHERAPY </li></ul>
  3. 3. TRIALS – RADICAL RT <ul><li>NO randomised trials of RT Vs Sx </li></ul><ul><li>5 yr survival with conventional RT : < 10% </li></ul><ul><li>Tumors < 5 cm , 5 yr survival : 20% </li></ul><ul><li>Stage wise 5 yr survival: </li></ul><ul><ul><li>Stage I – 20% </li></ul></ul><ul><ul><li>Stage II – 10% </li></ul></ul><ul><ul><li>Stage III – 3 % </li></ul></ul><ul><ul><li>Stage IV – 0% </li></ul></ul>
  4. 4. TRIALS – RADICAL RT <ul><li>For cervical esophagus, cure rates were similar with Radical RT or Sx alone. </li></ul><ul><li>RT or Sx alone DOES NOT alter the natural history of the disease. </li></ul><ul><li>RTOG 8501: RT Vs Chemo RT </li></ul><ul><ul><li>Better LRC and improved OS with ChemoRT </li></ul></ul><ul><li> RT alone should be used for palliation or in medically unfit patients. </li></ul>
  5. 5. TRIALS – PRE OP RT <ul><li>PRINCIPLE : </li></ul><ul><ul><li> resectability,  likelihood of tumor dissemination during Sx ,  radioresponsiveness due to unaltered blood supply </li></ul></ul><ul><ul><li>5 randomised trials </li></ul></ul><ul><ul><li>Only one trial ( Huang et al ) showed survival advantage of 46% Vs 25% with 40 Gy RT </li></ul></ul><ul><ul><li>Oesophageal Cancer Collaborative Group study showed no clear survival advantage. </li></ul></ul><ul><li> No difference in resectability rates, LRC or survival with pre-op RT </li></ul>
  6. 6. TRIALS – POST OP RT <ul><li>ADVANTAGES: </li></ul><ul><ul><li>Treat areas at risk while minimising dose to OAR. </li></ul></ul><ul><ul><li>Patients with node negative , completely resected T1 / T2 tumors can be excluded. </li></ul></ul><ul><li>DISADVANTAGE: </li></ul><ul><ul><li>Tolerance of stomach or bowel used for interpositioning </li></ul></ul>
  7. 7. TRIALS – POST OP RT <ul><li>2 randomised trials: </li></ul><ul><ul><li>Peniere et al :- </li></ul></ul><ul><ul><ul><li>221 pts, mid / low 1/3 rd growth </li></ul></ul></ul><ul><ul><ul><li>RT : 45- 55 Gy @ 1.8 Gy per # </li></ul></ul></ul><ul><ul><ul><li>3 yrs -  local failure rate ( from 35% to 10%) </li></ul></ul></ul><ul><ul><ul><li> - no significant disease free survival. </li></ul></ul></ul><ul><ul><li>Fok et al :- </li></ul></ul><ul><ul><ul><li>130 pts , RT – 49 Gy @ 3.5 Gy per # </li></ul></ul></ul><ul><ul><ul><li>Local failure rate  in patients who had palliative resection ( from 46% to 20% ) </li></ul></ul></ul><ul><ul><ul><li>No difference for completely resected patients </li></ul></ul></ul><ul><li> Post op RT improves local control, but does not confer any survival advantage. </li></ul>
