SlideShare verwendet Cookies, um die Funktionalität und Leistungsfähigkeit der Webseite zu verbessern und Ihnen relevante Werbung bereitzustellen. Wenn Sie diese Webseite weiter besuchen, erklären Sie sich mit der Verwendung von Cookies auf dieser Seite einverstanden. Lesen Sie bitte unsere Nutzervereinbarung und die Datenschutzrichtlinie.
SlideShare verwendet Cookies, um die Funktionalität und Leistungsfähigkeit der Webseite zu verbessern und Ihnen relevante Werbung bereitzustellen. Wenn Sie diese Webseite weiter besuchen, erklären Sie sich mit der Verwendung von Cookies auf dieser Seite einverstanden. Lesen Sie bitte unsere unsere Datenschutzrichtlinie und die Nutzervereinbarung.
Staging : Adenocarcinoma
Group T N M Grade
0 Tis (HGD)
IA T1 1-2, X
IB T1 3
T2 1-2, X
IIA T2 3
IIIA T1-2 N2
T4a N0 Any
IIIB T3 N2
IIIC T4a N1-2
IV Any Any M1
❚ Detailed history & Physical examination: Dysphagia,
odynophagia, hoarseness, wt. loss, use of tobacco, nitrosamines,
history of GERD. Examine for cervical or supraclavicular adenopathy.
❚ Confirmation of diagnosis:
❙ EGD: allow direct visualization and biopsy, measure proximal & distal distance of
tumor from incisor, presence of Barrett’s esophagus.
❙ CT chest and abdomen: Essential for staging because it can identify extension
beyond the esophageal wall, enlarged lymph nodes and visceral metastases.
Figure Esophageal cancer with tracheal invasion. CT
scan shows circumferential wall thickening of the
proximal esophagus (arrowheads), which shows
irregular interface with the posterior wall of the trachea
(arrows), indicating direct extension into the lumen
Figure Esophageal cancer with aortic invasion. An
arc (bent arrow) of the contact between
esophageal cancer (arrows) and the
(arrowheads) is more than 90 degrees, indicating
❙ assess the depth of penetration and LN involvement. Limited by the degree of
❙ Compared with EUS, CT is not a reliable tool for evaluation of the extent of
tumor in the esophageal wall.
Fig. —55-year-old man with T2 esophageal tumor (m)
shown on endoscopic sonogram. Note alternating
hyperechoic and hypoechoic layers (arrowheads) of normal
esophageal wall as seen on sonography. Innermost layer is
hyperechoic and corresponds to superficial mucosa. Second
layer is hypoechoic and corresponds to deep mucosa and
muscularis mucosae. Third layer is again hyperechoic and
corresponds to submucosa and its interface with muscularis
propria. Fourth layer is hypoechoic and corresponds to
muscularis propria, and outer fifth layer is hyperechoic and
corresponds to adventitia.
❚ most recently, proven to be valuable staging tool
❚ can detect up to 15–20% of metastases not seen on CT and EUS
❚ low accuracy in detecting local nodal disease compared to CT / EUS
❚ Value in evaluating response to Chemo Therapy & Radio Therapy
❚ addition of PET to CT can improve specificity and accuracy of non-
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.
❚ Bronchoscopy: rule-out fistula in midesophageal lesions.
❚Routine Investigations: CBC, chemistries, LFTs.
Cancer lower 1/3
Filling defect (ulcerative type)Rat tail appearance
Apple core appearance
Figure: A proposed treatment
algorithm for esophageal cancer.
Management depends upon:
❚ Site of disease
❚ Extent of disease involvement
❚ Co-morbid conditions
❚ Patient preference.
❚ 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
❚ 5-Year OS for surgery alone is 20–25% (no significant difference
between surgical techniques according to results of 2 meta-analyses)
❚ Local failure rate around 19–57% when used alone
❚ surgical morbidity/mortality related to experience of the surgeons.
Types of Surgery
❚ Transhiatal esophagectomy: for tumors anywhere in esophagus or
gastric cardia. No thoracotomy. Blunt dissection of the thoracic esophagus.
Left with cervical anastomosis. Limitations are lack of exposure of
midesophagus and direct visualization and dissection of the subcarinal LN
cannot be performed.