  8. 8. TRIALS – CHEMORADIATION CHEMO RT Vs RT ALONE <ul><li>RTOG 8501 INTERGROUP TRIAL: </li></ul><ul><ul><li>121 pts: 60 pts RT alone – 64 Gy @ 2 Gy per # </li></ul></ul><ul><ul><li> 61 pts chemoRT – 50 Gy RT </li></ul></ul><ul><ul><li> 5 FU + CDDP – on 1 , 5 , 8 & 11 weeks </li></ul></ul><ul><ul><li>Median survival : 8.9 Vs 12.5 months </li></ul></ul><ul><ul><li>5 yr survival : 0% Vs 30 % </li></ul></ul><ul><ul><li>Distant mets @ 5 yrs: 40% Vs 12 % </li></ul></ul><ul><ul><li>Acute toxicity : 25% Vs 44 % </li></ul></ul><ul><li> MEDIAN & OVERALL SURVIVAL,  LRR  </li></ul><ul><li>AND  ACUTE TOXICITY IN CHEMO RT ARM. </li></ul><ul><li> CHEMORADIATION IS A STANDARD NON-SURGICAL Tx. </li></ul>
  9. 9. TRIALS – CHEMORADIATION RT DOSE ESCALATION IN CHEMO RT <ul><li>INTERGROUP 0123 TRIAL – 218 pts </li></ul><ul><ul><li>Chemoradiation - either 50.4 Gy or 64.8 Gy </li></ul></ul><ul><ul><li>No significant difference in median survival, 2 yr survival or loco-regional failure. </li></ul></ul><ul><li> Intensification of RT dose beyond 50.4 Gy (in combination with chemotherapy ) does not improve results. </li></ul>
  10. 10. TRIALS – CHEMORADIATION PRE OP CHEMO RT Vs Sx ALONE <ul><li>4 Randomised trials </li></ul><ul><li>2 studies showed  in local recurrence </li></ul><ul><ul><li>Urba et al – 19 % Vs 42 % </li></ul></ul><ul><ul><li>Bosset et al ( EORTC ) – 28% Vs 40% </li></ul></ul><ul><li>One study showed significant survival benefit at 3 yrs ( in pts who had a pathologic CR ) </li></ul><ul><ul><li>Urba et al – 64% Vs 19% </li></ul></ul><ul><li>One study (Walsh et al) showed benefit in median (16 Vs 11 months ) and overall survival at 3 yrs ( 32 Vs 6%) </li></ul><ul><li> Results support TRIMODALITY approach. </li></ul>
  11. 11. EBRT TECHNIQUES <ul><li>PATIENT POSITIONING: </li></ul><ul><ul><li>CERVICAL ESOPHAGUS: Supine with arms by the side </li></ul></ul><ul><ul><li>MID AND LOWER THIRD: </li></ul></ul><ul><ul><ul><li>SUPINE if AP – PA portals are being planned </li></ul></ul></ul><ul><ul><ul><li>PRONE if posterior obliques are being included. </li></ul></ul></ul><ul><ul><ul><ul><li>Esophagus is pulled anteriorly and spinal cord can be spared. </li></ul></ul></ul></ul><ul><li>IMMOBILISATION : </li></ul><ul><ul><li>Perspex cast </li></ul></ul><ul><ul><li>Vertebral column should be as parallel to couch as possible. </li></ul></ul><ul><li>Barium swallow contrast to delineate the esophageal lumen and stomach. </li></ul>
  12. 12. EBRT – CERVICAL ESOPHAGUS <ul><li> AP – PA foll. by opposed oblique pair. </li></ul><ul><li> 2 anterior obliques and 1 posterior field. </li></ul><ul><li> 2 anterior obliques and 1 anterior field </li></ul><ul><li> 4 field box with soft tissue compensators foll by obliques ( Univ of Florida tech ) </li></ul><ul><li>SUPERIOR BORDER: At C 7 </li></ul><ul><li>INFERIOR BORDER : At T 4 ( carina ) </li></ul><ul><li>2 cm lateral margins. </li></ul><ul><li>SC nodes irradiated electively. </li></ul><ul><li>SC nodes will be underdosed if oblique portals are used to treat primary; can be boosted by a separate photon field if required. </li></ul>
  13. 13. CERVICAL ESOPHAGUS