❚ Right thoracotomy (Ivor-Lewis procedure): good for exposure of mid
to upper esophageal lesions. Left with thoracic or cervical anastomosis.
❚ Left thoracotomy: appropriate for lower third of esophagus and gastric
cardia. Left with low-to-midthoracic anastomosis.
❚ Radical (en block) resection: for tumor anywhere in esophagus or
gastric cardia. Left with cervical or thoracic anastomosis. Benefit is more
extensive lymphadenectomy and potentially better survival, but increased
❚ No data proving that chemotherapy alone provides improved
survival or palliation. Partial response, not long-term remission, is
❙ Used in combination with radiation for locally advancedcancers
❙ Used as single treatment modality in stage IVdisease
❙ Combination chemotherapy has been used preoperatively in a combined
modality approach to esophageal Ca in hopes of controlling occult metastatic
disease and improving the resectability rate.
❚ Platinum doublet is preferred over single agents
❚ Cisplatin plus 5-FU or docetaxel are commonly used combinations
❚ Paclitaxel and carboplatin
❚ Cisplatin and 5-FU or capecitabine
❚ Oxaliplatin and 5-FU or capecitabine
❚ Paclitaxel or docetaxel and cisplatin
❚ Carboplatin and 5-FU
❚ Irinotecan and cisplatin
❚ Oxaliplatin, docetaxel and capecitabine
❚ Epirubicin, cisplatin and 5-FU (Only for adenocarcinoma)
❚ Patient Positioning:
❙ CERVICAL ESOPHAGUS: Supine with arms by the side
❙ MID AND LOWER THIRD:
❘ SUPINE With arms above their head if AP – PA portals are being planned
❘ PRONE if posterior obliques are beingincluded.
• Esophagus is pulled anteriorly and spinal cord can be spared.
❙ Perspex cast
❙ Vertebral column should be as parallel to couch as possible.
Barium swallow contrast to delineate the esophageal lumen and
EBRT – Cervical Esophagus
❚ AP – PA foll. by opposed oblique pair.
❚ 2 anterior obliques and 1 posterior field.
❚ 2 posterior obliques and 1 anterior field
❚ 4 field box with soft tissue compensators foll by obliques ( Univ of
Florida tech )
❚ 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.
EBRT – Mid & Lower1/3rd
AP – PA followed by 1 Ant and 2 Post oblique pair
4 FIELD : AP-PA & opposed laterals – for mid 1/3rd lesions with
patient in prone position.
AP-PA upto 43 Gy foll by 2 Post obliques upto 50 Gy ( gross disease
boosted to 60 Gy )
❚ SUPERIOR BORDER: 5 cm proximal to superior extent of disease.
❚ INFERIOR BORDER:
❙ MID 1/3RD – AT GE jn. As visualised by Barium swallow
❙ LOWER 1/3RD - Coeliac plexus ( L 1 ) to be included.
EBRT - DOSES
❙ 6 – 10 MV linac orCo60
❙ 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
❚ 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
❙ Primary tumor length ≤ 10 cm length
❙ Tumor confined to esophagealwall
❙ Thoracic esophaguslocation
❙ No nodal / systemicmetastasis.
❙ T Efistula
❙ Cervical esophagouslocation
❙ Stenosis which cannot bebypassed
EBRT 45 – 50 Gy in 1.8-2.0Gy /#,5#/wk
❘ HDR – 5 Gy x two # one week apart , 2 – 3weeks after EBRT.
❘ LDR – single 20 Gy # @ 0.4 – 1.0 Gy per hr, 2 -3 weeks after EBRT.
Never concurrently with chemotherapy
Ext diameter of applicator must be 6 – 10 mm.
Active length : visible tumor by UGI scopy plus 1 – 2 cm proximal &
❚ Dose is prescribed 1 cm from mid source or mid dwell position.
Trials – RT alone
❚ No randomized trials of RT VsSx
❚ 5 yr survival with conventional RT : < 10%
❚ Tumors < 5 cm , 5 yr survival :20%
❚ Stage wise 5 yrsurvival:
❙ Stage I –20%
❙ Stage II –10%
❙ Stage III – 3%
❙ Stage IV –0%
❚ For cervical esophagus, cure rates were similar with Radical RT or
❚ 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
RT alone should be used for palliation or in medically unfit patients.
Trials– PreOP RT
❙ 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.
No difference in resectability rates, LRC or survival with pre-op RT
Trials– PostOP RT
❙ Treat areas at risk for recurrences while minimizing
dose to OAR.
❙ Patients with node negative , completely resected T1
/ T2 tumors can be excluded.
stomach or bowel used for
• ❚ 2 randomised trials:
• ❙ Peniere et al:-
• ❘ 221 pts, mid / low 1/3rd growth
• ❘ RT : 45- 55 Gy @ 1.8 Gy per #
• ❘ 3 yrs - local failure rate ( from 35% to 10%)
• - no significant disease free survival.
• ❙ Fok et al:-
• ❘ 130 pts , RT – 49 Gy @ 3.5 Gy per #
• ❘ Local failure rate in patients who had palliative
resection ( from 46% to 20% )
• ❘ No difference for completely resected patients
• Post op RT improves localcontrol, but does
not confer any survival advantage.
ChemoRT followed Sx
❚ Patient undergoing surgery
have worse quality of life.
❚ Surgery following combined
CRT appears to improve
local control, its impact on
ultimate survival remains
ChemoRT Vs RT Alone
❚ RTOG 8501 INTERGROUP TRIAL:
❙ 121 pts: 60 pts RT alone – 64 Gy @ 2 Gy per #
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 %
❚ Median & overall survival, LRR and Acute toxicity in Chemo RT
Chemoradiation is a standard Non-surgical Tx.
RT dose escalation in Chemo RT
❚ Intergroup 0123 TRIAL – 218 pts
❙ Chemoradiation - either 50.4 Gy or 64.8Gy
❙ No significant difference in median survival, 2 yr survival or loco-
Intensification of RT dose beyond 50.4 Gy(in combination with
chemotherapy ) does not improve results.
Sx ALONEPRE OP CHEMO RT Vs
❚ 44 Randomised trials
❚ 2 studies showed in local recurrence
❙ Urba et al – 19 % Vs 42 %
❙ Bosset et al ( EORTC ) – 28% Vs 40%
❚ One study showed significant survival benefit at 3 yrs (in pts who had
a pathologic CR )
❙ Urba et al – 64% Vs 19%
❚ One study (Walsh et al) showed benefit in median (16 Vs 11 months )
and overall survival at 3 yrs ( 32 Vs 6%)
Results support TRIMODALITY approach.
The role of preoperative
chemotherapy alone is
controversial, according to
mixed results from clinical
Stage Recommended treatment
Stage I–III and IVA
definitive chemo-RT (preferred for cervical esophagus)
Or, Pre-op chemo-RT →surgery. Surgery preferred for adenocarcinoma
regardless of response to chemo-RT.
Or, surgery. (noncervical T1N0 and young T2N0 patients with primaries
of lower esophagus or gastroesophageal junction.
Indications for post-op chemo-RT include: unfavorable T2N0, T3/4,
LN+, and/or close/+ margin.
Stage I–III inoperable Definitive chemo-RT
Stage IV palliative Concurrent chemo-RT (5-FU + cisplatin, 50 Gy) or RT alone (e.g., 2.5
Gy × 14 fx) or chemo alone or best supportive care.
Pain: medications ± RT
Bleeding: endoscopic therapy, surgery, or RT
❚ EBRT using 3D-CRT to a total dose of 50.4 Gy (1.8 Gy per daily fraction) is
❚ IMRT is often utilized to minimize exposure to adjacent structures.
❚ Proton beam in combination with chemotherapy is being explored.
❚ Targeted biologic agents added to standard cytotoxic chemotherapy is
❚ Esophageal cancer is the 7th leading cause of cancer deaths.
❚ Adenocarcinoma now accounts for over 50% of esophageal cancer in the
USA, due to association with GERD & obesity.
❚ Dysphagia and weight loss are the two most common presentations in
patients with esophageal cancer.
❚ Endoscopic ultrasound (EUS) is necessary to accompany a complete workup
for proper staging and diagnosis of esophageal cancer.
❚ Surgery is the standard of care for early-stage esophageal cancer.
❚ Preoperative chemotherapy and radiation is the standard option for locally
advanced esophageal cancer in surgically eligible patients.