  14. 14. EBRT - MID & LOWER 1/3 RD <ul><li> AP – PA followed by 1 Ant and 2 Post oblique pair ( coning down ) </li></ul><ul><li> 4 FIELD : AP-PA & opposed laterals – for mid 1/3 rd lesions with patient in prone position. </li></ul><ul><li> AP-PA upto 43 Gy foll by 2 Post obliques upto 50 Gy ( gross disease boosted to 60 Gy ) </li></ul><ul><li>SUPERIOR BORDER: 5 cm proximal to superior extent of disease. </li></ul><ul><li>INFERIOR BORDER: </li></ul><ul><ul><li>MID 1/3 RD – AT GE jn. As visualised by Barium swallow </li></ul></ul><ul><ul><li>LOWER 1/3 RD - Coeliac plexus ( L 1 ) to be included. </li></ul></ul>
  15. 15. 3D CRT IMRT
  16. 16. EBRT - DOSES <ul><li>CHEMORADIATION : </li></ul><ul><ul><li>50.4 Gy in 28 # at 1.8 Gy per # </li></ul></ul><ul><ul><li>Boost to 60 – 66 Gy for residual disease </li></ul></ul><ul><li>RADICAL RT: </li></ul><ul><ul><li>45 Gy / 25 # / 1.8 Gy per # </li></ul></ul><ul><ul><li>boost with 2 cm margin to total dose of 60Gy </li></ul></ul>
  17. 17. BRACHYTHERAPY <ul><li>As a boost after EBRT or as a palliative measure </li></ul><ul><li>Local control of 25% - 35 in palliative setting </li></ul><ul><li>In curative setting, addition of brachytherapy does not improve results compared to Radical RT or Chemoradiation. </li></ul>
  18. 18. A MERICAN B RACHYTHERAPY S OCIETY GUIDELINES <ul><li>PATIENT SELECTION: </li></ul><ul><ul><li>Primary tumor length ≤ 10 cm length </li></ul></ul><ul><ul><li>Tumor confined to esophageal wall </li></ul></ul><ul><ul><li>Thoracic esophagus location </li></ul></ul><ul><ul><li>No nodal / systemic metastasis. </li></ul></ul><ul><li>CONTRAINDICATIONS: </li></ul><ul><ul><li>T E fistula </li></ul></ul><ul><ul><li>Cervical esophagous location </li></ul></ul><ul><ul><li>Stenosis which cannot be bypassed </li></ul></ul>
  19. 19. A MERICAN B RACHYTHERAPY S OCIETY GUIDELINES <ul><li>EBRT 45 – 50 Gy with concurrent chemo foll by brachy : ( EBRT 60 Gy if chemo is not given ) </li></ul><ul><ul><ul><li>HDR – 5 Gy x two # one week apart , 2 – 3weeks after EBRT. </li></ul></ul></ul><ul><ul><ul><li>LDR – single 20 Gy # @ 0.4 – 1.0 Gy per hr, 2 -3 weeks after EBRT. </li></ul></ul></ul><ul><li>Never concurrently with chemotherapy </li></ul><ul><li>Ext diameter of applicator must be 6 – 10 mm. </li></ul><ul><li>Active length : visible tumor by UGI scopy plus 1 – 2 cm proximal & distal margin. </li></ul><ul><li>Dose is prescribed 1 cm from mid source or mid dwell position. </li></ul>
  20. 20. APPLICATORS
  21. 21. TOXICITY OF THERAPY <ul><li>SURGERY </li></ul><ul><ul><li>Cardiopulmonary complications, anastomotic leak, RL nerve palsy, stricture. </li></ul></ul><ul><li>RADIATION </li></ul><ul><ul><li>Acute – esophagitis , fatigue, weight loss, pneomonitis, perforation. </li></ul></ul><ul><ul><li>Chronic – stenosis ( 60%), stricture ( 20% ) </li></ul></ul><ul><li>CHEMOTHERAPY </li></ul><ul><ul><li>Bone marrow suppression , mucositis. </li></ul></ul>
  22. 22. <ul><li>T H A N K Y OU </li></ul>

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